Analysis of a model for pediatric physical therapy and clinical education via telehealth

2.1 Model description

As part of an entry-level pediatric PT course, groups of three to four students conducted an in-person examination of a child with their family under the supervision of a licensed physical therapist (called a clinical instruction [CI]). This in-person learning experience was intended to continue with intervention on a weekly basis but was discontinued after the examination due to the COVID–19 pandemic. In response, the learning experience transitioned to telehealth. The CIs, students and the legal guardians of the children provided written informed consent for participation in the sessions, video recording of all sessions (in person and via Zoom), and dissemination of findings.

Over a period of four weeks, these groups of three to four students completed four to five 60-minute telehealth pediatric PT sessions. The telehealth sessions with the children were provided in their homes with caregivers and siblings present (as this occurred during the COVID-19 pandemic). All sessions were carried out and recorded using password-protected Zoom video conferencing (Zoom Video Communications, San Jose, CA). All Zoom video recordings were stored in password-protected folders on the researchers’ computers and adherence to the HIPAA compliance checklist for videoconferencing was ensured [42]. In addition, all sessions were supervised by a CI who was a licensed physical therapist with prior experience treating pediatric populations. Students submitted documentation which included the history and examination, PT goals, and progress notes as a part of the CLE.

2.2 Participants: Students, CIs, and families

Twelve CIs, including four DPT faculty members, and 54 second-year entry-level DPT students participated in the experience. Twelve children with disabilities and their families were recruited from local pediatric physical therapists to participate. There were nine boys and three girls ranging in age from 22 months to 19 years with a variety of diagnoses and functional levels. The data from one child/family could not be analyzed because the video recordings were not saved and therefore not available to the researchers resulting in data analysis of 11 children (eight boys and three girls). The caregivers who participated in the sessions, the level of sibling involvement, and the learning opportunities can be seen in Table 1. Learning opportunities were defined as the resources available for motor learning and development. Literature supports the importance of learning opportunities in childhood development using resources including space, equipment and toys, caregiver/family availability and time [43].

Prior to the telehealth experience, the students and CIs reviewed and discussed guidelines for telehealth practice and key principles for the delivery of PT through telehealth [42, 45]. This preparation included viewing recorded telehealth sessions followed by discussion and role playing. The discussions and role playing were focused on preparation for the visit, management of technology and maintaining a video presence, interpersonal skills including verbal communication, and client privacy and safety. Expected challenges and strategies to overcome these challenges were also discussed prior to the experience. The procedure for the learning experience was modeled after the one previously described [18].

The students conducted a telehealth preparation visit via Zoom with each family to gather additional history and subjective information from the caregivers. Also, they evaluated the home environment and available learning opportunities for each child under the supervision of a CI. After this initial telehealth visit, each student developed a long-term goal for the child based on the in-person examination data, the goals of the child and family, and the child’s home environment. All goals were discussed with the licensed pediatric PT faculty and families, and revised as appropriate. Students also developed and documented a plan of care to address their goal under similar faculty direction and family consultation during the remaining three to four PT sessions. The students met as a group to discuss and plan prior to each session, then emailed the caregivers the overall plan for the visit with a list of activities and materials they might use. This plan included any preparation needed before the visit (e.g., placing a constraint on the child’s left hand 10 minutes before the session to prepare for constraint induced movement therapy during the session) [46]. Each student was responsible for directing a portion of the session while the other students actively observed. During each session, the Zoom chat feature was used by the CIs to direct students on how to enhance, modify, or proceed with the interventions, as well as provide direct feedback on the students’ performance, critical analysis, and active observations. Students used the chat to provide feedback to peers to enhance the intervention, or the flow of the session, and to share their observations with the group. The chat was visible to all participants, including the caregivers, which allowed them to appreciate the feedback and direction the students were receiving from their peers and CI (as they would during an in-person experience). At the outset of the experience, the purpose of the chat was explained to the caregivers who were directed to limit their attention to or close the chat at their discretion to minimize interference to both the family/child and the student/family interaction. Upon completion of each session, the family left the Zoom video conference, and the students and supervising CI remained on the Zoom call to discuss their reflections from the session. Students documented a progress note for each session. The learning experience did not include a discharge assessment as the focus of the experience was on the provision of therapeutic interventions. In addition, while recommendations have been published on performing assessments via telehealth in the pediatric population since the time of the CLE [7, 47], there is very limited evidence about the use of motor assessments via telehealth in adults with neurologic conditions [48, 49] and only one study was identified specifically in the pediatric population [50].

