VESTIBULAR REHABILITATION FOR AN ADOLESCENT DIAGNOSED WITH CHIARI MALFORMATION TYPE 1: A CASE REPORT
Adelstein L, Georgetti T. Connecticut Children's Medical Center
BACKGROUND & PURPOSE: Chiari malformation (CM) type 1 is described as cerebellar displacement through the foramen magnum. Symptoms such as vertigo and ocular disturbance can occur related to compression of neural tissue. Vestibular Rehabilitation (VR) is a recommended treatment for vertigo, but in the context of peripheral hypofunction. However, it is also recommended for central dysfunction, such as CM, in pediatric cases. A clinical practice guideline (CPG) exists for peripheral vestibular dysfunction, but does not recommend specific intervention practices for patients with central vestibular disorders. The purpose of this case report is to describe the benefits of VR for an adolescent patient with central vestibular disruption, utilizing recommendations of the peripheral hypofunction CPG.
CASE DESCRIPTION: A 19 year old female underwent surgical decompression after diagnosis of CM type 1, with referral to outpatient physical therapy secondary to vertigo, imbalance, and impaired functional mobility. The primary goal was to return to running and working in the food service industry. The patient was treated with VR combined with traditional rehabilitation twice per week for 15 weeks. One session per week was dedicated to focused VR. She demonstrated primary deficits in gaze stability, motion intolerance, and sensory weighting. Initial results indicated a positive dynamic visual acuity test (DVA) and positive head impulse test (HIT). She reported dizziness that was measured with the visual vertigo analogue scale and demonstrated poor performance on the modified clinical test of sensory interaction in balance (mCTSIB). The mini BESTest, used to assess postural control, was utilized to monitor improvements. Intervention consisted of progression from gaze shifting to gaze stability exercises utilizing the CPG recommended frequency for optimal exercise dosing (at least 3 times per day), habituation strategies for dizziness/vertigo, and static and dynamic balance exercises.
OUTCOMES: After completion of intervention, the DVA was negative, despite continued positive HIT bilaterally. The patient self-reported no dizziness with activities of daily living. Her mCTSIB total increased to 120 seconds (maximum score). Her mini BESTest score increased by 5 points to 28/28, exceeding the minimally clinically important difference. She was able to independently exercise and run without symptoms as well as return to work in a full time position at a local grocery store.
DISCUSSION: This case report describes successful use of prescribed VR, following CPG recommended frequencies for improving gaze stability, in a novel adolescent case. More research regarding recommended intervention principles is needed for central vestibular dysfunction, particularly in the young pediatric and adolescent population. Clinicians should consider use of VR in patients with diagnoses with known central vestibular pathway involvement.
FIVE YEAR POST-OP FOLLOW-UP: CHILD WITH OSTEOGENESIS IMPERFECTA TYPE III AND SCOLIOSIS FOLLOWING POSTERIOR SPINAL FUSION WITH INSTRUMENTATION
Baratta-Ziska F. Hospital for Special Surgery
BACKGROUND & PURPOSE: Spinal deformity is common in children with type III osteogenesis imperfecta (OI). Progressive spinal curves >30 degrees are almost certain in children with OI type III. Thoracic scoliosis >60 degrees in children with OI type IIi leads to adverse pulmonary function. Respiratory insufficiency is a leading cause of death in adults with severe OI. For this child, posterior spinal fusion (PSF) T2-L4 with instrumentation (PSF) and early physical therapy (PT) helped reduce these complications. Bone fragility in children with type III presents challenges for adequate spinal fixation, healing, early mobilization, and function. The role of PT and interdisciplinary care pre and post-surgery used to achieve a successful outcome will be highlighted. The World Health Organization- International Classification of Function model, helped organize outcome measures and findings. The Gross Motor Function Measure, Children's Assessment of Participation and Enjoyment, and the Gillette Functional Assessment Questionnaire Ambulation Scale were used to compare function and participation pre-surgery, subacute post-surgery, and at 1 & 5 years post-surgery.
CASE DESCRIPTION: A 13-year old child with OI type III and a 61 degree right thoracic, 13 degrees left lumbar scoliosis underwent PSF with instrumentation. The child received twice daily inpatient PT for exercise, body mechanic education, transfer and ambulation training, nutrition, and social work counseling. The inpatient post-surgical course was complicated by fear, pain, fever, and poor appetite. The child was discharged with home PT, nursing, and weekly follow-up to the pediatric orthopedic clinic. The post-discharge course was complicated by flu and fever, refusal to cooperate with home PT, and missed clinical appointments. The child was readmitted upon suspicion of spinal infection, underwent incision and drainage. A 12-week inpatient rehabilitation stays followed for consistency of medical follow-up and PT. The patient returned home with outpatient PT.
OUTCOMES: Despite a diagnosis of OI type III, progressive scoliosis, bone fragility, and a complicated post-surgical course, early mobility and functional improvements were attained as assessed by valid outcome measures for children with disabilities, including OI. The child resumed all pre-surgery activities with reportedly greater ease of movement and pain-free.
DISCUSSION: There is little information in the literature regarding rehabilitation and PT for children with OI type III and scoliosis following PSF with instrumentation. This case report outlines the pre and post-surgical course of a child with PSF with instrumentation. Additionally, outcome measures and results will be presented that track the child's progress from pre-operatively to post-operative acute phase, 1 year, and 5-year post-surgical follow-up.
A PARADIGM SHIFT WHEN WORKING WITH A REHABILITATION TEAM IN AN ORPHANAGE IN NANJING, CHINA
Baratta-Ziska F, Janowski LC. Hospital for Special Surgery
PURPOSE: The purpose of this presentation is to present the work of a multidisciplinary team of healthcare providers from the United States who worked with rehabilitation teams at orphanages in China over four consecutive years. The purpose was to educate and teach using didactic and practical methods. The therapists in China were given strategies to gain knowledge and enhance performance. The purpose of this case report is to share anecdotal information and perspective from the collaboration experience of rehabilitation teams from the US and China.
DESCRIPTION: A team of occupational, physical, speech-language pathologists, orthotists, pediatricians, and surgeons traveled to orphanages in China, providing direct medical care and education to therapists and children for 4 consecutive years. A multidisciplinary approach was emphasized. Therapists in China focused on a progressive teaching approach, layering knowledge with each mission each year; year one focused on lectures, PowerPoint sessions, demonstration, pre/post tests; years three and four emphasized manual labs, handouts to support practical application, case reviews, knowledge of the use of therapeutic equipment, educational resources, direct hands-on training by modeling techniques, of experienced therapists, rationale for treatment, case reviews, developing a plan of care, evaluation and treatment strategies.
SUMMARY OF USE: After 4 years of training and education on 4 separate missions, the pediatric interdisciplinary medical rehabilitation team in China demonstrated a paradigm shift in their approach in how they implement care to their children at the Welfare Institute in Nanjing, China.
IMPORTANCE TO MEMBERS: Our results show direct active learning occurred among the rehabilitation team using modeling, practical hands-on clinical application of evidence-based practice rationale. The learning was reinforced with therapists appraising their knowledge of performance, demonstrating the ability to make changes as needed. The methods of teaching went beyond lectures and handouts. The therapists in China expanded their depth of knowledge and understanding. They started weekly rounds and case reviews with the medical director and other team members to establish a collaborative care plan and develop goals that the patient-specific and achievable. They demonstrated a better understanding and use of handling techniques and therapeutic equipment and improved rationale for interventions and evaluations. Being mindful of the cultural sensitivities was critical to the success of this rehabilitation mission.
PEDIATRIC PHYSICAL THERAPISTS ROLE OF HEALTH PROMOTION WITH MOTOR PROFICIENCY, SELF EFFICACY AND SCHOOL ENGAGEMENT; AN INTERDISCIPLINARY INTERVENTION
Boynewicz K, Chroust A, Eveland-Sayers B, Dotterweich A, Davis B, Murphy B, Owens S. East Tennessee State University
PURPOSE/HYPOTHESIS: Pediatric physical therapists provide health promotion interventions to increase fitness, enhance wellness, and recommend health promotion strategies for all children. The purpose of this study is to investigate if children with higher or lower cognitive and affective engagement at school and higher or lower self-efficacy toward physical activity have higher or lower motor proficiency within a sample of school-aged children.
NUMBER OF SUBJECTS: One hundred thirty-five students ages 5–11 attending a laboratory college prep school in the Appalachian Region of East Tennessee.
MATERIALS/METHODS: Students in grades K-5 participated in a 30 minute Run, Jump, Throw (RJT) program during school hours once a week for 6 weeks. Motor Proficiency was assessed using the balance, running speed & agility (RSA), upper limb coordination (ULC), and standing long jump (SLJ) portions of the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) at baseline and following the intervention. Inter-rater reliability for the BOT-2 ranged between r = .83 and .99. Self-efficacy was assessed through the Children's Self-Perceptions of Adequacy in and Predilection for Physical Activity (CSAPPA) and school engagement was measured using the Student Engagement Instrument-Elementary (SEI).
RESULTS: Two groups of children were defined by their performance on the BOT-2. Group 1 scored in the very below, and below-average range, and group 2 scored in the average, above average, and well above average range. Independent sample t-tests were then used to compare the group's performance with their SEI and CSAPPA scores. Significant differences were found on both the CSAPPA and SEI pre and post-intervention with the ULC subscales. Group 1 scored lower on M CSAPPA = 14.54, n = 71 and lower on the M SEI = 4.15, n = 52. Group 2 scored higher on the M CSAPPA = 17.14, n = 29 and on the M SEI = 4.37, n = 18. Significant differences were found on the CSAPPA with the balance subscale and SLJ. Children who were able to jump longer distances had higher scores on the CSAPPA. Group 1 scored lower on the M CSAPPA = 14.09, n = 67 and group 2 scored higher M CSAPPA = 15.58, n = 59.
CONCLUSIONS: Typically developing children with increased motor proficiency measured by the SLJ, balance, and ULC of the BOT-2 were scoring higher on their self-assessment of adequacy in physical activity and engagement in the classroom. ULC contains many eye-hand coordination activities which is the subset that was positively correlated with both the CSAPPA and the SEI. This may translate into the classroom with activities such as looking up at the board and then down at their papers or the playground with catching and throwing balls.
CLINICAL RELEVANCE: The development of a child's motor proficiency and health promotion are crucial for building the structural framework for future health and wellness as an adult. To encourage health promotion, pediatric PTs can assist with screening and implementing programs like the RJT program to improve fundamental motor skills. A short, structured program of just 30 minutes per week, can have long-term positive implications on the overall wellness of these children as they enter adulthood.
