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What is the role of a Podiatrist in Early Intervention and/or Multidisciplinary Assessment?

Discussion in 'Pediatrics' started by Bug, Mar 14, 2009.

  1. Bug

    Bug Well-Known Member


    Members do not see these Ads. Sign Up.
    I am interested in others thoughts on this.

    We continue to see EI programs or Multi/trans/inter-disciplinary assessment teams set up with the core group of Psych, OT, Physio and Speechie. The manager that has done their research or in an act of desperation will then employ a Podiatrist or Orthotist or at least have either consult, rarely both.

    Do we not have the skill set or expertise to work in this area or is it presumptive to think what sort of difference we can make? What is our role in gait retraining or is that the physio job? We provide orthoses but not AFO's so the orthotist can be of more use there? Do we rehab, do we assess, do we diagnose?

    Now I realise the US is a different kettle of fish with the surgical component however in the UK/Aust where we should be on a level playing field with our colleagues, what do you think is holding us back?
     
  2. Bug

    Bug Well-Known Member

    Hmmm, I'm not sure if I take the gloomy silence as a "Don't think we have a role and we are kidding ourselves to think we do" or "Never thought of us being there?" or just really "who gives a toss, the majority of us here are in private practice and could think of nothing worse than working with kids and other health professionals in the room all day!".

    Come on, have the big girl undies on today, you can tell me what you think.
     
  3. Atlas

    Atlas Well-Known Member

    There is definitely a role there....minor now, but growing in the future as long as the profession can better understand the ankle and lesser extent knee.

    Pods have a great respect for infection control; they have a great understanding of wounds... Their knowledge of the foot should be second-to-none.

    Whenever I hear "multidisciplinary", I get this warm feeling of all boxes being ticked, but at the same time, I get this cold feeling of inefficiency, bureaucracy, handover discussions, meetings, duplicity, politics etc. etc.


    I am talking from an Australian viewpoint, and from someone who has been only partially involved in the public sector, mainly as a university student for 10+ years.


    Lets generalise for a moment. Physiotherapists in their halcyon days (before everything was attributed to core stability) had very good understanding of back, hips, knees, and even the ankle. Where their area got grey, and the assumptions magnified was any region distal to the ankle joint.

    In relation to Pods, I think the opposite is true; in that soon as we go proximal to the STJ, the thinking is grey and the assumptions grow. I have read one/two pieces of Howard's work, and IMO, his view of the tib-fib joints is plausable; but its not the rule. Moreover nowhere near the majority of pathological ankles present like that...and accordingly they don't improve subjectively or objectively with such intervention.

    As for orthotists, they have the right tools in the knapsack. They are potent, without being risky. I speak of the AFO, or the EVA insole (that can off-load and support), and the rockersole. These interventions can make a huge difference in QOL for those with below-knee pathology.





    The other thing about the multi-disciplinary approach is the political sensitivity about one profession questioning another. The patient is almost like a lemon tree, and the allied health professions, particularly over-lap professions (physio, pods, orthotists), are like dogs with a full bladder. Robust productive discussion isn't tolerated. As humans we don't like to be questioned. However, anyone who administers an approach should be accountable. And there needs to be plans b, c, d, and e ready for consideration.


    I might be igniting a public v. private debate, and I know there are many drawbacks in private health (dollar chasing etc.), but this is just my view of the dark side of the multidisciplinary approach. It needs more efficient shorter meetings, less paperwork, a greater emphasis on the things that really matter, less duplicity; less professional sensitivity; more robust discussion; more patient contact; and a greater willingness to go to plan b, c, d if plan a is not yielding significant dividends.




    The podiatrist isn't fully equipped to be the go-to person at this point in time in Australia. However, imagine the podiatrist with a better understanding of the ankle; and one that has more familiarity with EVA devices; and some understanding of AFO's and rockersoles...and then you have a super asset to the MD team.



