The goal of any health care system is to help people live healthy and productive lives.1 To accomplish this goal, we implement preventative strategies to reduce the occurrence of disease and strive to provide timely medical treatment when needed. In Canada, spending on health care has increased to 11.7% of the gross domestic product.2 Despite increased health care spending, waitlists for service continue to expand. This trend is especially evident in pediatric health care where referrals for torticollis and plagiocephaly have continued to rise.3
Torticollis is the ipsilateral head tilt and contralateral head rotation, caused by shortening and/or weakness of the sternocleidomastoid muscle,4 whereas plagiocephaly of positional origin is characterized as a flattening of the parietal-occipital area, anterior shift of the ipsilateral ear, as well as bossing of the ipsilateral forehead, usually caused by prolonged periods in 1 position.5 As suggested in the literature,6 the increase in referrals is partly attributable to the “Back to Sleep” campaigns in the United States7 and Canada,8 implemented to combat sudden infant death syndrome, as well as improvements in physician identification of these conditions.9
Increased referrals have resulted in longer waitlists for infants diagnosed with torticollis and plagiocephaly, raising concerns about clinical outcomes for patients who do not receive timely treatment.3 To address this issue, therapists at our hospital evaluated their standard, one-to-one assessment and treatment format and developed a new model to increase service delivery efficiency, incorporating the same practices but delivered in a team format. The primary focus of the program was to deliver assessment and treatment in a group setting to serve a greater number of these infants, while maintaining quality of service and outcomes, without increasing cost.
Before implementation of this program, using the hospital standard of one-to-one assessment and treatment of infants, approximately 10 infants per month met intake criteria and began treatment. On average, each child required 4.2 visits and 2.6 hours of therapist time to meet discharge criteria. One physiotherapist intervened with a single family at each visit during which the conditions were explained, the child was assessed, and caregivers were provided with a treatment plan consisting of proper positioning, stretching as needed, carrying, and strengthening techniques. This first appointment usually took 1 hour. Following the initial assessment, a ½ hour follow-up was scheduled for between 2 and 4 weeks later, dependent upon severity of the findings, and during which the therapist reassessed the child and reviewed the treatment protocol with caregivers. Families attended reassessment appointments until the child achieved all discharge criteria.
This study evaluated the effectiveness of group format service delivery through examining clinical outcomes of participating infants, caregiver satisfaction as reported through survey, and the efficiency and feasibility of operating the service under this model. Therapists were also interested in identifying ways to further improve the program. This study received institutional research board ethics approval. Informed consent was obtained from participating caregivers at the beginning of each initial assessment.
The caregivers of 35 infants aged between 0 and 9 months at the time of referral (median age = 24 weeks, range = 4-40 weeks, corrected age; male = 21 [60%]) who met the study criteria were invited to join this study. Participation was voluntary. To meet inclusion criteria, infants must have had a physician referral and torticollis of positional or congenital origin and no other associated conditions. Exclusion criteria from this program include paroxysmal torticollis, underlying bony malformation, suspicious tone or diagnosed neurological condition, older than 9 months, and concurrent treatment by other practitioners such as chiropractors, osteopaths, or craniosacral therapists. Discharge criteria were the same for both group and individual therapy delivery models: neutral head position, full passive range of motion with normal quality, equal head righting bilaterally, ability to follow a toy equally right and left into rotation, and independent sitting.
Each group consisted of approximately 6 infants and caregivers, on the basis of therapists’ estimate of program capacity at the time. In keeping with good clinical practice, physiotherapists maintained health and safety of children in their care, with attention to proper hand sanitizing procedures, toy cleaning, linen change, etc.
Each intake session lasted 90 minutes and was conducted by a team of 2 physiotherapists and a rehabilitation assistant. While one physiotherapist observed, the other gave a 20-minute presentation to the caregivers on incidence, etiology, pathology, and treatment approaches for torticollis and plagiocephaly. This was followed by comprehensive individual assessments conducted concurrently by the physiotherapists. While 1 therapist made individual assessments for each child of head shape, active range of motion (AROM), and strength by using toys to elicit desired movements, the other individually assessed each child for hip dysplasia, passive range of motion (PROM), and conducted a brief visual evaluation of gross motor skills. As therapists assessed each child, they explained findings to the caregivers. By the end of each assessment, caregivers knew whether they were caring for a child with right or left torticollis and whether their child showed weakness, tightness, or plagiocephaly; and they were made aware of any gross motor or hip concerns.