NEONATAL PHYSICAL THERAPY INTERVENTION TO INFANTS WITH NEONATAL OPIOID WITHDRAWAL SYMPTOMS IN AN ACUTE CARE SETTING
Boynewicz K, Dunlay A, Owens S, Pons M, Rogers L, Calderon K. East Tennessee State University
PURPOSE/HYPOTHESIS: The purpose of this study was to categorize and examine variation in types of neonatal physical therapy interventions delivered in a routine neonatal intensive care unit (NICU) in infants with Neonatal Opioid Withdrawal Symptoms (NOWS).
NUMBER OF SUBJECTS: Retrospective data collection from the electronic medical records of 125 infants from 2011-2016 at a level three NICU in an acute care setting.
MATERIALS/METHODS: Infant and maternal records were eligible for inclusion in this study when the infant had an initial examination for NOWS. Other inclusion criteria included birth weight, gestational age, in utero opioid exposure, toxicology results, pharmacological treatment, APGAR scores at 1 and 5 minutes, highest Finnegan score, and length of hospital stay. As part of neonatal clinical practice, therapists recorded the details of intervention types delivered at each treatment session. A checklist was created for researchers to extract coded intervention data. Researchers were checked for inter-rater reliability with data extraction and coding by analyzing for accuracy and completeness. Treatment interventions were categorized into 9 topics: state control/regulation/calming, sensory/perceptual, infant massage, therapeutic exercise, oral motor/feeding/non-nutritive sucking (NNS), equipment, patient/family/caregiver education, family coaching, and communication/coordination. Once data was extracted and coded, it was put into a spreadsheet developed by the research team to analyze the coded data.
RESULTS: 125 infants received PT interventions during their stay in the NICU receiving treatment for NOWS. The average length of NICU stay was 21 days, the frequency or number of treatments documented per infant was 6.14 sessions, with 750 interventions total. The duration of the intervention session averaged 30.20 minutes per session. The initial examination was performed and recorded on the day of life (DOL) 5.06 and treatment intervention was on average initiated on DOL 6.10 with a span of 1-18 days of life. The most frequent interventions delivered were strategies to assist with state control (79%), sensory/perceptual (30%), infant massage (54%), therapeutic exercise (57%), oral motor (14%), and education (12%).
CONCLUSIONS: Development of an extraction chart helped with understanding the types of neonatal interventions that are being delivered in an acute care setting for infants with NOWS. Combining types of neonatal intervention along with frequency, duration and intensity may be helpful to hospitals and therapists working with infants with NOWS. Further work is needed to determine if these types of intervention are being conducted at other locations and settings for this population.
CLINICAL RELEVANCE: With extensive literature searches in relation to this topic, very little if no data was found. Types and number of interventions delivered as well as the frequency of visits and time spent during sessions can help guide therapists, and develop pathways for hospitals that treat infants with NOWS. With this study, pediatric physical therapists should gain a clearer understanding of how to best treat these patients and apply this knowledge clinically.
PHYSICAL THERAPY INTERVENTIONS TO PROMOTE BOTH MOTOR DEVELOPMENT AND COGNITION IN CHILDREN AGED 0-3: A RAPID REVIEW
Brantley T, Pisacreta E, Yao J, C. Golub-Victor AC. Northeastern University
PURPOSE: To identify effective physical therapy (PT) interventions for infants and toddlers that promote both motor development and cognition based on the evidence.
DESCRIPTION: Motor development and cognition in infants and toddlers are intrinsically linked. With the acquisition of motor skills, infants and toddlers are presented with opportunities to problem-solve and explore their environment to acquire and use knowledge. Young children with motor delays or impairments are at risk for limited opportunities to act on their environment, thereby impeding development of focused attention, spatial memory, and other aspects of cognition. Physical therapists who serve infants and toddlers would benefit from evidence-based guidance to design effective intervention that takes advantage of the relationship between movement and learning to achieve optimal motor and cognitive outcomes.
SUMMARY OF USE: A rapid review process was used to examine published literature detailing PT interventions to promote both motor development and cognition in young children. Rapid reviews are designed to explore and synthesize current evidence more efficiently than systematic reviews. Searches were conducted on Embase, CINHAL, and Pubmed for articles published since 1980 on the topics of infant and toddler aged 0-3, motor and cognitive development, and PT interventions. Gray literature, study protocols and non-peer review literature were excluded. Inclusion criteria were subjects birth to 3 years, with or without developmental delay; and reported interventions had components which addressed both motor and cognitive development. Searches across the three data bases yielded a total of 525 articles. After removing duplicates, the remaining articles (n = 385) were screened for relevance based on title and abstract yielding 103 for full text review. The full text screening yielded 16 articles published between 2009 and 2020, including 4 randomized controlled trials, 1 longitudinal comparison of interventions, 3 quasi-experimental studies, 1 single-subject and 3 case studies. Six interventions were identified; 4 reported effectiveness to enhance both motor development and cognition. All effective interventions incorporated active, child-initiated problem-solving.
IMPORTANCE TO MEMBERS: Early intervention (EI) physical therapists include interventions that address multiple domains of development. Evidence for specific PT interventions that are effective for improving both motor development and cognition, however, remain limited. Based on this review, interventions that incorporate active motor-based problem-solving improved both motor development and cognition. Interventions such as Neurodevelopmental Treatment and massage were not reported to produce improvements in both areas. Rapid reviews offer physical therapists timely access to evidence-based information important for clinical decision-making. A systematic review synthesizing interventions from all EI disciplines aimed at both motor development and cognition may benefit physical therapists working with infants and toddlers.
ACCESS TO INCLUSION: DEVELOPING PROFESSIONAL STANDARDS FOR COMMUNITY INCLUSION FOR INDIVIDUALS WITH DEVELOPMENTAL AND RELATED DISABILITIES
Brinkman A, Turner C, Jones L, Wulliger P, Smith T, Smith J, Ayers K. Cincinnati Children's Hospital and Medical Center
PURPOSE: While laws and guidelines (e.g., Americans with Disabilities Act) exist for organizations to be physically accessible, true inclusion remains an exception because systematic and comprehensive professional standards for access and inclusion do not currently exist. True inclusion allows individuals with developmental disabilities to not only physically access a space, but also cognitively and socially interact in meaningful ways. The purpose of this project is to develop a scorecard with comprehensive standards to assess organizations' level of accessibility and inclusion in four domains, Policy, Physical, Sensory, and Communication, which will improve community engagement and well-being of individuals with DD and their families.
DESCRIPTION: While laws and guidelines (e.g., Americans with Disabilities Act) exist for organizations to be physically accessible, true inclusion remains an exception because systematic and comprehensive professional standards for access and inclusion do not currently exist. True inclusion allows individuals with developmental disabilities to not only physically access a space, but also cognitively and socially interact in meaningful ways. A literature review was conducted to identify existing guidelines and standards related to access and inclusion, as well as other rating systems. The scorecard prototype was drafted comprising of four domains (e.g., Policy, Physical, Sensory, and Communication). The prototype was designed for community organizations to self-assess their level of accessibility and inclusion, and to identify areas for growth within the organization. The scorecard is comprised of four grading criteria levels per domain, Emerging, Developing, Acquiring/Refining and Proficient, which were defined by our team. Each grading criteria level is comprised of a checklist (yes/no) of actions and items that organizations will fill out to determine which level they currently fit best in. Areas for supporting comments and self-identified areas for growth are provided for organizations to complete. Nicole Armstrong, community policy partner from Queen City Certified, was consulted regarding the development of a scorecard and cohort-based program. Additional grant funding was pursued through the Center for Clinical & Transitional Science & Training to design and pilot the scorecard.
SUMMARY OF USE: A scorecard draft was created, incorporating previously established broad categories for accessibility and inclusion standards, and a grant application was submitted. A team through Cincinnati LEND will continue to develop the scorecard, gather feedback from key stakeholders, pilot the scorecard with an engaged community partner, and apply for additional funding.
IMPORTANCE TO MEMBERS: This project highlights the universal need for improved access and inclusion for individuals with developmental disabilities and their families and the importance of ongoing partnerships between disability experts and community organizations.
OPTIMIZING SCHOOL-BASED PEDIATRIC PHYSICAL THERAPY RESOURCES FOR CHILDREN WITH MULTIPLE DISABILITIES
Canizares GD (Boston University), Neville E (Perkins School for the Blind)
PURPOSE: The purpose of this project is to increase the availability of resources for children with multiple disabilities in the school-based environment. As cited by Rowland et al,1 physical therapists are in a unique position to promote health and wellness for youth with disabilities. Due to the numerous interventions required to meet the specific needs of students with various medical complexities, students can have limited opportunities for additional physical activity outside the school setting. This project was formed with the Perkins School for the Blind to create tangible resources to distribute to caregivers for increasing accessibility of continued therapeutic activities in the home and during school breaks. 1. Rowland et al, 2015. doi:10.1097/PEP.0000000000000098. (reference paraphrased to save characters)
DESCRIPTION: This project is a series of information sheets and activity guides that have been either requested or deemed beneficial for caregivers of students at the Perkins School for the Blind. Some examples of the activity guides include ‘balance interventions for the home’, ‘adapted yoga poses’ and ‘fun in the sun!- gross motor water activities’. Some examples of the information sheets include ‘brace wearing guides: SMOs and AFOs’, ‘guides for using a stander’, and ‘positioning considerations for wheelchair users’. This poster presentation will focus on increasing awareness of the availability of these resources for distribution to caregivers of children with multiple disabilities to promote health and wellness outside of the school setting. This guide will be accessible to all members of the interdisciplinary school team via online and printed resources. Ideally, these sheets will be used as a resource that a team member can extract from to create individualized recommendations for each student.
SUMMARY OF USE: These activity guides and information sheets can be distributed to caregivers and members across a student's interdisciplinary team. An overwhelming amount of information is given to caregivers of children with disabilities that it is often hard to synthesize. These guides are meant to be distributed by related service providers to individualize caregiver education and physical activity recommendations to meet the specific needs of each student with the intention of increasing access to the educational environment and promoting gross motor skill development.