    Ron
    Physiotherapist (Masters) & Podiatrist
     
  4. Bug

    Bug Well-Known Member

    Thanks for that Ron,

    I totally get where you are coming from however you are talking to one of the few podiatrists that couldn't work her way around a wound dressing cupboard if she tried. It is interesting what you mention about the ankle and foot, way back when, was was taught up to the hip and still have no problems giving a range of hip stretch/strengthening stuff, especially for little ones that w sit.

    Our last physio used to joke that she love the job as she could concentrate on the upper body/head stuff but we used to see a stack of clients together.

    I will digest your comments more and come back when I don't have a chicken poxy toddler trying to type with me.
     
    Last edited: Mar 19, 2009
  5. Bug

    Bug Well-Known Member

    OK, now in a moment of silence I have mulling over these comments.

    I was interested to read a report about 18 month ago that showed increased measured functional outcomes and parental satisfaction of their child's treatment from multidisciplanary teams. It measured about 11 of them and 2 of them that scored the highest had podiatry within the team and the majority of the 50 children that were measured also had some form of assessment/intervention with them involved. They were also not some of the biggest team in numbers/disciplines. I have continually wondered about what millions of factors it could have been within those team and the dynamics. There was a theme though, increased dual/multi-assessment and increased case management. It would be interesting to see with that if an increased professional respect, limited blurring of boundaries and focus on the particular skill set of the individual was at play.

    I also look at the list that Ron provided and notice the amount of biomechanical/orthotic intervention. Which of course is a component but when will we pick up the pace? Why are the physio's leading the way in the Ponsetti treatment when it should be our kettle of fish? We have access to x-rays and from what I have seen far greater medical knowledge (or maybe just the pod's I hang with) of conditions that affect or show symptoms in the foot.

    I've recently been granted access to purchase some functional assessment tools. It wasn't too hard. Many of us could and yet we don't access things out there that are designed to measure an impact and many of us don't even know about them.

    Where is our post-graduate educational streams that allow us to extend ourselves in this area?

    Grumble, grumble, basically I think we can and should. I think with the right training we have a valid role and a varied role. Far more than what you mention Ron however I think we need to pull our finger our. Get some more training and get our foot (boom boom!) in the door as often as we can!
     
  6. dyfoot

    dyfoot Active Member

    I agree with Cylie,

    Many of us pods are so busy at the coalface that, unless we take time out to research and upskill in the latest diagnostic and treatment techniques, we get left behind.

    Our associations and other continuing education organizations are flat out keeping many of us up to speed with well established protocols, let alone the latest!

    Thank heavens for compulsory CPD! At least this keeps the ball rolling, but governments (particularly in more remote places like much of Australia) need to get involved more in continuing education.

    For those of us restricted by the tyranies of time, money and distance the options are few.

    Brad Randazzo
     
  7. Mint80

    Mint80 Welcome New Poster

    Hi Cylie

    I have just started a round of kinder screenings (the first one was today) with Speech, physio, OT and counselling. It has proved very successful with several children needing review apointments. These children would probably not have presented at clinic for a few years (if ever) as the parents thought that the leg pain and reduced activity was laziness or growing pains.

    As this was my first attempt at a screening it was pretty basic but got the point across. I certainly think we have a place in the process that can't be filled by Physio.

    Samantha
     
  8. Sue

    Sue Welcome New Poster

    Hi Samantha,
    I have recently taken on a post in which i have to design some screening in schools. I am interested to find out the sort of things you are dealing with, how all the disciplines have become involved and anything else you feel would be helpful in giving me encouragement and ideas.
    Thanks Sue
     
  9. Cameron

    Cameron Well-Known Member

    Bug

    I work as a consultant to a multidiscipline team in diabetes and partake in regular foot health awareness classes for recently diagnosed diabetics run in conjunction with Diabetes Ediucators. I also have experience with multi-discipline teams supporting people living in the community with chronic diseases such as diabetes, peripheral vascular disease and Chronic Obstructive Pumonary Disease (CPD).

