Telemedicine in the management of children with clubfoot in the UK during the COVID 19 pandemic - Global Clubfoot ...
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Telemedicine in clubfoot treatment 1.2
Telemedicine in the management of children with clubfoot in the UK during the
COVID 19 pandemic
Introduction
Children in the UK with clubfoot and their families have experienced disproportionate challenges and
difficulties due to the Covid-19 pandemic. Through the course of 2020-2021 clinicians and support
charity ‘Steps Charity Worldwide’ reported high levels of anxiety amongst families of children with
delayed treatment. Children in the maintenance phase of treatment found adherence with treatment
protocols difficult without their regular in-person clinical reviews due to ‘non-essential’ treatment
being put on hold. Treatment delays and reduced adherence may result in increased relapse of
clubfoot deformity and subsequent surgeries to correct these cases. Clinicians have been adapting
to new ways of working using virtual consultations and this guidance document has been produced
in order to guide clinicians in order to utilise telemedicine effectively to support children and their
families.
This document has been produced with information collated from families of children with clubfoot
and a group of clinicians with considerable experience and understanding of the Ponseti Method
and the ongoing management of children with clubfoot using telemedicine.
Aim
To determine, from the perspective of patients and clinicians, how telemedicine can be used most
effectively to support parents of children with clubfoot and prevent relapse of clubfoot deformity.
Methodology
In order to effectively analyse the efficacy of telemedicine for our specific patient group we created
two surveys. One survey targeting expert clinicians and the other for parents/carers of children
with clubfoot who were still receiving ongoing follow up reviews. The clinician survey was sent to a
group of 33 clinicians known to have expertise in treating clubfoot at the end of November 2020
with requests to forward it on to others with clubfoot management expertise. The survey was
open for 2 weeks and was completed by 16 clinicians, a mixture of Consultant Orthopaedic
Surgeons and Specialist Paediatric Orthopaedic Physiotherapists. Follow up interviews were
conducted with 5 of these experts to gather further information. The survey for families of children
with clubfoot was reviewed by the leadership team from the support charity ‘Steps’ who provided
valuable feedback and advice. Recruitment for the families’ survey occurred through advertising on
family support social media pages and through Steps charity newsletter. This survey was opened at
the end of January and closed at the beginning of March 2021. Within this time period it was
completed by 50 parents/carers of children with clubfoot.
The emerging themes from each of these information gathering exercises are presented below.
1Telemedicine in clubfoot treatment 1.2
Survey results
Themes gathered from the Parent/Carer’s survey
Parents were asked a variety of multiple choice and free text allowing for both qualitative and
quantitative data to be collected. The following results represent the data extrapolated from their
answers.
Did you feel that the virtual consultation met your/your child’s needs?
Positive Neutral Negative
52% 24% 24%
Parent experience with telemedicine accessibility
Advantages reported Disadvantages reported
30% 22% 20% 9% 19%
Less travel time to Less anxiety No perceived Less travel costs Other*
clinic about coming into advantages
a clinical area
during COVID-19
pandemic
Advantages Other: Easier to fit into other life commitments, able to stay in home environment, both parents able to attend, reduced anxiety for the child, keep
in touch with medics who are treating our child, better than no access to a consultant
Disadvantages Other: Parental anxiety (2%), Unanswered (3%)
2Telemedicine in clubfoot treatment 1.2
Do you feel adequately supported to manage the bracing stage / boots & bar, through virtual
consultations?
Positive Neutral Negative
61% 25% 14%
If, given the choice, what would your preference be for the type of consultation you would
receive in the future?
Virtual consultation only Mixture of virtual and face-to-face Face-to-face consultation
0% 46% 54%
Suggestions from parents
General consensus from parents was that virtual consultations offer a number of advantages but
are not superior and cannot replace face to face appointments. When asked what could be
changed to improve parental experience of telemedicine, several parents commented that they
believe a secure upload centre would be useful in order to share videos and photos with the
clinician prior to the appointment, especially when parents had specific concerns that they wanted
to demonstrate or discuss as it can be difficult to predict compliance of the child during the virtual
consultation.
3Telemedicine in clubfoot treatment 1.2
Themes gathered from the Clinician Survey and follow up interviews
What has worked well with virtual consultations?