2.4 Provision of PT services

Three to four PT goals were set for each child leading to therapeutic focuses (Table 2). Goals focused on dynamic and static balance in various positions or activities, quantitative (e.g., percentage of reaches with the more involved extremity) and qualitative (e.g., use of a more precise vs. crude grasp) use of the upper extremity, gait quality, coordination, achievement and maintenance of various developmental positions, and aerobic fitness.

A variety of interventions were performed to target the goals designated for each child based on their functional level (Table 2). The low-functioning group was defined as being unable to stand without external support, the middle-functioning group as being able to stand and walk without upper extremity support, and the high-functioning group as being able to run and jump. For example, with goals related to balance training, children who were lower functioning performed interventions such as stepping over obstacles, standing still without upper extremity support, and reaching outside their base of support. Those categorized as middle functioning performed interventions such as clearing higher obstacles, maintaining balance in a single limb stance position, and ambulating without losing balance while holding an item with their upper extremities. Children categorized as higher functioning completed balance interventions such as ambulating over compliant surfaces, navigating obstacles of varying heights, maintaining single limb stance, and catching a ball without losing balance.

Each of the 11 children had different learning opportunities. Some had limited learning opportunities including one who lived in a group home, while others had extensive ones available to them. For those who had more resources available, there was a greater opportunity for incorporation of those resources into the treatment plan with the use of a variety of toys and other items. For example, one child had a trampoline which was used in treatment. Those with limited resources required greater creativity from the students and families for intervention implementation. In every case, various items were used in place of traditional PT clinical tools such as using couch cushions as a compliant surface or a tissue box as an obstacle to step over. The children’s siblings assisted in therapy in several ways including holding the camera, helping to stabilize the child being treated, helping to pass an item back and forth, retrieving items needed for the session, and demonstrating the activity to the child (e.g., follow the leader). In one case, an older adult sibling, with help from additional siblings, directed the session when their mother was not available for that session.

All researchers performed an initial review of the videotaped recordings and the student documentation. Given the challenges with measurement via telehealth [18, 51] and that the researchers were reviewing videotaped recordings and the student progress notes, the researchers were unable to perform direct objective outcome measures to evaluate the child’s progress and therefore established target behaviors. After the initial review of documentation and video recordings, the researchers held several consensus meetings to establish the target behaviors and their operational definitions based on the goals set for each child and the observed focuses of the therapy (Table 2). Target behaviors were developed to assess quantitative outcomes based on the therapeutic focuses for each child. Each recorded session was then analyzed independently by two researchers (CM, MT, CD, or AH) to assess the target behaviors as well as subjective and qualitative outcomes. These researchers did not participate in the CLE. Consensus meetings were held to resolve any discrepancies between reviewers.

Upon completion of the retrospective analyses of the video recordings and documentation of the experience, the researchers sought to examine the participants’ perspectives on the feasibility and acceptability of both the PT and CLE. To do this, questionnaires were developed and distributed to the caregivers, CIs, and students who participated in the experience. The questionnaires were adapted from published ones examining the feasibility and acceptability of similar models [52, 53]. Additionally, to assess the perspectives regarding the CLE, questions were developed regarding how the experience addressed relevant items evaluated on the Clinical Performance Instrument (CPI), which is a validated measure utilized to evaluate PT student performance in their full-time CLEs [54]. The questionnaires were piloted to two experts in survey development and their feedback was incorporated prior to distribution. The questionnaires were distributed electronically 18 months after the experience and data were analyzed using Qualtrics Software (Qualtrics XM, Provo, UT).