IMPORTANCE TO MEMBERS: Ideally, these guides will be distributed to caregivers of children with multiple disabilities to empower them to encourage activity in the home environment for their child. These guides can provide an additional therapeutic intervention for these children besides what they are already receiving in therapy to continue functional gains. Additionally, children may not be receiving therapy during school or holiday breaks, so these sheets can provide a structured mobility plan during those times. Lastly, the information sheets can provide useful information on topics often difficult to understand, such as the importance of standers and TLSO brace wearing.
IMPROVEMENTS IN GROSS MOTOR SKILLS IN ATAXIC CEREBRAL PALSY THROUGH UTILIZATION OF INTENSIVE TREATMENT MODEL-A CASE STUDY
Chole D. Children's Therapy Center, University of Missouri-Columbia
BACKGROUND & PURPOSE: Ataxic cerebral palsy (CP) accounts for only 5-10% of CP cases, making it the smallest subgroup of cerebral palsy. “Ataxia is defined as an inability to generate a normal or expected voluntary movement trajectory that cannot be attributed to weakness or involuntary muscle activity about the affected joints” (Sanger, 2006). Children with ataxic CP are often described as having poor balance, difficulty with postural control, difficultly with grading or force of movements, and poor coordination. Limited research exists regarding the outcomes for ataxic CP utilizing an intensive model of treatment. The purpose of this case study is to describe the benefits of the intensive model for a child with ataxic CP.
CASE DESCRIPTION: This case follows outcomes over a 3-year period of a young child with ataxic CP secondary to cerebellar stroke at 2 days of age. Child first presented to outpatient clinic at the age of 3, GMFCS level II, primarily crawling at home and using a walker in the community. Intensive physical therapy (PT) was 3 hours a day, 5 days a week, 4 weeks in duration and principles were rooted in neuroplasticity and motor learning theories. Child returned for intensive PT every 6 months until the child was 5.5 years old. Functional goals were to get off the floor and stand independently, walk without a walker, and later advanced to walking on uneven surfaces, and running safely. Treatment interventions focused on increasing proximal strength, postural control and balance, use of compression garments and orthoses, whole body vibration, treadmill, and gait training.
OUTCOMES: At each six-month mark, client had improvements in independent mobility, standing balance, and meaningful change in scores on the Gross Motor Function Measure-88 (GMFM-88). GMFM-88 scores increased from 52% to 57% to 77% over 18-month period. During first episode of intensive PT, child gained independent standing balance and was taking 2-3 steps between surfaces. During second episode, standing balance improved to allow for participation in self-care skills, and began consistently walking 10-15 feet. The largest gains were after third episode, when he began walking indoors independently and utilizing a walker only for outdoor play. By age 4.5 years, child was GMFCS Level I and returned to home and preschool able to safely navigate classrooms and hallways while walking independently.
DISCUSSION: In this case, significant gains were made utilizing intensive treatment model of PT. This model is beneficial for applying principles of neuroplasticity, such as repetition, intensity, salience and specificity during treatment. Longer sessions allow for higher repetitions and opportunities to build intensity within the same task-based activity. Daily sessions provided frequent practice, which was valuable for independent walking skills, increasing confidence and distance almost daily. Family provided additional opportunities to generalize skills and child had high internal motivation and drive for independence. In this present case, the intensive model proved successful and may be a beneficial model of treatment for other kids with ataxic CP.
COLLABORATIVE EYE EXAMINATIONS TO PROTECT THE PREEMIE
Clary E (UNC Hospitals), McCarty D (The University of North Carolina at Chapel Hill)
PURPOSE/HYPOTHESIS: Retinopathy of prematurity (ROP) is a potentially blinding eye disorder that primarily affects premature infants born before 31 weeks of gestation or born weighing less than 1250 grams. Routine eye examinations to assess ROP in at-risk infants can increase pain and stress exposure during the NICU stay. This novel, interprofessional quality improvement aimed to reduce infant pain and increase team efficiency during ROP exams with the addition of neonatal therapy.
NUMBER OF SUBJECTS: A total of 102 eye exams on 48 unique infants were analyzed.
MATERIALS/METHODS: Baseline data was collected across 3 weeks for 2 different ophthalmologists completing exams in the UNC Newborn Critical Care Center. In the intervention phase, neonatal physical therapists rotated with the ophthalmology team to prepare, position, and soothe infants before, during, and after ROP exams. Intervention data was also collected for a 3 weeks for each ophthalmologist. Outcome measures included infant vital signs, infant pain scores (PIPP), and time to complete exam. We also examined qualitative feedback from key stakeholders including the ophthalmology team, neonatologists, bedside nurses, and parents.
RESULTS: The goals of this collaborative quality improvement project were to reduce infant pain and variability in physiologic state, improve efficiency for ophthalmology team, and to reduce interruptions to bedside nursing care. Data analysis is currently in progress, and is being assessed for differences between pre- and post-intervention groups including changes in infants' pain scores during exam, infant's HR and SpO2 variability during and after exam, and time at the bedside completing exams for the ophthalmology team members. Qualitative data will be analyzed and summarized as available.
CONCLUSIONS: Data analysis is currently ongoing. Differences between pre- and post-intervention groups and positive qualitative data would support the addition of neonatal therapy to ROP exams to improve the experience of infants and multidisciplinary team members.
CLINICAL RELEVANCE: Repeated exposure to painful stimuli in the NICU environment has been associated with altered cortical development, decreased developmental and cognitive outcomes, decreased pain threshold, and development of intraventricular hemorrhage. This quality improvement projects highlights the role of neonatal therapy in reducing infant pain as well as the benefits of multidisciplinary collaboration to improve patient care.
EXPERIENTIAL LEARNING: ENTRY LEVEL DPT STUDENT VIRTUAL SIMULATION FOR PEDIATRIC LIFE STAGE TRANSITION AND FAMILY CENTERED CARE
Cobb LP, George KW, Salazar R, McCarthy J. Seton Hall University
BACKGROUND & PURPOSE: Life stage transitions can be challenging for teens with physical disabilities and their families. Simulation promotes integration of didactic studies through experiential learning using trained standardized patients (SPs). The purpose of this experience was to evaluate the student's communication and affective skills necessary for family centered care.
CASE DESCRIPTION: During the pandemic, 37 entry-level DPT students each conducted a virtual video conference with a SP portraying the primary caregiver of a teen living with a disability. The SP evaluated student communication skills as the student discussed the teen's college transition plans and PT recommendations including initial wheelchair use. SPs provided written feedback on the student's communication skills through a 10-item Standardized Feedback Form (SFF), items scored from 0-5 points with a max score of 50 points. Students reflected on their simulation using the Plus Delta standardized reflection tool to identify what went well and what could be improved in the experience and a reflection paper on their perspective of personal effectiveness and what they might change in the future.
OUTCOMES: The mean student score on the SP rated SFF was 45.5/50 points (SD: 3.6, Range: 32 -50). A review of student reflections identified 6 common themes important for difficult conversations with family members. The themes and the percent of students recognizing traits were: adaptability (84%), active listening (78%), building rapport (70%), incorporating family goals (62%), teamwork-PT and family (62%), and clear communication (35%). The SP SFF score and the number of themes identified by students were associated (R = 0.58; R2 = 0.34, p = < .001). A post-event survey revealed that 94% of students felt virtual simulation was useful to enhance skills for family centered communication.
DISCUSSION: While a virtual simulation was necessitated by the pandemic, it proved to be a viable alternative to face to face simulation. The virtual format allowed students to engage in difficult conversations and encourage caregivers to create effective plans for their adolescent. Students identified important aspects of family centered care including being open to parent ideas, active listening, justification of goals/recommendations, and adaptability for family needs. The simulation and post-experience reflection assisted DPT students to integrate didactics with attitudes they will use in future practice.
REFERENCES: Cech D, Krzak JJ, Anderson DK. Linking the essential core competencies to pediatric content in entry-level physical therapy education curriculum: a case report. J Phys Ther Edu 2017:31:89-94. Doty A, Ray L, Clark K, Bethune L, Test D. Evidence-Based secondary transition predictors for physical therapists working with high school students. Pediatr Phys Ther 2020:32;258-265. INACSL Standards Committee. INASCL Standards of best practices simulation: Operations. INACSL, 13, 681-697. Mueller, K., Prins R, de Heer, H. An online intervention increases empathy, resilience, and work engagement among physical therapy students. JAllied Health. 2018;47(3):196-203.
THE USE OF WHOLE BODY VIBRATION TO PROMOTE TRUNK CONTROL IN A TODDLER WITH CHARGE SYNDROME: A CASE STUDY
Cole M (Azusa Pacific University), Adamiak-Pellow K (Chapman University).
BACKGROUND & PURPOSE: Previous studies indicate the use of whole-body vibration (WBV) is effective in improving motor function, strength, and posture in children (Duquette, Guiliano, & Starmer, 2015; Emara, 2016; Stark et al., 2015; Unger, Jelsma, & Stark, 2013). Stark and colleagues (2016) have shown WBV to be a safe intervention for children as young as 12 months of age. A stable posture is foundational for functions including object manipulation, eating, and verbal communication (Adolph & Franchak, 2017). Delayed emergence of sitting in infants has the potential to impact overall development through limiting means of independent exploration and social interactions (Adolph & Franchak, 2017; Haworth et al., 2013). This case was part of a trial seeking to determine the effectiveness of WBV in improving trunk control in toddlers who are delayed in their development of independent sitting.
CASE DESCRIPTION: A 2 -year-old male with a diagnosis of CHARGE syndrome was referred to the whole body vibration trial program by his primary physical therapist. His clinical presentation included hearing loss. At the onset, the child did not attempt to maintain independent sitting. The intervention took place over 16 sessions scheduled twice a week. The protocol for each session consisted of 5, 3-minute blocks of alternating treatment and rest. During the treatment blocks, the child was placed in a seated position on the Galileo Kiddy vibration platform (Novotec Medical GmbH, Germany) with support provided at the lowest level that still allowed the child to maintain an upright position. The vibration frequency was maintained at 18Hz throughout. The child was removed from the platform and allowed to play freely during the rest periods. A pre and post- Segmental Assessment of Trunk Control (SATCo) was conducted, recorded, and blindly scored.
OUTCOMES: The child's initial SATCo showed he was able to maintain static and active control with support provided at the “axillae” level (upper thoracic control), and no reactive control was observed. Following the 16 sessions, the child demonstrated static, active, and reactive control with support as low as the “pelvis” level (lower lumbar control). During this time his independent sitting skills improved to allow him to maintain propped sitting for a short period of time. Subjectively, the child appeared to enjoy the intervention and demonstrated improved attention and participation following each session. His occupational therapist reported increased toy exploration and use of his hands in play.