    The podiatrist has much to offer (is my experience) and dovetail into the holistic approach in team care with much ease. The primary function is as an educator and trainer helping colleagues and clients cope from an informed foot care perspective. In a country so diverse and of multi ethnicity it is no surprise to see excellent examples of 'working together' as exemplified by the Indigenous Foot Care Project run by SARRAH.
    http://www.sarrah.org.au/site/index.cfm

    Again in my experience where preventative programs breakdown is when the role of the podiatrist is primarily clinical. Once you start offering a clinical service to a chronically ill demographic the process becomes labour intensive, very expensive and a commitment which becomes life long. A major part of the 'education process' is accessing people to available and reliable podiarty services (such as the Government funded Enhanced Care Plan ). I think this is why many programs will employ a consultant for advisory purposes only then sub contract the clinical work to practising pods. Not only does it make economic sense, it is just more practical.

    The problem can arise when community based clinical services are unavailable (i.e. an absence of public podiatry) and there is limited access to the private sector. Existing hospital services are usually too busy to pick up the population generated by the preventative programs. In some cases they too are experiencing problems by not being able to refer their 'stable cases' back into a reliable community podiatry service. The absence of a structure public podiatry service in Australia makes this problem more acute.

    In my opinion early intervention programs are positive and working within a multi-team extremely rewarding. Where programs work well is when there is already an existing (safety net) podiatry service available and this leaves the role of the team podiatrist as an advisor.

    Hey, what do I know?

    toeslayer
     
  10. Cameron

    Cameron Well-Known Member

    netizens

    School screening is an interesting topic which can become a proverbial mine field. In the UK clinical screening of children was at one time a vogue (60s) but due to cost and ethical problems fell into abeyance. Following the success of dental school screening in the 50s where the incidence of carries was almost obliterated, some pods embarked on foot screening programs. One luminary was Vincent Denvir (Stirling, Scotland) and Gordon Watt (Glasgow Caledonian University) who is the better published. There are many others including Peter Thomson - so there is no shortage of experience.

    The main problem with screening was what to do when children presented with need for treatment. This called into account the ethics of screening based on the assumption best not to know these things otherwise there is a liability to the screening authority to do something about it. As part of the process permission from parents or guardians is essential before screening and there is always the potential those responsible for the child do not want or cannot afford to have the child undergo treatment. This can create problems with for example verucae. If the child does not undergo treatment are they then treated differently form the other kids eg banned from swimming.

    The added problem was when biomechanical asessments were undertaken and
    "potential" pathomechanics was identified. Easy to procastinate about future pathomechanical problems and if you believe it unethical to leave it untreated, but without parent permission or funding, what to do? There would certainly be a duty of care to inform the parents as to the likely outcome of care or no care. The funding for most screenings do not run to this.

    Gordon Watt published some of his findings on inner city school foot screening and the results are frightening. A significant number of the children present with either no shoes or innapropriate foot wear and there was a significant number of the population carrying blood borne virus infection. The kids come from a low socio-economical group who could scarcely afford food or clothes let alone podiatry treatment and a foot orthoses bill. His study was conducted nearly twenty years ago so you can imagine what things are like in today's recession?

    Routine school foot screenings in the UK were stopped and apart from a few keen individuals are few and far between.

    toeslayer
     
  11. Bug

    Bug Well-Known Member

    Thanks for Toeslayer. A very long time as a new graduate you gave me similar advice about school screenings via a list server. As a keen new graduate, looking to generate private practice referral's I was all gunge ho about it and quick taken back with how some of the leaders in podiatry viewed screenings. It took a few years to step back and bit more learning, to realise and agree with how ineffectual it was. My time was much better spent in the network meetings with the kindergarten teachers, the education forum of the school teachers or the maternal and child health nurses to see what an impact 1-2 hours of chatting about what a they may see, would make. It was only then that we started to see a dramatic increase in relevant referrals. These are often the people that observe far more than just the 10 minute walk across the room. 