3.1 Outcomes: General observations

Over time, several observations were made in relation to the pediatric PT telehealth experience. At the beginning of the sessions, caregivers seemed nervous and provided limited assistance outside of what was asked by the students. As the sessions continued, some caregivers reported they had initiated novel activities outside of the scheduled telehealth sessions related to the therapeutic focuses they were working on within the sessions. An example included a caregiver continuing the fine motor activity throughout the week using small crackers and a small container during snack time to encourage carryover and progression of the activity. It was also noted that caregivers asked more questions and provided more input on new therapeutic ideas in order to better assist their child during the therapy sessions in the home as the sessions progressed. Inclusion of siblings in sessions also increased over time. This appeared to increase the engagement of the child in the session and decrease caregiver stress associated with caring for multiple children while participating in the therapy session. Over time, siblings assumed different roles within therapy sessions including performing the interventions, encouraging their sibling to actively participate in therapy, motivating their sibling, and helping the caregiver manage the computer or other device used for video communication. This allowed the caregiver to increase focus on the intervention, therapist instruction, and feedback.

Some technological issues were encountered during the sessions which limited carrying out interventions and assessment of results. These issues were experienced with six of the 11 children. The primary issue was a weak or disrupted internet connection, which often occurred when there was a change of location of treatment within the home, moving room to room, or when the session was relocated outside. The most common issues included a freezing or delayed screen, poor quality audio, or a decrease in the video quality. When these issues occurred, observations became obscured and it was difficult to visualize what was occurring at that point in the session for the students and CIs carrying out the interventions, as well as for the researchers’ video analyses. Of the six children with technological issues, one child had issues during every session while the others had issues occur in approximately 50% of the sessions. Poor internet connectivity occurred primarily with those families using phones rather than computers and those in more remote areas with limited broadband service availability. It also occurred frequently with those who changed location during the sessions for interventions that required a different room or being outside the home. Additionally, in some cases, the camera angle was not optimal for viewing certain tasks. This occurred with approximately 25% of the tasks analyzed. This was more likely to occur when there was only one parent or caregiver present, due to the difficulty of adjusting the camera angle while implementing the treatment and maintaining the safety of the child. These suboptimal camera angles also occurred more frequently in the higher-functioning children because the camera had to be moved throughout the sessions since the child was more mobile.

3.2 Outcomes: Response to PT

Based on video analyses, all 11 children made qualitative and quantitative improvements in at least one target behavior (Table 2). Quantitative improvements were noted in 62.5% of the target behaviors of the children in the low-functioning group and in 64.3% and 50% of the children in the middle- and high-functioning groups, respectively. Children who made progress in more target behaviors were more likely to have more family members present during the sessions while those who made less improvement were more likely to have only one caregiver participating, substantial distractions within the environment, limited time between sessions, and limited access to resources. For example, the four children who had only one person present during the sessions made progress in five of the 12 (41.7%) target behaviors while the seven children with more than one person present (including siblings) made progress in 14 of the 21 target behaviors (66.7%).

Categorically, improvements were noted most in target behaviors related to static balance, dynamic balance, and stair navigation. All of the children with static balance as a target behavior showed improvement in this area, while 57% of the children with dynamic balance as a target behavior improved. While only 33% of children improved quantitatively in stair navigation, all of the children demonstrated qualitative improvements in stair climbing. Qualitative observations for improved stair navigation included decreased verbal cues needed, increased initiation of a reciprocal pattern, and an increase in the quality of trunk movement. Sixty-seven percent of the target behaviors related to grasp and upper extremity use and 71% of the target behaviors involving developmental and transitional positions showed improvements. Qualitative improvements were seen in transitional positions as noted through observations of progression to compliant surfaces, decreased level of support required, and use of more challenging equipment to complete tasks.

3.3 Outcomes: Perspectives of experience

Ten of the 12 (83%) CIs, seven of the 12 (58%) caregivers, and 21 of the 54 (38%) students responded to the survey. Seventy-six percent of student respondents were female and the mean (standard deviation [SD]) age was 26.3 (1.4) years. The amount of prior experience with children (in any capacity) in student respondents varied from no experience (5%) to more than five years (29%). CI respondent demographics are presented in Table 3. Seventy percent of CI respondents and 90.5% of student respondents had little to no experience with telehealth prior to this experience. Following this experience, the average level of student interest based on a 100-point scale, ranging from no interest to complete interest, increased in both pediatrics (45.2 to 52.9) and telehealth (40.3 to 64.1).