DISCUSSION: Though the child continued to receive both PT and OT services during this trial, the whole body vibration appeared to have a positive impact on his trunk control and body awareness. He tolerated the intervention well and was reported to have improved participation with his therapists and caregivers following each treatment session. Further exploration of the use of whole-body vibration to promote early trunk control in children with developmental delays and sensory impairments is warranted.
CASE REPORT: WHOLE-BODY VIBRATION AND TREADMILL TRAINING FOR A CHILD WITH PITT-HOPKINS SYNDROME
Conklin A (Rutgers, The State University of New Jersey), Clark L (Children's Specialized Hospital), Daniels K (Rutgers, The State University of New Jersey), Palmer L (Rutgers, The State University of New Jersey), Rubin K (Rutgers, The State University of New Jersey), Scotto E (Rutgers, The State University of New Jersey)
BACKGROUND & PURPOSE: Pitt-Hopkins Syndrome (PTHS) is a rare genetic condition present in early childhood. Children with PTHS exhibit hypotonicity and have associated gross motor delays, including average age of ambulation onset between five and seven years. Although genetically unrelated, children with Down Syndrome (DS) exhibit some congruous clinical characteristics to children with PTHS. Physical therapy (PT) is recommended to mitigate gross motor delays in both conditions. Whole body vibration (WBV), which utilizes a vibrating platform to increase somatosensory input, and treadmill training (TMT), are two PT interventions that have been found to be effective in facilitating gross motor improvements including earlier ambulation onset in children with DS. Unlike children with DS, there is a paucity of research supporting PT interventions for children with PTHS. Considering the clinical similarities between PTHS and DS, it is hypothesized that implementation of WBV and TMT in children with PTHS may result in similar gross motor improvements. The purpose of this case report is to present the outcomes of a 3-week PT program combining WBV and TMT in a young child with PTHS.
CASE DESCRIPTION: A 2-year, 11-month-old girl with PTHS presented with hypotonia, generalized weakness, poor standing balance and gross motor delay including inability to ambulate. PT sessions were conducted in an outpatient pediatric setting three times weekly for one hour over three weeks incorporating 10 minutes of WBV while standing without support on a vibrating platform. The intensity of vibration increased over time from level 10 to 23 and progressed to include dynamic reaching activities in unsupported standing. Eight to ten minutes of TMT at speeds ranging from 0.1- 0.9 miles per hour immediately followed WBV. Each session concluded with overground standing and facilitated ambulation using a reverse rolling walker.
OUTCOMES: A total of nine PT sessions over 3-weeks were completed. Gross motor improvements included progression of standing balance ability from independent static standing to independent dynamic standing while reaching. Additionally, the child independently ambulated six steps using a reverse rolling walker, which is approximately two years prior to the average age of ambulation onset for a child with PTHS.
DISCUSSION: This case report is the first to highlight the potential impact of WBV and TMT for a child with PTHS and adds to the literature supporting PT for this population. The gross motor improvements obtained suggest that a 3-week PT program combining WBV and TMT may facilitate improved balance and an earlier onset of ambulation in a young child with PTHS. It remains unclear if gross motor improvements can be attributed directly to WBV, TMT, or the combination of both interventions. Future research with a larger sample of children with PTHS should aim to identify optimal treatment parameters for clinical effectiveness. In conclusion, implementation of WBV and TMT should be considered when working with children with PTHS.
PEDIATRIC TELEHEALTH SESSIONS IN GRADUATE PHYSICAL THERAPY EDUCATION DURING COVID-19
Conklin A, Simonds A. Rutgers, The State University of New Jersey
PURPOSE: Telehealth is described by the American Physical Therapy Association as the “the use of electronic information and telecommunication technologies to remotely provide health care information and services.” In Spring 2020, the Covid-19 pandemic impacted the delivery of physical therapy (PT) practice and education. Telehealth became an essential element of care delivery and enabled patients' continued access to care despite limited in-person treatment. The loss of in-person learning experiences forced PT educators to innovate within remote environments. PT curricula rely on hands-on experiences to enhance student comprehension and practical application of content. In pediatric PT, hands-on learning experiences with children are essential. The purpose of this report is to describe the implementation of pediatric PT telehealth sessions to substitute for the lack of in-person learning experiences for students engaged in pediatric curriculum during the pandemic.
DESCRIPTION: Two, 1-hour telehealth sessions with 7 pediatric patients and their caregivers were scheduled for student physical therapists (SPTs) engaged in pediatrics coursework of a graduate PT program. Patients who were able to tolerate 1 hour of activity and actively engage with SPTs were recruited. Participation was voluntary and no compensation was provided. All patient volunteers were diagnosed with neuromuscular conditions and ranged in age from 13 months to 13 years. SPTs were assigned to evaluation teams of 4 students each and assigned 1 patient for the experience. First, SPTs conducted a 1-hour initial examination including administration of a standardized gross motor assessment under the direct supervision of a licensed PT. Next, SPTs developed a plan of care and intervention plan based on examination findings and implemented them with the patient the following week. Password-protected video conferencing software was utilized. Written informed consent was obtained from caregivers prior to the experience.
SUMMARY OF USE: Telehealth was feasible and effective to provide hands-on learning experiences with children with neuromuscular conditions to SPTs amidst the pandemic. SPT performance on both examination and development of a care and intervention plan was comparable to pre-pandemic SPT performance in traditional, in-person format. Execution of the telehealth sessions required a 50% less student time commitment compared to an in-person format with comparable positive feedback from the students and caregivers involved.
IMPORTANCE TO MEMBERS: This report is important for both clinicians and educators responsible for development of SPT learning experiences in pediatric PT. Continued restrictions on face-to-face student experiences in pediatric facilities due to the pandemic may result in reduced SPT exposure to children in the clinical environment. Telehealth is a viable option to be adopted by institutions with fewer available learning opportunities for SPTs to gain exposure to children in direct PT patient care settings.
EFFECTS OF POSITIONING INTERVENTIONS PERFORMED BY HEALTHCARE PROVIDERS ON PAIN IN PRETERM INFANTS IN THE NEONATAL INTENSIVE CARE UNIT (NICU)
Conway L (Columbia University Programs in Physical Therapy), Schutzman E (Columbia University Programs in Physical Therapy), Miller H (John Hopkins Children's Center), Montes J (Columbia University Programs in Physical Therapy), Yoon L (Columbia University Programs in Physical Therapy)
PURPOSE/HYPOTHESIS: During long hospital stays in the NICU, preterm infants are routinely exposed to painful interventions and stressful environments.1,2 Research suggests that infants may feel pain more intensely than children and adults as immature inhibitory pain control mechanisms decrease their ability to modulate pain.3 Physical therapists and other professionals in the NICU can use positioning techniques, as an alternative to pharmaceutical interventions, to reduce pain and stress.
NUMBER OF SUBJECTS: 715 premature infants (27-37 weeks gestational age (GA))
MATERIALS/METHODS: Four databases including PubMed, CINAHL, Embase, and Web of Science were searched using the following strategy: (((NICU OR “neonatal intensive care unit”) AND (prematurity OR (premature AND (infant OR birth)))) AND (“physical therapy” OR physiotherapy OR position* OR “positioning strategy” OR swaddling OR “facilitated tucking” OR “hammock position” OR containment OR “developmental care”)) AND (outcome OR “treatment outcome” OR (pain AND (manag* OR reduction)) OR “heart rate” OR “oxygen saturation” OR Sp02 OR “respiratory rate”). Studies were included if published in English in the past 15 years, if they included premature infants in the NICU born at < 37 weeks GA who were medically stable, included a pain scale, and involved a direct positioning intervention performed by a healthcare professional. Studies with infants on mechanical ventilation were excluded. This study was registered with PROSPERO (registration number: CRD42021222930) and was approved on January 13, 2021.
RESULTS: Five hundred and forty-nine studies were screened by two reviewers, and discrepancies were resolved by a third reviewer. Eleven studies met the inclusion criteria. Two additional articles meeting the inclusion criteria were obtained through a manual search. Eleven articles were randomized controlled trials and two were repeated measures designs. Five of the thirteen articles assessed provided sufficient information to allow for effect size calculation. In comparison to controls, lower pain scores were found for the intervention group in all four swaddling studies 2,4-6 (Cohen's d: −3.62 to −0.72), five of the seven facilitated tucking studies 2,7-12 (Cohen's d: −8.47 to −0.08) and all three of the decubitus positioning studies 13,14,15 (Cohen's d: −0.82).
CONCLUSIONS: The majority of the literature reviewed demonstrated significant effects of positioning techniques performed by healthcare professionals on reducing pain in premature infants in the NICU. However, the studies reviewed were of varying quality and utilized a variety of positioning and intervention protocols. Further research is warranted to generalize these findings.
CLINICAL RELEVANCE: Positioning interventions in the NICU are inexpensive, relatively low-risk, and non-invasive to implement for pain control.
STRATEGIES TO SUPPORT THE DOCUMENTATION AND MONITORING OF IEP GOALS THROUGH TELETHERAPY
Diep J, Clifford J, Friedman S, Gallano M. New York City Department of Education
BACKGROUND & PURPOSE: During the COVID-19 driven shift from in-person to teletherapy, the school-based therapists of the NYC Department of Education explored ways to assess and monitor progress related to student's Individualized Education Plan (IEP) goals, remotely. Currently, there is a lack of evidence supporting the use of tests and measures for school-based physical therapy outcomes via teletherapy. The purpose of this case report is to describe how the authors collected data and information regarding the student's school participation within the student's home environment, via teletherapy. The authors explored the evidence to support the feasibility of administering commonly used school-based assessments such as the Timed Floor to Stand (TFTS), Timed Up and Go (TUG), and Timed Up and Down Stairs (TUDS), as well as adapting organizational questionnaires related to home environment participation.
CASE DESCRIPTION: Case subject is a 7-year-old male, diagnosed with Cerebral Palsy, with a Gross Motor Classification Scale Level ll. He has been enrolled in remote school since March 2020 and opted to continue with remote school and teletherapy throughout the 2020-2021 school year. School-based goals strived to work on stair negotiations, transitions, and playground activities within the home environment for optimal carryover. To monitor improvement and collect data, specific test and measures were used via the teletherapy platform.
