Pediatric telerehabilitation medicine: Making your virtual visits efficient,effective and fun

To promote an efficient, productive, and child-centered interaction, there are a few considerations for the environment where the visit is conducted. The child should feel comfortable and safe, and ideally be easily entertained. The caregiver should ensure adequate floor space for the child to demonstrate gross motor skills, including sitting, creeping, walking, running, jumping, and/or skipping as appropriate for age and development. It is helpful to have a flat surface where the child can lie down or sit for examination of range of motion, strength, and postural reactions. Ideally, two caregivers will be present, one assisting with equipment and exam elements as well as audio and video operation, while the other caregiver focuses on the child and provider. It is helpful to reduce potentially distracting background noises and activities from sources such as other family members, pets and television. On the other hand, just as in the office, plan for the unexpected, such as a child’s meltdown or a chaotic environment. Always remember to thank the family for inviting you into their home.

Prepare families prior to the visit to have all equipment that needs to be evaluated during the visit on hand, such as DME. For the provider, seeing patients use their equipment in their home environment allows for assessment of fit as well as a greater understanding of current level of function along with potential barriers in that setting.

Prepare families to have other items readily available to help the child demonstrate age-appropriate gross and fine motor skills. For example, have them gather shoes and socks so the child can demonstrate donning and doffing of footwear or a beverage and snack if feeding or swallowing are concerns. For an assessment of fine motor skills, favorite toys in different sizes with features that can be pushed, pulled, opened, pieced together or otherwise physically manipulated can aid in the assessment. Clothing with buttons or zippers, books for turning pages, and paper and crayons or writing utensils can serve a similar purpose. For older children, a rubber spatula may facilitate testing reflexes. For adolescents, if there are certain activities that are a challenge, such as independence with putting their hair in a ponytail, having a hair brush and ponytail holder available to demonstrate the challenges is helpful. Some of these activities may also require the virtual visit to move to a different room of the house in order to be able to perform the activity.

Finally, it is important to prepare the child for the virtual visit. In order to transition quickly to the physical exam when the time comes, dressing infants and toddlers in easily removable clothing and older children and teenagers in shorts and a t-shirt or tank top prior to the start of the visit is recommended. In addition, suggesting that young children are rested, fed, and freshly diapered in advance of the visit helps to create a more enjoyable overall experience for the child. Preparation of the child goes beyond their physical needs. As much as possible, the caregiver should verbally prepare the child for what to expect with a live video interaction. As many children have participated in video visits with family members through various online technology platforms, most will have some familiarity with interacting with an individual using technology. If the child has a favorite toy, they should be encouraged to bring this to their virtual appointment for a “show and tell” with the provider. Ideally, this builds the child’s excitement and their eagerness to demonstrate what they can do during the visit.

2.2 For the provider

The provider should take care to create a professional and inviting virtual space. This includes dressing in professional attire and maintaining a well-groomed appearance with a visible clinic name badge as one would in an in person clinic visit. The provider’s workspace should be clean, professional, quiet and well lit. Consider having a few toys on hand to share and discuss with the child. If available within your virtual platform and appropriate, an interesting virtual background, such as one including animals or nature, can help to capture the child’s attention. The ability to share a screen is a helpful option for reviewing imaging studies and test results with the patient and caregiver.

Despite the differences from an in person encounter, fostering a therapeutic provider-patient relationship remains vital. To that end, begin the encounter with a warm greeting to both the patient and the caregiver. Identify yourself, your institution, and your medical specialty, and then confirm the identity of the patient and anyone else who may be in the room with them. If not done by support staff prior to your visit, obtain a phone number to be used as a call back number if you get disconnected. Confirm the location address of the patient in the unlikely event that the child or care provider experiences a medical emergency during your visit for which emergency services needs to be notified. As a matter of informed consent, briefly discuss the uniqueness of the telerehabilitation medicine encounter, including the limitations of the physical exam when not performed in person. Patients and caregivers may have some fears or reservations about the quality of care given the limitations of a virtual visit. Take a moment to orient them to how the visit will proceed and reassure them of the benefits of the virtual visit. As with an in person visit, begin observing the child as soon as the visit begins, noting the child’s candid behaviors, which can be clues to developmental milestones and level of function.

During the encounter, be creative and engage the child as much as possible. While older patients may appreciate their provider’s head steadily centered on screen, young children might enjoy a game of on screen peek-a-boo. There is some evidence that at about 16 months of age children are able to engage more interactively with the video screen [21]. Remember to smile, speak at a normal volume and tone as you would in the in person setting, and talk to the child as well as their caregivers. Looking directly at the camera, the virtual equivalent of making eye contact with the patient, is even more important when interacting with the child. Narrate any actions you take off camera, such as looking up records on another screen or writing notes, as this could be interpreted as being distracted. Non-verbal cues remain a significant part of communication, even remotely. When children have difficulty cooperating during the visit, remain calm, empathize with the caregiver, and improvise your information gathering and exam while prioritizing the child’s best interests. Flexibility is key.