Upon completion of assessments, each caregiver was tutored on specifics of assisting their child. One therapist reviewed each possible problem and then demonstrated the appropriate treatment method on a doll, while the second therapist circulated through room and corrected caregiver technique as they applied these strategies with their infants. A discussion of the importance of tummy time and proper positioning, stretching, carrying, and strengthening strategies also took place at this time.
Therapists encouraged caregivers to interact with each other, as well as their child, and to notice how each infant was responding to treatment. For example, the therapists might say, “Look at Sophie. She is avoiding the position. Let's see if we can help her mom straighten her out,” as a coaching cue from which the wider group could learn and benefit. Caregivers were able to practice specific treatment strategies with their own child, review their home programs developed from assessment findings, and ask additional questions.
During both initial and follow-up treatment appointments, a series of 4 photographs were taken by the second therapist and the assistant, documenting resting head position, right side head righting, left side head righting, and a skyline view of the child's head. At the end of the assessment class, caregivers were scheduled for a reassessment class. These follow-up appointments used the same protocol as the initial assessment class and were limited to groups of 4 children and their caregivers so that all checkups could be managed effectively within the 30-minute appointment window. Reassessment was scheduled between 2 and 8 weeks from the initial visit, depending on each child's needs. Caregivers were also provided with contact information for both physiotherapists and encouraged to connect with them if they had any issues or concerns; however, this did not occur at any point during the study treatment period. Please refer to the Figure for the clinical management flow diagram.
The physiotherapists who conducted the initial assessment classes also conducted the reassessment class, maintaining the same role each had in the assessment class. The photography protocol was repeated at the beginning of each class and printed so that therapists and caregivers were able to visually compare progress made since the previous appointment. Caregivers reviewed their home programs and were encouraged to ask any emerging questions. As necessary, caregivers and children were scheduled into a subsequent reassessment class. Caregivers continued to attend classes until their infants achieved the discharge criteria.
Clinical Measures. Left and right side flexion and rotation were noted in each infant's resting position. There are no reference values to be found in the literature relating to cervical ROM in babies.10 Both AROM and PROM were assessed by units of degree, in conjunction with full, one-fourth, one-half, or three-fourth qualitative assessment comments. Hence, within this study, “full” was described as equal bilateral movement with the same end feel. In this context, 90° to 100° of rotation was defined as full motion and side flexion of 75° was defined as full motion.10 Pre- and postprogram chart data on AROM, PROM, resting position, and severity assessment for plagiocephaly were collected for all participating infants.
The “Severity Assessment for Plagiocephaly”11 scale was used to score infants from 0 (no change) to 3 (severe changes) on the basis of the severity of symptoms for 5 factors: posterior flattening, anterior ear shift, anterior forehead bossing, neck tilt, and facial asymmetry, for a possible total score of 15.
Parent Satisfaction Questionnaire. The Client Satisfaction Questionnaire–8 (CSQ-8), scored on a scale from 1 to 4,12 is an 8-item version of the CSQ-18, a 1-dimensional 18-item instrument to assess global patient satisfaction.13 The shorter version has the same construct validity and internal consistency reliability as the longer version,12 with a Cronbach α of 0.93 and a possible score range from 8 to 32. To assess the overall level of satisfaction with treatment received, a mean satisfaction score was computed for each individual. At discharge, patient satisfaction was measured by using a modified version of the CSQ-8,12 which included an additional section to capture open-ended comments.
Knowledge Questionnaire. To assess change in knowledge acquired by caregivers through the program, an internally developed questionnaire consisting of 4 multiple-choice items was administered before assessment while the caregivers waited for the classes to begin, and before the first reassessment class. The items and responses to the questionnaire are documented in Table 1.
Feasibility. Two aspects were considered to determine whether the group format delivered service advantages: did it increase capacity to treat children on the waiting list to the same standard as the individual format, and was it cost-effective.
Evaluation of the volume of patients treated consisted of a straight census of enrolment numbers before, during, and after the study, averaged to obtain a monthly rate for the 3 sampling points.