All CIs, students, and caregivers believed that the children and caregivers were able to work towards their PT goals during the experience. All Cis and caregivers, as well as 95% of students, believed the children benefited from the experience. In addition, all CIs believed that the students were able to build a connection with the caregivers, and 95% of students said the same. Seventy-one percent of caregivers believed they were able to build a connection with the students but only 54% of the caregivers believed the students were able to build a connection to the child. Eighty-six percent of caregivers believed they were able to effectively implement the interventions as instructed via telehealth and the remaining 14% were neutral on their ability. Ninety percent of the CIs and 86% of caregivers believed they could understand the clinical reasoning behind the PT interventions delivered via telehealth while the remaining respondents were neutral on their ability to understand the reasoning. All of the caregivers reported that they continued to implement some (80%) or all (20%) of the recommendations provided during the experience with most caregivers reporting that the reason for stopping implementation was shifting of goals and child progress (Fig. 1).

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Fig. 1

Perspectives of the students (A), CIs (B), and caregivers (C) on the telehealth PT and learning experience from questionnaires. The percentage of students (A), CIs (B), and caregivers (C) who agreed/ disagreed with statements regarding the ability to benefit from the experience in regards to physical therapy intervention and student learning.

All CIs and all students believed that it was a valuable student CLE. All CIs and 95% of students believed the CIs were able to effectively instruct, provide feedback, and promote student autonomy via telehealth. Ninety percent of CIs and 86% of students also believed that CIs were able to promote student confidence through the learning experience. All CIs and 86% of families felt that the students were able to learn clinical skills through the experience while the remaining 14% of families were neutral (Fig. 1A–C).

For 13 of the 15 relevant CPI domains, 90% or more of CIs believed the students were able to effectively learn. Eighty percent of CIs believed the students were able to effectively learn in the remaining domains (cultural competence and outcomes assessment). For 10 of the 15 relevant CPI domains, 90% or more of the students believed they were able to effectively learn. For the remaining domains, 86% believed they effectively learned in screening, 81% in examination, evaluation, and outcomes assessment while 71% believed they effectively learned in diagnosis and prognosis (Fig. 2).

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Fig. 2

Perspectives of the students (A) and CIs (B) on the student ability to learn clinical skills in the 15 relevant CPI domains. The percentage of students (A) or CIs (E) who agreed/ disagreed with the statement “I feel that I was able to effectively learn clinical skills in the area of () through telehealth” is depicted. CPI: Clinical Performance Instrument.

Students, CIs, and caregivers provided qualitative perspectives comparing the in-person delivery of PT and education to the delivery via telehealth (Appendix). The most commonly reported benefit of telehealth delivery by students and CIs was an increase in family engagement in therapy because of the “forced” nature of family involvement inherent to telehealth.

Students, CIs, and caregivers commented on the improved access to services with the telehealth delivery for both medically complex patients and patients whose access is limited by distance. The telehealth delivery was believed to be more convenient. One caregiver commented that it was less distracting and overwhelming to the child, particularly with multiple students present. The benefits of treating in the child’s natural environment was noted several times by both CIs and students, including the more meaningful nature of treating in the child’s home with the child’s family and toys.

In the area of student learning, several benefits of telehealth were noted including increased autonomy, learning of communication skills, patient/caregiver education skills, developing creativity, and ability to learn from peers. CIs also noted the benefit of increased discussion with the group for reflection without the family present (i.e., before and after the family joined the session). Finally, it was noted that having experience with telehealth is an important skill for the future.

CIs, students, and caregivers expressed the benefits of in-person therapy over telehealth. Manual contact and assessment were the most common limitations reported for telehealth. The lack of manual contact was thought to limit demonstration, ability to assess accurately, and provision of appropriate sensory cues. Interestingly, one CI noted that the lack of hands-on education might actually improve student skill development in that it forced students to verbalize the knowledge behind the skill. Challenges including visualization, technology, and safety were also noted with telehealth. Inability to visualize appeared to limit the assessment of performance most. Interpersonal connections and the ability to “play” were considered better in-person. This viewpoint was more strongly communicated by caregivers than it was by CIs or students. One perspective that emerged from the caregivers was the benefit of a hybrid model in which the caregiver could learn in person and practice at home with guidance via telehealth. Caregiver comments suggest that familiarity with PT improves the telehealth experience.