July 2021

Pandemic’s ‘Marathon Journey’ Forces Change

By Sarah Curran, PhD

Forcing Change…

The intensity, uncertainty, and rolling grip of the COVID-19 pandemic has, without doubt, challenged many of us, both professionally and personally. The arrival of innovative vaccines at the end of 2020 and early 2021 has enabled many countries to slowly return to some degree of normality. Like many healthcare services, the delivery of care that includes assessment and management of lower limb conditions was forced to change during the pandemic. For some services, the influence of such changes has altered the delivery of pathways of care and assessment. In the UK, as the pandemic gained momentum from early 2020, services such as assessment and management of the lower limb was significantly reduced as the pandemic tightened its grip globally beginning in March 2020. For example, within the National Health Service (NHS), podiatry triaged all foot and lower limb conditions (vascular, wounds, musculoskeletal, dermatology, etc.) with some services stopping altogether for musculoskeletal conditions. Due to the transferable skillset of podiatrists, many were deployed to support frontline health workers and systems.1 In a recent online survey, Williams et al2 documented the experiences of Australian podiatrists and podiatric surgeons working during the COVID-19 pandemic. Of the 465 respondents, the authors identified the variable impact of the pandemic, such as personal protective equipment availability and related business decisions, drawing out a number of themes from the data. The authors further stated that many podiatrists described a “marathon journey” with many outlining the challenges faced as well as the highlights. However, what is evident not just from this study, but from other literature that links podiatry and other health professions, is the ability for resilience and adaptability throughout a sustainable period.

Digital Technology – Telemedicine and eLearning

The sudden end to most in-person consultations brought on by the pandemic spurred a revitalized interest by a wide range of professionals in different options to continue patient assessment and care. Whichever your preferred phrase, the use of telehealth or telemedicine has become a prominent feature the past 18 months in clinical assessment and management, and the examples notably used in this commentary relate to musculoskeletal lower limb conditions. Although pre-pandemic use of video and phone consultations are evident in the literature, the sudden onset of the pandemic forced health professionals and their patients to engage in variations to delivery of care, all of which have benefits and challenges. For example, embracing online (video) or telephone consultations facilitates easy access to general and specialized care, and provides benefits for patient populations that may be excluded from such care, a feature of which became more prevalent during COVID-19. There are, however, some barriers, to such approaches – in particular those associated with video consultations for musculoskeletal assessment of the lower limb and foot in particular. This can range from the clinician being unable to view the limb – which is perhaps more challenging as you move down the lower limb to the foot and ankle to gain camera angles for the clinicians to view the relevant area of the presenting complaint and condition. This, however, is much more dependent on the patient’s ability to navigate the software and camera angles for a clear and relevant view, along with network connectivity to actually access a computer, smart phone, or tablet to have their consultation.

For many clinicians, remote (video and phone) consultations are a new skill to acquire – a feature rarely covered in undergraduate training — and is clearly something that universities should consider including in their curriculums as we move forward, even when COVID-19 becomes a less prominent feature in our lives. Prior to the pandemic, there were pockets of research and literature published supporting and delivering the use of both video and phone consultations. In a clinical update based on musculoskeletal assessment, Hohenschurz-Schmidt et al3 presented a unified theme based on the need for deliberate and patient-centerd communication. The authors offer a useful step-by-step approach based on practical applications that relate to communication, which includes non-verbal and verbal communication, empathy, remote physical testing (including palpation), reassurance and education, advice on physical activity and exercise, and how a consultation should be ended.

In a recent study, Hasani et al4 employed telehealth for the management of Achilles tendinopathy. Using gym-based exercise interventions (calf load parameters) patients were monitored weekly through videoconference calls. Using a combination of semi-structured interview and focus groups and inductive thematic analysis, the authors showed that this approach was acceptable to patients and physiotherapists. Whilst this is an important contribution to the literature, what is useful are the discussions from the authors that focus on the clinical and theoretical practicalities of enablers and barriers to this approach that can influence practice going forward. At the start of COVID-19, Albornoz-Cabello et al5 also employed the use of telemedicine to implement video consultations of prescribed therapeutic exercises for patients with patellofemoral pain syndrome. Whilst a short follow-up is noted, a greater reduction in pain and disability was observed when compared to those patients who received just information sheets with images. The link and communication with the physiotherapist enhanced engagement for the patient from the comfort of their own surroundings, features that should be viewed as positive and efficient use of time for the clinician and patient.