OUTCOMES: Case subject demonstrated improvements in stair negotiation speed, based on the TUDs test, obtaining a score of 94 seconds at baseline in October 2020 and 41 seconds upon re-test in June 2021. Case subject also demonstrated improvement in TFTS transitions speed, obtaining a score of 26 seconds at baseline and 25 seconds upon re-test in June 2021 through teletherapy. Data was collected using evidence-based tests and questionnaires via teletherapy.
DISCUSSION: Based on the available evidence and the use of the school-based assessments during teletherapy, the authors were able to administer and gather information related to the IEP goals. Other measures explored included the ABILOCO-kids, School Function Assessment, and Goal Attainment Scale. In addition, the authors organized the translation of school-functional tasks through the home environment lens. This case study will support school-based therapists who want to assess and monitor progress for their students in teletherapy sessions using school-based assessments, questionnaires, and functional task performance.
A PHENOMENOLOGICAL INVESTIGATION OF THE SUPPORT PHYSICAL THERAPISTS WORKING EARLY INTERVENTION PROVIDE TO FAMILIES
Donahue ML, Bateman M, Ensby P, Gatto J, Joyce M. Nazareth College
PURPOSE/HYPOTHESIS: In the US, 437,234 children received Early Intervention (EI) services in 2020. Literature focuses on the initial support given to families when first transitioning into EI; however, limited research on the continuous support by PTs throughout the entire episode of care exists. A nuanced understanding of the support provided by PTs is necessary to educate and mentor therapists to provide effective family-centered care. The purpose of this qualitative study was to understand the support provided by PTs to families of children receiving EI services for at least six months.
NUMBER OF SUBJECTS: Participants included nine PTs (eight female, one male) who provided EI services to at least one child and family for six months, recruited by purposeful sampling.
MATERIALS/METHODS: Data was collected in the form of semi-structured interviews to gather information about the therapists' experiences, opinions, and feelings. Interviews were recorded and transcribed. Data analysis included a round of open coding with in-vivo, value, and focused coding to highlight the salient features condensed into descriptive categories. Axial coding collapsed information into smaller, more meaningful units of analysis to explore categories and develop a new understanding of support provided to families. Member checking data established qualitative rigor and trustworthiness, rich descriptions to explain findings, and bracketing to reduce bias.
RESULTS: The qualitative analysis yielded several themes. Support was defined as communicating with families, addressing questions and concerns, providing resources, and attending to emotional and educational wellness under the guidance of a family-centered care approach. All participants emphasized the importance of establishing a relationship with families, coaching parents, and engaging in interprofessional collaboration while simultaneously considering family dynamics and adapting to the reliance on telehealth for service provision.
CONCLUSIONS: PTs consistently described individualized support that extended beyond the discipline-specific role of the PT. PTs are responsible for treating the child and must also be mindful of the need to advocate for families' concerns, empower families to raise their children confidently, and ensure needs are met throughout their time receiving EI services. Establishing trusting relationships, being aware of family dynamics, and addressing concerns using various coaching strategies were often acquired through clinical experience rather than entry-level education.
CLINICAL RELEVANCE: Findings suggest that patient care in EI encompasses more than just hands-on, discipline-specific service delivery. This nuanced understanding of the unique support provided to families may assist academic faculty and clinical mentors to help new clinicians practice effectively as providers, given the emphasis on individualized support and family-centered care in EI.
NEWBORN NEUROBEHAVIOR CLINICAL PRESENTATION OF INFANTS EXPOSED TO PRENATAL THC: A CASE SERIES
Dragotta K, Quartano J. Brooks Rehabilitation Institute of Higher Learning
BACKGROUND & PURPOSE: Cannabis is the leading illicit drug used among women who are pregnant or of childbearing age. This results to 34% of pregnancies impacted, which may be associated with recent legalization in the US. Prenatal exposure to cannabinoids may affect homeostasis and neuroplasticity, raising concern for adverse effects on the developing fetus. Research tools have been developed to capture effects of substances in utero, such as the Modified Finnegan Neonatal Abstinence Score System (MFSS). The information researched on this has shown that children exposed to opioids and other illicit drugs often demonstrate withdrawal following birth. However, to our knowledge, there is no standardized assessment that accurately captures the clinical presentation of neonates exposed to prenatal THC. Therefore, the purpose of this case series was to identify common symptoms between patients exposed to marijuana using the MFSS, and provide insight to physical therapists in the NICU of the clinical presentation of these infants.
CASE DESCRIPTION: Three infants in the NICU were used in this case series with a history of prenatal exposure to THC. Infant A is a 2,100g male infant born at 36 weeks. Infant B is a 3,480g male born at 37 weeks. Infant C is a 1,800g female born at 33 weeks. The infants were admitted to the NICU for RDS, requiring CPAP. All three infants presented with clinical signs primarily influencing the CNS, such as hyper-irritability, tremors, hypertonia, and tachypnea.
OUTCOMES: None of these infants scored greater than an 8 on the MFSS, therefore pharmacological intervention is not indicated and it is recommended that these infants are monitored and supported in a comfortable environment. The use of a momaroo and dependent carry helped to minimize hyper-irritability and maintain stable vital signs. Passive range of motion was also used to prevent prolonged hypertonicity and improve the organization of movement. Promoting physiological flexion with the use of blanket rolls and side lying positioning increased hands to midline to assist with self-soothing techniques. Parent education was crucial with this population as it aimed to provide optical care for the infant after discharge. The length of stay in the NICU for Infant A, B, and C were 7, 4, and 21 days respectively.
DISCUSSION: With the increased incidence of marijuana use among expecting mothers, it is important for physical therapists to understand the clinical presentation of infants born after prenatal exposure. The majority of symptoms that were observed disturbed the CNS such as hyper-irritability, tremors, hypertonia, and tachypnea, suggesting alteration to neurobehavioral regulation. During the first days of life, documenting effects of prenatal exposure to THC is critical for identifying areas for intervention, preventative measures, and assessing for neurobehavioral involvement. Cannabis-exposed infants required external support to calm, greater difficulty to self-regulate, and increased arousal was noted. In conclusion, this case series provokes the discussion of what signs and symptoms are most commonly seen in infants born to prenatal exposure of THC.
EFFECTS OF A NOVEL PRENATAL EDUCATION COURSE IN PREVENTION OF PLAGIOCEPHALY AND TORTICOLLIS
Emmel L (University of Mary), Poland A (University of Virginia), Rabaey S (University of Mary), Rowles M (Kids in Motion), Schild G (Billings Clinic)
PURPOSE/HYPOTHESIS: The purpose of this research study was to investigate the effects of a prenatal education course on parents' knowledge on the benefits of supervised tummy time while the child was awake. The primary hypothesis was that this online educational course will increase parents' knowledge about the effects of plagiocephaly and congenital muscular torticollis (CMT), increase knowledge of how to prevent these conditions, and increase knowledge of when a caregiver should seek care from a healthcare professional related to these conditions.
NUMBER OF SUBJECTS: Five (5) participants provided informed consent and completed the pre- and post-surveys.
MATERIALS/METHODS: Following signed informed consent, participants, who were expectant parents, completed a pre-survey indicating knowledge of the benefits of supervised tummy time during play in order to decrease the severity and prevalence of plagiocephaly and CMT. The participants were then encouraged to participate in an online TummyWise Prenatal Education Course. Following the course, a post-survey was distributed to participants to assess if they had increased their knowledge and understanding of the benefits of supervised tummy time because of the educational video. Quantitative data was collected through pre- and post-surveys to determine the effectiveness of the online prenatal education course at increasing expecting parent's knowledge of strategies to prevent plagiocephaly and CMT. Data analysis occurred using 1-tailed paired t-tests to evaluate the hypothesis that the post-survey scores improved when comparing to the pre-survey scores. This helped researchers to note if the TummyWise Prenatal Education Course was beneficial for expecting parents.
RESULTS: Six of the responses to the surveys indicated statistically significant changes (p < 0.05), allowing the researches to accept the hypothesis that the TummyWise Prenatal Education Course increased parents' and caregivers' knowledge about the effects of plagiocephaly and CMT as well as provided strategies for prevention.
CONCLUSIONS: The purpose of this study was to investigate the effects of TummyWise Prenatal Education Course on parents' and caregivers' knowledge on the benefits of supervised tummy time while the child is awake. Online prenatal education courses are effective in increasing parents' knowledge of tummy time. However, due to the limited sample size, additional research should be conducted to strengthen any findings established in this study.
CLINICAL RELEVANCE: Prenatal education on tummy time is an important component of preventing plagiocephaly and CMT. This study demonstrated the ease and effectiveness of providing online prenatal education for expecting parents and caregivers. Physical therapists could use this format of education to decrease the prevalence of torticollis and plagiocephaly and increase the acquisition of optimal gross motor development in infants.
100-YEAR HISTORY OF PEDIATRIC PHYSICAL THERAPY: FULFILLING OUR MISSION
Goncalves S (Ivy Rehab for Kids), Lovelace-Chandler V (Allen College), Aguirra Valenzuela ME (Newark Therapy Services), Weinstein FD (Private Practice: Pediatric and Aquatic Physical Therapy), Glumac L (Aspirations, LLC, Early Intervention Agency)
PURPOSE: This special interest topic demonstrates how preserving the rich history of pediatric physical therapy and the APPT will enhance pride of membership, provide testimony to achievement of the Academy's mission of excellence in advocacy, education, and research, and inform strategic planning.
DESCRIPTION: In the 1900s, early physical therapists (PTs) in the US established the profession and a professional organization because of two societal forces: war and polio. Reconstruction Aides in Physiotherapy (RAPTs) were educated and deployed to care for wounded warriors. Other practitioners, often called Rehabilitation Aides, worked in the US to optimize outcomes for children affected by polio. One therapist, Janet Merrill, integrated these two realms through her expertise in pediatrics and her experience in teaching by serving as an educator for RAPTs. In 1921 when the association was formed by RAPTs returning from World War I, these founders “adopted” Ms. Merrill. As a pediatric PT who was the only charter member not having served as a RAPT, she became an elected officer bringing a pediatric perspective to the organization. Soon after, special hospitals, clinics, and schools were developed to meet the unique needs of children. Over the next 100 years, pediatric PTs emerged to lead research and treatment protocols of commonly treated pediatric disorders, and eventually, they were considered colleagues with physicians and other interprofessional team members. The Section on Pediatrics formed in 1974 under the leadership of G.E. “Bud” de Haven. The Section quickly advanced to recognize Pediatric Certified Specialists (1986), create a peer-reviewed professional journal, Pediatric Physical Therapy (1989), promote special interest groups for an expanding scope of practice (now numbering 10 SIGs), and to recognize the Advanced Proficiency Pathway for Physical Therapist Assistants (2018). Renamed the Academy of Pediatric Physical Therapy (APPT) in 2016, these accomplishments provide evidence of excellence in fulfilling the mission of advocacy, education, and research. The APPT History Committee invites all members to assist in preserving the historical documentation of important work being accomplished throughout the country. Please contribute to “ourstory” by sharing artifacts, oral or written narratives, and pictures.
