Multidisciplinary Team in Managing Clubfoot

Original Editor - Africa Clubfoot Training Team as part of ICRC and GCI Clubfoot Content Development Project

Top Contributors - Naomi O'Reilly, Kim Jackson, Rachael Lowe, Simisola Ajeyalemi, Vidya Acharya, Rucha Gadgil and Meaghan Rieke  

Introduction

Eduardo Salas defines a team as a “distinguishable set of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/objective/mission, who have been each assigned specific roles or functions to perform, and who have a limited life-span of membership.”

Successful management of clubfoot requires a multi-disciplinary approach.  It is generally considered to be best practice for children with clubfoot to be treated by a specialist team, with specific training and in a dedicated clubfoot clinic which allows families to interact and expertise to be built up.  Exactly who is included in the team and in what roles depends on which professionals are available locally and how the health system is set up.

Paediatric orthopaedic consultants, assisted by physiotherapists, nurses, plaster technicians or orthotists, traditionally lead the Ponseti method, applying the weekly casts. In countries with few specialists, the Ponseti method has been taught to, and effectively applied by, trained nonsurgical health-care providers. The same has occurred in high income settings where specialist medical time is often an expensive and scarce resource, or the volume of patients is overwhelming. Combined consultant/physiotherapist-delivered Ponseti service has been shown to be effectively and successfully administered, as have physiotherapy delivered Ponseti service.

Multidisciplinary team approach

The roles that will generally be required for treatment of a child with clubfoot include:

Manipulation and casting

Two trained clinicians are required for the manipulation and casting portion of the treatment:

• One to manipulate the foot, hold it in position and mould the plaster
• One to wrap the plaster onto the foot and leg. 

Tenotomy

An appropriately trained clinician who does the achilles tendon tenotomy.  In most cases this is an orthopaedic surgeon but in countries where there is a shortage of surgeons this is sometimes carried out by general surgeons or orthopaedic clinical officers.

Follow up and foot abduction bracing (FAB)

Regular follow up is required by a clinician able to monitor the child’s progress, identify signs of relapse, encourage the families to adhere with the FAB protocol and to check and fit the FAB.

Orthopaedic surgeons may or may not be involved on a daily basis in the clubfoot clinic but their involvement is crucial in tenotomy, clinical direction and oversight, and providing any surgical input for older children, relapse or other cases where surgery is needed.

Supplementary roles

In some countries, parent advisors, or counsellors are needed in addition to clinical staff to support families throughout their treatment journey. This is particularly important where families need extra support to adhere with the treatment protocol or where clinic staff are very busy.

Clubfoot is identifiable on ultrasound scan ante-natally.  Where this is available, counselling of families about clubfoot and the treatment process is valuable.

On a national level, where these are not already in place, the roles of the MDT may also include:

• FAB fabrication
• Identification of cases and awareness raising
• Orthotics provision
• Supply chain management
• Community support and follow up

Role and responsibilities of the physiotherapist in multidisciplinary team

The exact roles of physiotherapists within the MDT vary from location to location. In some countries, clinical services (manipulation and casting, follow up, foot abduction bracing and parent advice) are led by physiotherapists with clinical oversight and provision of tenotomies by orthopaedic surgeons. 

In other countries the corrective phase of treatment is led and applied primarily by surgeons with support from physiotherapists for FAB and working with families. 

In all locations physiotherapists have a very important role in working with and supporting families throughout treatment. 

Some patients will require a physiotherapy programme of muscle strengthening or stretching alongside or after completing Ponseti treatment. Patients with clubfoot that do undergo surgery benefit from physiotherapy for rehabilitation. Functional physiotherapy method (FPM), also called the French method is based on manipulations of the foot, bandages, splints, and exercises adapted to the motor development of the child aimed to achieve a plantigrade and functional foot. A retrospective review suggests the Saint Vincent de Paul (SVP) method of the FPM more efficient than the Robert Debré (RD) method of the FPM to treat idiopathic clubfoot with no need for a complete release in any case.

As well as the above, physiotherapists’ roles may also include collection and evaluation of clinical data, clinic oversight and management and treatment quality assessment and assurance.  For those patients presenting with other conditions (many of which are not identified at birth), physiotherapists may be the first to notice these and to develop a management plan for them.

Globally, physiotherapists from around the world have played an important role in raising awareness of clubfoot, advocating for children with clubfoot and training other clinicians in clubfoot management.

Roles and responsibilities of other team members

Orthopaedic Surgeon

The orthopaedic surgeon has traditionally led management of the child with clubfoot, including manipulation, casting and tenotomy. More recently the manipulation and casting part of the treatment has been passed to other health care professionals, in particular physiotherapy led services. In this situation the surgeon has a major role in educating and mentoring.

The paediatric orthopaedic surgeon continues to perform tenotomy and any other surgical procedures as appropriate.

Surgeons also remain available for consultation and review at any time at the discretion of the physiotherapist, or other members of the health care team.

Prosthetists and Orthotists (PO)

In some settings brace fabrication and fitting is the responsibility of the PO service. In addition to this they will provide orthotic s where needed, i.e. post operatively.

Roles and responsibilities of other parents / carers

Families of children with clubfoot play a very large, and essential role in their treatment.  Once the position of the foot is corrected and foot abduction bracing is started it is the parents that must apply braces every night until they are 4-5 years old. They must also attend multiple and frequent clinic visits.

Read more about the parent / carer role