“Simple instructions
for parents on camera
“Good information work”
before the appointment
on how to log on and the
likely format of the “Two carers are
appointment, e.g. have helpful if
boots and bars readily available, as
available” one can move “Advice sheets
the foot and one for parents on
can use the how to adjust
camera” their own boots
and bars”
How confident do you feel in your assessment when using virtual appointments?
Identifying relapse
Identifying compliance issues
with foot abduction brace
1.No confidence
Skin condition 2. Slight confidence
Pirani Score 3. Moderate
Confidence
4. Very confident
Strength
5.Extremely
confident
Gait
Range of motion
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
4Telemedicine in clubfoot treatment 1.2
What treatment(s) are you confident to give during a telemedicine consultation?
What advice would you give to other clinicians to help with problem solving during virtual
appointments?
The majority of clinicians responded highlighting the importance of not relying solely on virtual
appointments and being ready to bring patients in for a face to face review if any concerns arise:
“Have a structured approach of what exactly you are looking at, just
as you would in a face-to-face appointment. If any concerns do not
hesitate to bring in face to face”
“There is a time and place for virtual appointments but patients will
still need F2F reviews. At first signs of relapse or skin issues bring
in for a F2F review”
“Have a low threshold for transitioning to a face to face
appointment: If you are unable to see everything well, the child is
non-compliant or they are experiencing pain, invite them into clinic”
Additional Comments from Clinicians
Despite clinicians reporting several benefits of using telemedicine for this cohort of
patients, many clinicians also stressed that telemedicine did not shorten consultation times.
In terms of time efficiency, some clinicians commented that telemedicine can be more
demanding on time than a face to face appointment. This was reportedly due to
complexities in teaching parents how to access telemedicine, how to adjust the boots and
bar and additional administration time required in sending boots and bars to each patient.
Concluding Considerations
1. . Recommended patient selection for use of virtual consultations:
- Antenatal consultations- both clinicians and parents reported that this is the ideal format
for these appointments. Parents valued being able to stay in their own home and clinicians
found that using a virtual platform has been an extremely effective way to provide parental
5Telemedicine in clubfoot treatment 1.2
support and education. Both parents and clinicians commented that there is not a need for
this appointment to be completed face to face.
- Children already well established in the foot abduction brace with good compliance-
clinicians consider that the most appropriate use of virtual consultations are with parents
who are already very familiar with the use of the foot abduction brace and the format of
appointments. The use of video can be useful in identifying relapse, particularly in the
walking child. Parents of children who were older reported higher satisfaction levels.
- During maintenance phase of treatment- clinicians stated that they believe parents can be
well supported if the children are already well established in the foot abduction brace with
good parental compliance and no prior clinical concerns. Parents who had children that had
been in the foot abduction brace for longer were more familiar with the use of the foot
abduction brace, format of the appointments and equally felt more supported than parents
of younger children.
As seen in the results of the parental survey, when given the choice 54% of parents
reported that they would rather be seen face to face, however, 46% of parents opted for a
mixture between virtual and face to face appointments. When interviewed, some clinicians
felt alternating between virtual and face to face appointments for this patient group could
be an option in future to relieve the parental demands.
2. Patients who are not suitable for telemedicine reviews:
- Any child with previous safeguarding issues
- Significant parental anxiety regarding the use of virtual consultations or poor IT literacy
- Co-morbidities affecting the patient or parents’ ability to use the technology.
- Healthcare worker unable to communicate effectively in the same language as patient or
parent, after efforts to obtain a translator have been exhausted
- Poor compliance with foot abduction brace
- Pre-existing clinician concerns
- New confirmed diagnosis of CTEV/babies or infants in the corrective phase of treatment
3. Information to give prior to the telemedicine appointment:
- How to access the specific platform you are using e.g. Zoom, Attend Anywhere and what
device is best to use
- Department email address/contact- in case of any difficulties accessing virtual platform or
to send photos/videos prior to appointment
- What they may need for the appointment: foot abduction brace, socks, shoes, appropriate
clothing that exposes the legs, if able a space to enable gait analysis
- If available two adults are helpful- one to hold the device and one to instruct the
child/move the foot
- Steps Charity Worldwide: Talipes/Clubfoot Parents guide
https://www.stepsworldwide.org/conditions/talipes-clubfoot/
- How-to guide on adjusting the abduction bar
4. Tools/equipment to use during the appointment:
- Foot abduction brace- to demonstrate how to adjust the bar/explain specific features
6Telemedicine in clubfoot treatment 1.2
- Rubber models and skeletal are useful specifically for antenatal appointments to
demonstrate how the foot moves, also useful to demonstrate stretches and handling
- Two screens are helpful for the clinician to type notes and review previous patient
information
- Photos/pictures of clubfoot
5. Useful information to share with families during/after appointment:
- Tips to avoid blisters
- GCI video on ‘How to keep the foot mobile’:
https://vimeo.com/channels/globalclubfoot/409715599
- GCI video, ‘Tickle and Move’: https://vimeo.com/channels/globalclubfoot/409716896
6. Suggested objective assessment:
- Passive range of movement
- Review of foot posture: at rest, on activity, in standing.