SUMMARY OF USE: Data were collected from the earliest historical archives and documents of the APTA and the Section/Academy to the present. Persistent themes and critical milestones of the advancement of the field of pediatric physical therapy were analyzed for credibility and evaluated for importance.
IMPORTANCE TO MEMBERS: Documentation of APPT's history is crucial to honoring the contributions of individual members, past and present; to enhancing the pride and strength of the APPT derived from awareness fulfilling the mission, vision, and values through significant past experiences; and to providing resources for members and stakeholders to reflect upon the past, appraise the present, and evolve for the future.
THE DEVELOPMENT OF A PEDIATRIC PELVIC FLOOR REHABILITATION PROGRAM WITHIN A PEDIATRIC OUTPATIENT PHYSICAL THERAPY SETTING
Higgins L, Heschle A. Children's Specialized Hospital
PURPOSE: One in seven healthy, school-aged children are affected by some form of incontinence. Physical therapy treatment is an effective method of treating incontinence, however pediatric physical therapists are not often trained in the treatment of this specific condition. Due to the prevalence of incontinence and other related pelvic floor conditions affecting the pediatric population and the lack of trained physical therapists, there is a gap in accessing care. The goal of this platform presentation is to highlight outpatient physical therapy pelvic health program development to facilitate implementation in other clinics, thereby improving access to care.
DESCRIPTION: In January 2020, a proposal for the development of a Pelvic Health Program at Children's Specialized Hospital in Mountainside, NJ was accepted and supported by senior leadership and administration. With proposed deadline of June 2020, a task force including 2 pediatric pelvic floor trained physical therapists developed and implemented a clinical pathway for evaluation and treatment of pediatric patients with pelvic floor dysfunction. This included development of program specific documentation including evidenced based evaluation and treatment templates supported by APTA documentation guidelines, purchase and training of evidence supported assessment tools and treatment devices. Additional education and training was implemented to support departments including scheduling, insurance verification and authorization, and referral development and marketing.
SUMMARY OF USE: The Pelvic Health Program initiated physical therapy and evaluations in September 2020. During initial evaluations, patients are assessed using evidence based supported symptom and quality of life measurement tools, in addition to strength, range of motion, and functional testing. Patient treatment emphasizes standard urotherapy including strengthening and coordination of the pelvic floor musculature, bladder retraining, bowel and bladder logs and patient/family education. Although these treatment techniques are generally used for all patients with incontinence, they are tailored to meet the individual needs of the patient. Significant change in symptom scale scores is supported by evidence to indicate symptom improvement and resolution. Therefore, these tools are utilized to assess patient's progress through the course of treatment and to analyze trends of overall patient outcomes.
IMPORTANCE TO MEMBERS: This platform presentation will demonstrate the program outcomes to date, an assessment of outcomes in regards to overall patient progress, and interpretation of the performance of the pelvic health program as a whole. Areas of success as well as areas of improvement for the program will also be discussed. This presentation is aimed to serve the pediatric physical therapy profession by sharing the processes and the tools required to develop a pediatric pelvic health program within an outpatient setting in order to provide much needed care to this underserved population.
THE ROLE OF THE PEDIATRIC PHYSICAL THERAPIST IN SCREENING, EXAMINATION, AND INTERVENTION STRATEGIES FOR THE YOUTH DANCER WITH AND WITHOUT GENERALIZED JOINT HYPERMOBILITY
Holt DG, Benedetto M. Drexel University
PURPOSE: To describe common injuries, screening tools, and rehabilitation principles for the youth dancer with and without generalized joint hypermobility.
DESCRIPTION: In this special interest presentation, we will (1) present common injuries in the youth dance population; (2) appraise current screening methods for the given population; (3) describe rehabilitation principles specific to the youth dancer with and without generalized joint hypermobility; (4) discuss the role of the pediatric physical therapist for the youth dancer. Clinical reasoning strategies that focus on progressions for developmental positions that are dance-specific (relevé, coupe, plie, etc.) will be presented.
SUMMARY OF USE: This educational platform is intended to inform pediatric physical therapists of their role in the management of the youth dancers with and without generalized joint hypermobility. We will provide screening tools that the pediatric physical therapist can use in clinical and community dance settings. Examination tools include, but are not limited to, measures for flexibility and alignment, core strength and control, and dance-specific moves. Evidence-based intervention strategies for common dance injuries that focus on dance-specific neurodevelopmental progressions will also be presented.
IMPORTANCE TO MEMBERS: Youth dancers, especially those with generalized joint hypermobility, are at increased risk for musculoskeletal injury. They often do not have access to comprehensive prevention and treatment programs that include dancer wellness, education, and intervention strategies. At present, screening and management of the youth dancer may not be well understood by the general pediatric clinician, which further limits access to appropriate care. Clinical reasoning for this population requires, not only understanding of the musculoskeletal and neuromuscular systems, but also the role of general development and development of postural control and balance. Furthermore, it is important for pediatric physical therapists to recognize and screen for generalized joint hypermobility and determine appropriate interventions and/or referral for further medical testing. This special interest topic will help bridge this knowledge gap and provide tools for the pediatric physical therapist to maximize the health of the youth dancer.
THE USE OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) IN ADOLESCENTS WITH SPONDYLOSIS AND SPONDYLOLISTHESIS
Irwin RR (Faulkner University), Likens C (University of Tennessee Health Science Center), Kingsley KR (Faulkner University)
PURPORSE/HYPOTHESIS: PURPOSE Adolescents with spondylolysis and grade I or II spondylolisthesis have pain that may impair the ability to function at home and school. Non-narcotic medication such as paracetamol and ibuprofen are recommended for the pain. Often, this does not provide relief and opioids or opioid-like medications are prescribed. The media's coverage of the Opioid Epidemic has heightened society's awareness of this serious problem that often begins in adolescents. In response, schools have developed “Opioid Emergency” plans and parents may struggle to ensure consistent school attendance. The purpose of this study was to determine if using transcutaneous electrical nerve stimulation (TENS) as an alternative pain control solution is effective in pain management and improve the quality of life in such adolescents.
NUMBER OF SUBJECTS: Twenty-six subjects with spondylolysis or grade I or grade II spondylolisthesis were contacted to participate in the study. Fourteen subjects between the ages 12-18 met criteria and were randomly assigned to an experimental or control group. Eleven completed the two-week trial.
MATERIALS/METHODS: Participants were provided pre and post quality of life questionnaires including: The Pediatric Quality of Life Pain Coping Inventory (PedQL PPCI), the Pediatric Quality of Life Visual Analogue Pain Scale (PeDQL™VAS), and the Scoliosis Research Society-22 Quality of Life Survey (SRS-22). The experimental group was provided with Empi SELECT TENS and instructed to wear it 2 hours daily for 14 days. The control group did not receive units. Both completed a post SRS-22, PedsQL™VAS, and the PPCI.
RESULTS: The mean age for the TENS group was 15.2 and the control 13.6. A student's T test indicated no significant difference in the mean age of the groups (P = 0.285). Data was analyzed using non parametric Mann Whitney U statistics (n = 11, experimental n1 = 5, control n2 = 6, cv = 3 and a = .05). The change in the Ped™VAS 7 day revealed a significant change in pain scores in the TENS group (u = 2.5 cv of u = 3). The change in Ped™VAS scores of the TENS group approached significance (u = 6, cv = 3). There was no significant difference in the PPCI scores between the TENS and the control group (u = 9, cv of u = 3). The SRS-22 revealed no significant changes in the quality of life of those who wore TENS compared to the control (u = 13, cv of u = 3).
CONCLUSIONS: This pilot study revealed that TENS may be an effective tool in reducing pain in adolescents with spondylosis and grade I and grade II spondylolisthesis. Further study is warranted to investigate the use of TENs with adolescents and its effect on the quality of life and pain coping skills.
CLINICAL RELEVANCE: Pain management in adolescents with spondylolysis or spondylolisthesis is difficult and the growing opioid epidemic adds to the complexity. Many adolescents have pain for prolonged periods of time and the use of non-narcotic pain relievers may not provide adequate relief for the child to return to school and non-sports activities. This pilot study suggests that TENS may provide relief for adolescents with spondylolysis and spondylolisthesis.
CARING FOR CHILDREN IN IMMIGRANT FAMILIES (CIF) BY UNDERSTANDING ACCULTURATION: HOW INTERNATIONALLY EDUCATED PHYSICAL THERAPISTS (IEPTS) CAN INFORM PEDIATRIC PHYSICAL THERAPY
Joshi SV (University of Illinois at Chicago), Aguila MC (Life in Motion Physical Therapy), Dholakia K (Widener University), Aguila B (Life in Motion Physical Therapy)
PURPOSE: In the US, 18.4 million children are from immigrant families and they face barriers in healthcare access, coverage, and utilization. Many CIF receive physical therapy and pediatric physical therapists (PTs) identify familial cultural beliefs that hinder service delivery but may struggle to apply culturally appropriate strategies to maximize family engagement. The purpose of this Special Interest Report is to introduce acculturation, as experienced by IEPTs, as a framework through which pediatric PTs can delve into lived experiences of immigrant families. The presenters will demonstrate how reflecting on one's cultural experiences can enhance service delivery to families from diverse backgrounds.
DESCRIPTION: IEPTs are 12% of the PTs, mostly first-generation immigrants that are part of the fabric of American society. The IEPT staff workgroup of the APTA provides a platform for dialogue between IEPTs and the PT profession. The presenters (members of the workgroup) will utilize Berry's Acculturation model to describe their professional and personal journeys. Acculturation refers to what happens when individuals that grow up in one cultural context move to a different culture. The processes of marginalization, separation, assimilation, and integration can inform how immigrants adopt/reject values of their home/host cultures and deal with acculturative stresses. Presenters will discuss examples of how cultural, linguistic, and economic diversity in the US adds layers to the acculturation process for immigrants. IEPTs develop a deliberate understanding of American culture “on the job” and learn how child-rearing practices, attitudes towards disability, health beliefs relate to families' ethnicity and race. Within this, are the cultural, socioeconomic, and geographic variables impacting children's activity choices and affordances. IEPTs can empathize with, and articulate the acculturation process for immigrant families and its impact on children's rehabilitation. Most US-trained PTs have firsthand experience of American family life and values that are implicit in their upbringing. In contrast, for IEPTs, this learning is explicit and informal. Neither group receives educational preparation on acculturation.