The aforementioned studies are a snapshot of examples within the present literature of using video and phone consultations for the assessment and management of musculoskeletal conditions. This is encouraging and whilst there may be issues with limitations of palpation, determining skin texture, and determining areas of pain, these can be minimized by issuing patients with pre-recorded video patient instructions and combining these with patient-reported outcomes.6,7 Likewise, the testing of ligaments for patency (such as that with the anterior cruciate ligament, anterior tibiotalar ligament) is limited on video consultation – but ligament and limb stability can be checked using functional testing, which can include hopping, balancing on one leg, and changing direction – each of which are done face-to-face, but can be done under instructions with video and its associated analysis for some patients. The latter of which offers recording and the ability to slow down the maneuvers to determine instability and dysfunction, which the naked eye and brain may miss, forget, and/or misinterpret, compromising reliability and validity.

Recovery and Research Directions

Whilst the pandemic is still very much with us, globally and locally the recovery phase has begun for many countries. Long COVID-19 has been reported by a significant volume of patients in general, and one of which – COVID toes – has been reported by those younger affected individuals. Within the recovery plans are the need to monitor, record, and report any foot and/or lower limb pathologies and dysfunction to build up an evidence base. Whilst this may come predominantly from podiatry, there is a need to integrate a multidisciplinary approach to capture these observations and also support rehabilitation. With what appears to be the tide of change for telemedicine (video and phone) in lower limb conditions (and beyond) – and, in particular, those related to musculoskeletal conditions, there is a need to collect more data to support the evidence of service provision.

The final note relates to the resilience of health professions, be it podiatrists, podiatric surgeons, physiotherapists, and occupational therapists, amongst others, and the suggestions outlined by Williams et al2 in the need for more research on the impact of mental health and burnout within podiatry as well as other professions post-pandemic. Arguably these research directions already had a need pre-pandemic, but the events of the past year have heightened the application to gain further evidence.

Sarah Curran, PhD, is professor of podiatric medicine and rehabilitation at Cardiff Metropolitan University in Cardiff, Wales. She is a long-standing member of the Editorial Advisory Board for Lower Extremity Review.

REFERENCES
  1. Chadwick P, Ambrose L, Barrow R, Fox M. A commentary on podiatry during the Covid-19 pandemic. J Foot Ankle Res. 2020; 13(1):63.
  2. Williams CM, Couch A, Haines T, Menz HB. Experiences of Australian podiatrists working through the 2020 coronavirus (COVID-19) pandemic: an online survey. J Foot Ankle Res. 14(1):11.
  3. Honenschurz-Schmidt D, Scott W, Park C, Christopoulos G, Vogel S, Draper-Rodi J. Remote management of musculoskeletal pain: a pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice. Pain Rep. 2020;5(6):e878.
  4. Hasani F, Malliaras P, Haines T, Munteanu SE, White J, Ridgway J, Nicklen P, Moran A, Jansons P. Telehealth sounds a bit challenging, but it has potential: participant and physiotherapist experiences of gym-based exercise intervention for Achilles tendinopathy monitored via telehealth. BMC Musculoskelet Disord. 2021; 22(1):138.
  5. Albornoz-Cabello M, Barrios-Quinta CJ, Barrios-Quinta AM, Escobio-Prieto I, de los Angeles Cardero-Duran M, Espejo-Antunez L. Effectiveness of tele-prescription of therapeutic physical exercise in patellofemoral pain syndrome during the COVID-19 pandemic. Int J Environ Res Public Health. 2021;18(3):1048.
  6. Richardson BR, Truter P, Russell TG. Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation. J Telemed Telecare. 2017;23(1):88-95.
  7. Russell TG, Blumke R, Richardson B, Truter P. Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother Res Int. 2010;15(3):167-175.

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