The average number of therapy hours required to successfully treat a child with torticollis and/or plagiocephaly in individual therapy was compared with the number of therapy hours required to successfully treat a child with torticollis and/or plagiocephaly in group therapy. The average number of hours required per child was calculated by computing the average number of visits per child multiplied by the number of minutes per session, divided by the number of children in each session. To determine the cost of treating each child, we multiplied the average number of hours per child by the required number of therapists and the average wage for physiotherapists in this region. The average number of visits was determined by referring to the service charts.
Data analyses were performed using SPSS version 18.014 to examine results from the multiple-choice knowledge questionnaires, modified CSQ-8, and chart review data. McNemar tests or paired t tests (where appropriate) were used to determine significant changes in knowledge at the item level, as well as differences in the severity assessments for plagiocephaly pre- and postsession. An α level of .05 was established for testing significance. Descriptive statistics were used to summarize AROM, PROM, and the resting position of infants, as well as caregiver responses to the modified CSQ-8. The average total CSQ-8 scores, ranging from 4 to 32, were calculated, with higher scores representing greater levels of satisfaction. Qualitative data from the open-ended questions were reviewed to identify themes.
Table 1 summarizes the pre- and postsession measures of parent knowledge about torticollis and plagiocephaly, which show significant improvement in knowledge of the condition and how to recognize it.
Table 2 illustrates the pre- and postsession AROM and PROM results for participating infants. The data show that all infants achieved full active and passive rotation, as well as full passive side flexion postsession. Although all children did not reach full right or left head righting immediately, those unable to meet this discharge criterion did achieve a neutral resting position within the study period.
Table 3 summarizes results for plagiocephaly treatment. Overall, data show that this condition improved significantly over the course of treatment for measures of occipital flattening and frontal bossing, and however, remained nonsignificant for anterior ear shift. Facial asymmetry also showed improvement between initial and final sessions.
Response Rate. Pre- and postsession clinical outcome data were obtained on all 35 participating families. One questionnaire was provided to each family. Twenty-five caregivers (71%) returned the pre- and postsession knowledge questionnaires and 12 (34%) completed the modified CSQ-8. Twelve caregivers, 1 per family, completed 8 questions measuring parent satisfaction with the group therapy program. As presented in Table 4, generally caregivers reported high levels of satisfaction with the group therapy program. Two questions, “Were you satisfied with the help you received?” and “Would you come back?” received lower ratings, so results were compared with both those of the rehabilitation service and outpatient physiotherapy department statistics to see whether this represented a service satisfaction anomaly. Where questions were comparable, our respondents endorsed statements reflecting satisfaction with the group program at rates that met or exceeded those of the larger service area. All caregivers (100%) indicated that they were very satisfied, and all endorsed responses indicating that they thought the quality of the program was excellent. Three caregivers provided comments, 2 expressed gratitude and satisfaction with the program, and the third suggested provision of more handouts for caregivers to take home.
Efficiency and Effectiveness
Shortly after implementation of the group delivery strategy, this outpatient clinic was able to increase service intake and treatment for children diagnosed with torticollis and plagiocephaly by 70% while personnel costs and staffing for other activities covered by study personnel in the outpatient service were stable.
Individual therapy clients averaged 4.2 visits before discharge and 2.6 therapist hours, whereas group therapy clients averaged 4.29 visits (nonsignificant difference) before discharge but with an average of 1.82 therapist hours per client, translating into a time savings of 0.78 hours per child. Using an estimation of average wage of a physiotherapist at $36.67/hour (base year 2010), the group program effectively treated children with torticollis and plagiocephaly while saving the hospital $28.60 per child. In the course of the study period, this represented a modest saving of $1001, however, with concomitant increased treatment capacity.
Health care systems must continually adapt to changing demands to provide efficient and effective treatment. In pediatric physical therapy services, therapists have had to adapt to an exponential increase in demand for service due to “Back to Sleep” campaigns, which promote placing children in the supine position for sleep to reduce the incidence of sudden infant death syndrome, as well as to improvements in physician awareness and ability to diagnose torticollis and plagiocephaly. As with any change to service delivery, there have been challenges to implementation of a group therapy model since therapists had to be conscious of time allotted to each family so that caregivers perceived fair treatment. Neglect of this consideration had the potential to influence satisfaction with the program negatively. Change in the traditional practice pattern met with some initial resistance, which is not unusual until evidence is established for an unfamiliar service model; however, group delivery is now well accepted among the referring community.