SUMMARY OF USE: Immigration status is a determinant of health outcomes for children. Knowledge of acculturation will spur pediatric PTs to reflect on their experiences with culture, respond to immigrant families with curiosity, and create a safe environment to increase families' engagement in Physical Therapy. The rich acculturation experiences of IEPTs could make them effective “culture brokers” in bridging gaps of cultural knowledge among their colleagues.
IMPORTANCE TO MEMBERS: Increased awareness among Pediatric Academy members of the acculturation experiences of immigrant families. Improved understanding of the impact of acculturative stresses on participation of CIF in Physical Therapy. Stronger therapeutic alliances between immigrant families and pediatric PTs.
PARTICIPATION OF STUDENTS WITH AUTISM SPECTRUM DISORDER ON SCHOOL TRIPS: PARENT EXPERIENCE
Kellar BL (University of the Sciences - DPT Department), Wynarczuk KD (Moravian University), Fadel K (University of the Sciences - DPT Department), Davis M (University of the Sciences - DPT Department), Pullen A. (University of the Sciences - DPT Department)
PURPOSE/HYPOTHESIS: The purpose of this study was to identify barriers and strategies to the successful participation of students with autism spectrum disorder (ASD) on school trips, as noted through the perspectives of their parents. Students with ASD often require individualized accommodations and planning, however, educational teams often don't have standardized strategies to appropriately accommodate them.
NUMBER OF SUBJECTS: A total of 268 parents of children (ages 6-21) with a diagnosis of ASD participated. The mean child age was 11.0 years. Most were enrolled in elementary school (62%) and attended public school (81%) in a suburban setting (66%). Most received special education services (96%). Most spent their day in regular education (43%), or special education (32%).
MATERIALS/METHODS: A Qualtrics survey was distributed through Facebook groups for parents of children with disabilities. The survey included questions regarding their child's school trip experiences, education, functional abilities, and demographics. Thematic analysis was used for analysis of open-ended responses, and SPSS was used for quantitative analysis. Crosstabulations were used to examine associations between student's communication function classification system level and their school trip experiences.
RESULTS: Two-thirds of parents reported that they do not have a voice in planning their child's school trips (66%). Most reported that their child looks forward to school trips (67%) and 44% reported that their child experiences stress when anticipating school trips. Parents reported that their child's participation in school trips was limited a tremendous amount or quite a bit by their sensory (55%) and behavioral (49%) needs. Only 27% of parents reported that their child can fully participate without accommodations. One-third (33%) reported that their child has been excluded from school trips because of their autism diagnosis. There was a statistically significant association between the child's functional communication and their history of being excluded from school trips; their ability to participate without accommodations; the extent to which their disability, sensory needs, and behavioral needs limit their participation; and their feelings of being safe and included during school trips. Parents reported that their child was “punished”, “shamed”, and/or “disciplined”, for their behaviors, and went into “in meltdown” or “shut down” due to “sensory overload”, and “they didn't let him participate”.
CONCLUSIONS: To promote the participation of students with Autism Spectrum Disorder on school trips, parents value having a voice in advanced planning, a culture that values inclusion and acceptance, and accommodations addressing their child's sensory and behavioral needs.
CLINICAL RELEVANCE: Physical therapists can collaborate with other educational team members and destination site personnel to address challenges, promote adaptability, and foster meaningful participation of students with ASD during school trips.
GROSS MOTOR FUNCTION IN A PRESCHOOL AGED CHILD WITH SPINAL MUSCULAR ATROPHY TREATED WITH NUSINERSEN, A CASE REPORT
Lastra S. Hackensack University Medical Center
BACKGROUND & PURPOSE: Spinal muscular atrophy (SMA) is a genetic, neurodegenerative disease with motor neuron demise culminating in progressive weakness and functional decline. New pharmacological therapies are revolutionizing treatment of the disease prior to motor decline. The purpose of this case report is to provide a clinical example of gross motor (GM) function in a child with SMA who received intrathecal nusinersen intervention, and to provide prognostic insight for physical therapists to modernize their plan of care.
CASE DESCRIPTION: A four-year-old child with asymptomatic SMA with 3 copies of the SMN2 gene, treated with nusinersen since infancy, received two episodes of physical therapy (PT) over a 20-month span from ages 29-49 months. PT interventions were devised based on clinical findings after initial evaluation, parent concerns and goals, and adjusted over time relative to patient needs and progress. GM skill testing was performed at varying intervals using the Development Assessment for Young Children 2nd edition (DAYC-2) and/or the Hawaii Early Learning Profile (HELP).
OUTCOMES: During the treatment period the child displayed low muscle tone, mild weakness and joint hypermobility. Initial GM assessment with the HELP indicated GM performance below age level; however successive HELP scores over the 20-month period demonstrated steady improvement in skill development with GM performance increasing to match and then surpass the child's age. During the second episode of PT care, gross motor testing using the DAYC-2 calculated the child's GM skill level in the “average” range between the 26th and 66th percentiles, indicating typical performance. At the end of PT treatment, the child was capable of independent community level participation in school and recreation.
DISCUSSION: With the advent of new medical therapies, a child with presumed SMA type 2 treated with nusinersen may have potential for typical GM function and independent community level participation despite underlying issues of low muscle tone, weakness and postural deviations inherent to SMA. For this new patient phenotype, the PT prognosis and plan of care need to evolve from a traditional maintenance focus to one which proactively pursues goals of timely acquisition of GM skills.
EFFECTIVENESS OF FUNCTIONAL PARTIAL BODY WEIGHT SUPPORT TREADMILL TRAINING PROGRAM ON MOTOR AND FUNCTIONAL SKILLS OF CHILDREN WITH ATAXIA
Lepoura A (University of West Attica), Lampropoulou S (University of Patras), Panagopoulos T (Kinitro&Kinisi:Child's Functional Therapy), Papadopoulou M (University of West Attica), Sakellari V (University of West Attica)
BACKGROUND & PURPOSE: Intervention and evaluation strategies for children with ataxia are poorly studied, indicating the need for high-quality and child-focus studies on physical therapy interventions, which could constitute optimal training strategies for improving motor and functional related skills. The purpose of this study is to investigate the effects of a functional partial body weight support treadmill training (fPBWSTT) on motor and functional skills, applied on children with ataxia.
CASE DESCRIPTION: Two children with non-progressive cerebral ataxia, one boy (13 years old, Gross Motor Function Classification System- GMFCS II) and one girl (12 years old, GMFCS III) followed a 4-week fPBWSTT, applied for 5 days/week for 45 minutes/day. Twenty minutes of treadmill training over a 30 minute period was performed in individualized low and high speed intervals of every 30 sec. High speed was progressively increased every day by 5% of the maximum high speed achieved at the previous day. Afterwards, in a 15 minute period children performed functional activities while walking in their low individualized speed. In a cyclic rotation three out of a total six functional activities were trained in each day. Motor and functional skills were assessed at baseline and by the end of the 4 week period, using the 10 Meter Walk Test (10MWT), the 6 Minute Walk Test (6MWT), the Pediatric Balance Scale (PBS), the Scale for Assessment and Rating Ataxia (SARA), the Timed Up and Go Test (TUG), the Gross Motor Function Measure-D and E (GMFM D-E) and children's spatiotemporal gait features were assessed through GaitSens software recording over a 2 minute low gait speed.
OUTCOMES: In both children SARA remained the same, while improvements were found in 10MWT (mean values, slow: from 0,553 m/sec to 0,636 m/sec and fast: from 0,94 m/sec to 1,17 m/sec), 6MWT (from 218,5 m to 276 m), TUG (from 12,8 sec to 11,94 sec), PBS (from 28/56 to 37/56), and GMFM D (from 66,6% to 70,5%). The GMFM E improved only to one child (from 59,7% to 68,05%). Spatiotemporal features of gait were improved in terms of step width (from 19,6 cm to 15,85 cm), stride (from 60,77 cm to 69,65 cm) and step length (from 30,75 cm to 34,9 cm) in both children. Variability of different changes between the lower limbs for both children was found at stance, swing and double support gait phases, while stride and step time were increased or remained the same.
DISCUSSION: The fPBWSTT is clinically feasible and could be beneficial for functional balance skills, functional motor skills in standing position and could enhance gait related improvements in speed, endurance, self-selected walking cadence, step width, stride and step length. Ataxia features may not be affected by the training, while no change trend on gait phases and time related changes seemed to be apparent. The fPBWSTT seems to have promising effects, but no conclusion can be drawn before a sufficient sample is evaluated.
USE OF NEUROPROSTHESIS AS AN ADJUNCT TO CONVENTIONAL PHYSICAL THERAPY METHODS TO IMPROVE PAIN LEVELS AND GAIT MECHANICS IN A CHILD WITH A VENOUS MALFORMATION IN THE CALF: A CASE STUDY
Lonergan M. Children's Specialized Hospital
BACKGROUND & PURPOSE: Intramuscular venous malformation is a condition that when present in the calf muscle can lead to a heel cord contracture, pain, and abnormal gait. While there is literature supporting the effects of serial casting, bracing, stretching, and functional electrical stimulation (FES) to improve passive range of motion (PROM) and gait mechanics in children with cerebral palsy (CP), there is a lack of evidence regarding effective treatment of these impairments in children with a venous malformation, especially in regards to pain management. Therefore, the purpose of this case study was to demonstrate the efficacy of a multi-modal treatment approach consisting of serial casting and traditional physical therapy (PT), in conjunction with FES training using the Bioness L300 neuroprosthesis, to improve pain levels and gait mechanics in a child with a venous malformation in the calf muscle.
CASE DESCRIPTION: Patient was a 13-year-old female with a venous malformation at her left (L) calf, with resulting L heel cord contracture. Patient/caregiver primary complaints were in regards to her walking pattern and significant pain with ambulation, running, and jumping, limiting her ability to participate with her peers and engage in daily activities without pain. Patient completed 8 weeks of serial casting to improve L ankle dorsiflexion (DF) ROM, followed by 8 weeks of outpatient PT 1x/week focusing on stretching/strengthening of L lower extremity. To complement these conventional methods, patient also participated in 5 sessions of FES training utilizing a more novel neuroprosthesis (Bioness L300 GO foot drop device) at her L lower leg for neuromuscular re-education, gait training, and pain reduction.