    We do however work closely with 2 schools in our LGA's. They are the one's identified with children most at risk. In one we actually have a treatment area that if the child is referred, the parent sign's and we see them during class time. We would never see them otherwise as the parent would never bring them to our service. We also run groups with the OT, Speech, Physio etc. The other school has an issue with shoes. The other pod that works with kids goes in and screens for footwear. It has a very high refugee population and she has generally found most shoes to be 2-3 sizes too large. Parents are wanting more bang for their buck and planning a tad too far in advance. Both I think are relevant use of pod time in screening, however I think the days of watching a kid walking and wiggling their legs in 5 sec in their class rooms should be pushed to the dark ages. My advise would be to train up the refers or focus on the major issue they are presenting.
     
  12. aliciaj

    aliciaj Member

    Hi Guys,

    I am lucky enough to function in a couple of multidiscpliary clinics, one of which is within a high refugee population the other in the middle of a big growth area. I have had the oportunity to work along side speech, physio, OT and child Psychology. I have to admit my global developmental skills, speech development, sensory/OT skills are always on the improvement. How much as practitioners can we learn from our collegues and how much can we teach them?

    The use of validated tools (eg Carolina Curriculum) expands our skill set while ensuring that the child is truely assessed (not just the foot, their is an entire child there). A referral letter to a paediatrician via a GP might be greatly appreciated with a validated assessment to co-operate our findings.

    I often see students looking at me crazy as I sit on the floor and sing about an elephant as I test a childs hips. By singing the song I get to assess their hips, the GMS and their language (articulation and comprehension). Early observation in a podiatry clinic may lead to a referral that may not have presented till kindergarten!!

    Podiatry has a role in early intervention we just need to prove it!!

    Alicia
     
  13. Sally Smillie

    Sally Smillie Active Member

    It took a few years to step back and bit more learning, to realise and agree with how ineffectual it was. My time was much better spent in the network meetings with the kindergarten teachers, the education forum of the school teachers or the maternal and child health nurses to see what an impact 1-2 hours of chatting about what a they may see, would make. It was only then that we started to see a dramatic increase in relevant referrals.

    ABSOLUTELY!!! I couldn't agree more. I just wouldn't bother with screening (and not just that I simply don't have the time). I have found that bang-for-buck you are so much better off investing some time in your referral base. Once or twice a year I give a talk to the GP's - they have a weekly session for CPD training. It is a great chance to catch them all at once (about 200). I do the same for the Health Visitors and school nurses. It takes me a few hours a year, generates much better quality referrals and reduces the silly ones (can you tell I work in public?) - and we promote the profession. I also always get the GP's-in-training on the roster to sit in on my clinics when they have to do their paeds stuff. That way I can indoctrinate them while they're young ans impressionable. It raises the profile of the profession and is a good investment.

    It also sounds better if a doctor or other health professional recommends you, rather than youself ;0)
     
  14. Sally Smillie

    Sally Smillie Active Member

    Can you teach me your elephant song? 'Wheels-on-the-bus' is getting monotonous. I hear 'Wind the bobbin up" in my sleep. What's worse is I can't stand it!

    On a serious note, I can't agree more. I work F/T as a pod in an MD paediatric team (child development centre), I share an office with 45 colleagues from different professions who treat the same children as me - OT, physio (neuro and MSK), speechies, and dietetics - and we all work together. I have learned unbelievable amounts from them, but they also me and I'm always developing further. Part of my job has become training the physio's in lower limb mechanics and foot and ankle in our joint clinic. This is superb for tricky hip and spinal assessments. I do a Podiatry 101 course for them too as new staff when they start at our centre.