Results of this evaluation were very positive on all aspects measured. The group format proved to be an effective therapy method for infants since more children were treated in the same time frame and achieved discharge criteria at a similar rate and cost as children treated under the one-to-one service delivery model.
The program now runs both assessment and follow-up sessions weekly, thus implementing early treatment for approximately 20 to 24 children per month. Using the group service model, therapists have been able to continue to provide high-quality care to more children at a lower cost while mitigating the effect of a large increase in referrals due to the “Back to Sleep” campaign and improvements in physician capacity to diagnose torticollis and plagiocephaly.
The group therapy program met the needs of caregivers, as reflected by their expressed satisfaction with the program. They demonstrated significant increases in measures of knowledge about the medical conditions. Some caregiver comments expressed a need for more take-home information such as Web site references or pamphlets with pictures so that they could refer to the information when performing strengthening and stretching exercises, and these have been developed by the therapists and incorporated into the program.
Additional advantages to group therapy have emerged. Research by Sullivan15 has indicated that it is often easier to change behavior of individuals within a group rather than to change behaviors of individuals separately, and although no measures were made of superiority of group delivery, comparable outcome has been demonstrated. By consenting to the group intervention, each caregiver accepted that other parents would hear details of his or her child's diagnosis and treatment, just as he or she would hear details of the others; however, rather than create privacy issues, caregivers were observed to interact with each other, share information, and build relationships and support networks; for example, we overheard previously unacquainted people arrange coffee meetings.
On the basis of the results of this study, some areas of improvement were identified and have been incorporated into the Torticollis Parent Education program. First, to address the parent request for additional written information on torticollis, additional take-home materials addressing positioning, head righting, and tummy time strategies were developed. Second, therapists spend more time with each child instead of completing minor tasks, as now 2 rehabilitation assistants take photographs, further streamlining clinical assessment. Evaluation of upper and lower quadrants has been added to the objective assessment to reflect functional AROM. A more detailed assessment of surrounding muscles and connective tissues such as fascia and skin bands has also been incorporated through more comprehensive palpation and observation, and parents are advised accordingly on how to resolve these.
As a result of changes implemented in this process, we also initiated a pilot community outreach program to educate public health nurses, doulas, and midwives on strategies to prevent torticollis and plagiocephaly. A “Back to Sleep/Tummy to Play” campaign, in addition to implementation of group-based assessments and therapy, may be an effective approach to assist pediatric hospitals in waitlist management for children with torticollis and/or plagiocephaly.
The number of patients assessed and treated in this program configuration has risen gradually and, with the addition of a second physiotherapy assistant, has increased the capacity of this unit to implement early intervention and treatment by 100% over that demonstrated before initiation of the group treatment program. In addition to delivering the group intervention, the 2 physiotherapists maintain responsibilities of a mixed caseload for outpatient services and have added community outreach for prevention education.
This study had 2 potential limitations. Since no formal standardized test is available to assess AROM and PROM in the pediatric population,10 our physiotherapists relied on observation and assessment skills, and dichotomous and parameter methods of recording ROM (degrees, full/not-full, one-fourth vs one-half vs three-fourth), as well as findings from a previous interrater reliability study16 that demonstrated the efficacy of different approaches for the treatment of congenital muscular torticollis. As well, only 25 caregivers (71%) returned the pre- and postsession knowledge questionnaires, whereas 12 (34%) completed the modified CSQ-8.
Although the standard of care for physiotherapy treatments for torticollis and plagiocephaly has been one-on-one delivery, the challenges of an increased waitlist led our department to successfully implement a group service format to assess and treat infants presenting with these conditions. In accordance with good standards of practice, the therapists at this hospital evaluated their program to determine its effectiveness for treating torticollis and plagiocephaly and the economic feasibility of operating the program.
The results of this evaluation indicate that the torticollis group intervention program is an effective, economically feasible method for delivering comprehensive and timely service to infants with torticollis and/or plagiocephaly, offering the same clinical outcomes within a similar treatment period. Combining group therapy with preventative measures will enable pediatric hospitals to reduce the number of infants on waitlist for treatment of torticollis and/or plagiocephaly.
The authors thank the Rehabilitation Research Committee of Children's Hospital of Eastern Ontario for granting the investigators time to complete the study. The primary author expresses gratitude to Lloyd Cowin, former operations director for the Rehabilitation Patient Service Unit, for being open-minded, lending his support, and believing in this project.
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