- Gait analysis- front/back and side
- Functional tasks and strength- squatting, jumping, hopping, single leg balance
- Observe parents applying the foot abduction brace and review fitting and size of both
boots and width of bar.
7. Additional considerations:
- Gaining parental consent and how to document this.
- Trust policy on secure platforms that can be used and how to keep patient confidentiality.
- Organisation of sending foot abduction braces to parents in a timely manner- preempting
where able or alternatively sending out boots when scheduling the appointments therefore
enabling the boots to be tried on and checked during the virtual consultation.
- Other Covid19 related resources from GCI and the UK Clubfoot Consensus Group can be
found at:
GCI site: https://globalclubfoot.com/covid-19-resources/
BSCOS site: https://bscos.org.uk/covid19/resources.php
8. Environmental/practical considerations:
- Consider background noise/lighting/backdrop to minimise distractions
Produced by Global Clubfoot Initiative, March 2021 with funding from the National Lottery Fund
Coronavirus Community Support Fund
We gratefully acknowledge the support of Aisling Russell (research and writing), Steps Charity
Worldwide and UK Clinicians and families of children with clubfoot in producing this document. UK
Clinicians providing responses to the survey:
• Sharon Bickerton, Highly Specialised Paediatric physiotherapist, St. George's Hospital,
London
• Nicola Cox, Specialist Paediatric Orthopaedic Physiotherapist, Chelsea and Westminster
Hospital, London
• Lindsay Parker, Senior Paediatric Physiotherapist, Chelsea and Westminster Hospital,
London
7Telemedicine in clubfoot treatment 1.2
• Simon Barker, Royal Aberdeen Children's Hospital, Aberdeen
• Mia Dunkley, Clinical Specialist Physiotherapist, Great Ormond Street Hospital, London
• Stuart Evans, Orthopaedic Surgeon, Chelsea and Westminster Hospitals, London
• John Cashman, Consultant Orthopaedic Surgeon, Sheffield Children's Hospital, Sheffield
• Fran Thompson Clinical Specialist Paediatric Orthopaedic Physiotherapist, East Kent
University Hospitals Trust
• Rachel Buckingham Oxford
• Jenny Anstead, Bristol Royal Hospital for Children
• Anastasios Chytas, Consultant Paediatric Orthopaedic Consultant, Royal Manchester
Children's Hospital
• Christine Douglas, Paediatric Extended Scope Practitioner, Royal National Orthopaedic
Hospital, Stanmore
• Charlie Martin, Clinical Specialist Paediatric Orthopaedic physiotherapist, Ipswich Hospital
• Denise Watson, Advanced Practice Physiotherapist, Chelsea and Westminster Hospital,
London
The information presented in this document is made by Global Clubfoot Initiative (GCI) in
collaboration with Steps Charity Worldwide and represents the findings of a recent survey
investigating the management of children's treatment of clubfoot during the COVID-19
pandemic with the use of Telemedicine. The aim of the survey was to assess whether
Telemedicine is an effective tool used by health professionals to support parents of children with
clubfoot to prevent relapse of clubfoot deformity. The information and content in this document
is sourced from healthcare professionals with considerable experience and understanding of the
Ponseti Method and personal stories and experiences from children and parents. GCI and Steps
Charity Worldwide do not provide medical advice, diagnosis or treatment and this document is
not intended to be a substitute for professional medical advice through your regular health care
provider. This document is for informational purposes only. Always seek the advice of a qualified
healthcare professional as to your specific circumstances and needs. We have tried to ensure
that the information in this document is correct at the time of publishing however neither Steps
Charity Worldwide or GCI make any representation and give no warranty in respect of the
accuracy or fitness for purpose of the information in this document and accepts no liability for
any personal injury or other loss or damage resulting from you relying on this information.
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