    We are truly MD due to a shared office and also joint training. All our staff do training together and each profession trains each other. I sit opposite a dietician and between an OT and Physio. The best stuff comes out of this, we refer across to all the professionals we need to because we discuss them in the office. We keep in touch and follow up all our patients the same way. It isn't expensive as others have described, because I only do 4 hours joint clinic a week but because of the setting in which we work and train, every thought of every day for every patient is MD. We do our MD part in the office, not necessarily always in the clinic, although we do that too as needed.

    Some people will have plenty to say on this, but I have been trained to do hand and writing assessements ala OT, by OT's, and I can presribe exercises to help. I work with the OT's and discuss it with them, so I am under guidance as required. You will find that a huge number of the hypermobile kids you see that are suffering lower limb complications at age 4-6, once they're up around 8 they will really suffer with their hands. Just ask them in your history how they cope with handwriting... you will be shocked. The earlier the intervention, the better the child copes later at school. The tasks required of them in handwriting develop much faster than they can catch up and they fall further and further behind. We can help that. If you aren't trained, refer them on. But ask the questions. You can make a huge difference while they are young.

    After working side by side with physios for so long, I can now do a pretty mean spinal assessment. I don't treat it and wont advise on it, but will always pick up a problem and can get them into physio within weeks of me spotting it. Often in our joint clinic. Likewise, some of our physio's and OT's can do a pretty mean lower limb assessment - enough to know when to chat to me about it and refer on.

    Other pod skills have become utlised as people realise what a pod can do: I now go into the special schools with the neuro team. They find it really useful. Children with neuro-disability quite often have severely deformed feet, have stiff toes with significant catchement areas for toe jam and have a higher risk of pressure sores. They often have poor peripheral vascular supply, so all my old wound care and tissue healing skills are dusted off and used well. I also get loads of dermatology thingies too.

    We tend to take these skills of ours and take them for granted, not thinking they're anything special. But they are. Others don't know this stuff as well as us and we need to get our feet in the door. A lot of people just think pods do nails - I haven't touched a nail in 3 years. I began here doing 1 day a week, my boss soon began to say things like "oh, I didn't realise Pods did that" and within 6/12 of starting was full-time, now I need another pod to help with the load.

    We have much more to offer than many of us think. As for MD, I just couldn't do my job outside of the other disciplines. When I was doing adults, I think you can operate independantly, but much much less effectively in paeds. True MD working does mean boudary blurring, but we should feel enhanced, not threatened by this. I certainly do.

    Cheers,
    Sally

    Favourite quote from patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"
     
  15. Bug

    Bug Well-Known Member

    Sally, you've been away for too long and forgotten your playschool/Pasty Biscoe roots.

    Hey-de, hey-de ho, the big grey elephant is so slow,
    Hey-de, hey-de ho, the elephant is so slow.....

    He swings his trunk from side to side
    As he takes the children, for a ride
    Hey-de, hey-de ho, the elephant is so slow.



    It's perfect for swaying side to side on ball/roll, checking out postural stability, righting reactions, stretching hams, stretching adds, swaying a leg back and forth and generally being an elephant.

    I must say Alicia does sing it very nicely too :D

    You want songs, we'll give you songs!! As much as I am not a Wiggle fan, this is getting a bit of air play around the clinics - http://www.youtube.com/watch?v=7sDWSSeteYk
     
  16. Sally Smillie

    Sally Smillie Active Member

    Too true, it has been far too long! I think I have all my old Patsy Bicoe records at Mums in box collecting dust :0) I'll have to learn some Wiggles I think.

    Oh my gosh, I can rant when I want to! - apologies to anyone who managed to stay awake thru my last post. Take home message - What is the role of Pod in MD: essential. Earlyl intervetnion: ditto

    Cylie, it sounds like you are doing a lot of what our OT's do here. It is modulation things you are doing (linear vestibular) or for some other purpose?

    Cheers,
    Sally
     
  17. Bug

    Bug Well-Known Member

    Both modulation but sometimes it is about simple functional ROM testing in addition to creative righting reaction testing.

    I'm happy to read your rant any day so go ahead!
     
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