OUTCOMES: Outcome measures included the Numeric Pain Scale (NPS) and objective gait mechanic data utilizing GAITRite software and Observational Gait Scale (OGS). Measurements collected pre-intervention (T1), immediately post-casting (T2), and 3 months post-casting with Bioness L300 unit donned (T3). Immediately post-casting, NPS score with ambulation improved from 5/10 to 2/10 and from 8/10 to 4/10 with running/jumping, however, pain was still present. While donning Bioness L300, patient reported 0/10 pain with ambulation, running, and jumping activities. OGS scores improved from L 7/22, R 15/22 (T1) to L 18/22, R 19/22 (T2) to L 18/20, R 20/22 (T3). GAITRite data revealed increased gait velocity, step length, and stride length, with noted improvements in symmetry from pre-intervention to while donning Bioness L300.
DISCUSSION: This case study provides preliminary evidence that a comprehensive, conservative approach combining the conventional methods of serial casting and PT with a more novel neuroprosthesis may be effective in children to address some of the secondary impairments associated with a venous malformation in the calf, specifically pain and asymmetries in gait.
COMPARISON BETWEEN PEDIATRIC PHYSICAL THERAPY PROCESS OF CARE AND HOME EXERCISE PROGRAM IN TELEHEALTH AND IN-PERSON SETTINGS
Ludes K, Powell E, Redwine L, Roseberry K, Sanchez L, Tiwari D. Simmons University
PURPOSE/HYPOTHESIS: The purpose of this study was to assess the physical therapy process of care related to home exercise programs (HEP) in the pediatric telehealth and in-person setting. The COVID-19 pandemic posed unique challenges for the healthcare system that resulted in a considerable increase in telehealth utilization as a standard of pediatric physical therapy practice. Increased utilization of telehealth has changed the way HEP is administered, how adherence to the HEP is measured, and the utilization of outcome measures. Therefore, an accurate understanding of the differences in the process of care of increased utilization of telehealth services on pediatric physical therapy is needed. This study aimed to 1) describe factors perceived by physical therapists that facilitate or hinder adherence of HEP in pediatric telehealth, 2) determine the degree of adherence of pediatric patients with HEP via telehealth versus in-person, 3) describe commonly used outcome measures in the pediatric setting and their utility when used for telehealth.
NUMBER OF SUBJECTS: Seventy-five pediatric Physical Therapists within North America who have practiced via telehealth in the last 6 months participated in the study.
MATERIALS/METHODS: An anonymous survey consisting of 25 items was developed and validated. The survey comprised of questions related to demographics, telehealth process of care, adherence with HEP, and barriers and facilitators for practice. The survey was disseminated electronically via email and social media. Descriptive statistics were used to report data from the survey.
RESULTS: Overall, 62.7% therapists believed telehealth as a whole improved HEP adherence. High parental involvement, better perceived therapist-patient relationship, high patient participation, better access to technology, and caregiver understanding of HEP were considered as facilitators of adherence with HEP. Lengthy HEP (duration of >30 minutes) was the most identified factor (78.8%) for hindering adherence to HEP. Thirty five percent of therapists reported changing outcome measures because they were unable to complete these measures via telehealth, 21% of therapists reported not using any new measures over telehealth. Additionally, 63% of the therapists reported having technical difficulties while practicing telehealth.
CONCLUSIONS: Providing shorter HEP, involving patients/families in the planning, and improving access to technology could facilitate adherence with HEP.
CLINICAL RELEVANCE: The recent pandemic forced clinicians to find alternate methods of providing care. Telehealth in pediatrics is a novel concept with a promising future. This study provides preliminary data on the pediatric telehealth process of care and adherence to HEP.
ASSESSING FACILITATORS AND BARRIERS TO PARTICIPATION IN REGULAR PHYSICAL ACTIVITY IN ADOLESCENT PATIENTS WITH CYSTIC FIBROSIS WHO RESIDE IN APPALACHIA
Mason A, Neidermeyer C, Ball M, McCutcheon A, Martin M, Peek S. Marshall University
PURPOSE/HYPOTHESIS: Research suggests that regular, aerobic physical activity (PA) is beneficial in improving lung function and enhancing quality of life of adolescents with cystic fibrosis (CF.)1,2 Many patients with CF do not participate in regular PA or are less active than their peers.1 Adolescents in Appalachia tend to participate in less PA than their peers in other geographic locations.3 The purpose of this research was to explore attitudes toward regular PA by assessing facilitators and barriers in adolescents with cystic fibrosis (CF) who live in Appalachia.
NUMBER OF SUBJECTS: 7
MATERIALS/METHODS: Physical Therapists (PTs) who work with adolescents with CF were identified through an email listserv and asked to provide feedback on a survey to be administered to adolescents with CF who reside in Appalachia in order to discover facilitators and barriers towards regular PA. 4 PTs responded to the request and were asked questions regarding experience with CF, feedback on the survey, ideas regarding facilitators and barriers of PA, and common health problems noted in this specific population. Their answers were used to modify the existing survey. Participants for the survey were then recruited through convenience sampling from a CF Center in Charleston, WV. Participants and their legal guardian were required to read and sign the consent and assent forms. One interview was conducted in person. All others were conducted via phone due to the COVID-19 pandemic. Participants were asked open-ended questions and interviews were recorded and transcribed. Answers were then categorized into common themes of facilitators and barriers of regular PA.
RESULTS: Seven adolescents (4 male, 3 female) were recruited from the CF Center in Charleston, WV with ages ranging from 11-16 years. The data collected through the interview process was broken down into emergent themes that included facilitators and barriers. Facilitators included perceived benefit of socialization and perceived health benefits. Participants described barriers as internal or external. Internal barriers included feeling worse after PA, inability to keep up with peers, fatigue, and fear of injury. External barriers included heat, time constraints, electronics, and COVID-19 restrictions.
CONCLUSIONS: Due to the known benefits of PA on the health of patients with CF, understanding the factors that influence participation is important in order to implement interventions that will increase PA in this patient population. Facilitators and barriers to PA were identified and should be considered when prescribing an exercise program or addressing non-adherence to a program when working with adolescents with CF.
CLINICAL RELEVANCE: Physical therapists are advocates for wellness and health promotion. The results of our study will help PTs educate patients and implement effective strategies to improve overall health of patients with CF. Specifically, noting fatigue as a perceived barrier, education on benefits of exercise and its implications on fatigue levels is very important. Also, identifying group exercise programs for patients with CF to participate in may be beneficial as socialization was a perceived benefit.
PEDIATRIC PHYSICAL THERAPY DURING A PANDEMIC: ASSESSING PERCEPTIONS OF PROVIDING SERVICES THROUGH TELEHEALTH
McNamara KCS, Thorpe D. University of North Carolina Chapel Hill
PURPOSE/HYPOTHESIS: The COVID-19 Pandemic required a sudden shift in the provision of pediatric physical therapy from in-person service to a telehealth platform. Previously, telehealth studies have targeted adults,1,2,3,4,5 but little research exists on telehealth services in pediatric physical therapy (PT)6. The purpose of this study was to identify the perceptions of pediatric physical therapists and identify barriers and facilitators to providing telehealth services.
NUMBER OF SUBJECTS: A total of 165 pediatric physical therapists participated in the study.
MATERIALS/METHODS: A mixed methods approach utilizing an online, national survey asked questions related to demographics, and participants' perceptions of providing pediatric PT through telehealth.
RESULTS: Thirty-four percent had more than 20 years' experience and 16% had 0-3 years' experience. Ninety-eight percent of therapists had no prior training or education related to provision of telehealth therapy services prior to COVID 19. Twenty-nine percent rated their pre-pandemic level of comfort with providing telehealth services as “somewhat uncomfortable” and 35% as “very uncomfortable”. After utilizing a telehealth platform, 48% of therapists reported their perception of telehealth as “somewhat positive”, and 18% as “very positive”. Therapists indicated main barriers to providing a successful telehealth session were 1) poor patient and parent participation, and 2) technology issues. Main facilitators were: 1) hands on involvement from parents, 2) ability to share information/simultaneously, and 3) ability to use items/toys in the home. Main perceived benefits for patients and families included 1) access to care, 2) continuity of care, and 3) consistent parent/patient involvement. Main benefits for therapists were 1) consistent patient/parent involvement, 2) direct application to the home environment, and 3) adaptation of the activity to the home environment. Predominate themes to open-ended responses of pre-telehealth perceptions were: How to provide pediatric physical therapy utilizing telehealth and concern for efficacy of telehealth services and potential benefit(s) of telehealth. Predominant themes regarding perceptions of telehealth after implementation, were: The benefits of telehealth for patients and their parents, the impact of telehealth on physical therapy practice, the importance of parental participation to the child's continued progress, and parent empowerment.
CONCLUSIONS: Overall, pre-COVID-19 perceptions of therapists related to telehealth were negative. However, after implementing telehealth services during COVID- 19, a majority of therapists indicated their perceptions shifted to somewhat or very positive.
CLINICAL RELEVANCE: These results indicate promising applications of telehealth for pediatric therapy services; however, educational, socioeconomic and infrastructural or technological barriers need to be addressed.
PHYSICAL THERAPIST ROLE IN TREATING AND MANAGING PATIENTS WITH VENTRICULAR ASSIST DEVICES
Parish A. University of Alabama at Birmingham
PURPOSE/HYPOTHESIS: Over the past decade, usage of pediatric ventricular assist devices (VADs) in those with heart failure has grown tremendously. Children with VADs are now transitioning from acute care based settings to outpatient based-settings. As VADs are considered life sustaining devices, it is imperative that physical therapists (PTs) understand how to screen to prevent VAD emergencies, as well as how to handle them in clinical settings. Examples of emergencies include hemorrhagic stroke, machine failure, as well as code events. The purpose of this study is to assess demographics and setting practices of PTs working with patients with VADs, as well as the frequency of services, types of VADs seen in practice, and if PTs are trained to handle VAD emergencies.
NUMBER OF SUBJECTS: 47
MATERIALS/METHODS: 47 PTs who work with children in heart failure ages 18 and under were surveyed through Milestones and the Academy of Cardiovascular and Pulmonary Listserv to identify demographics, percentage working with VADs, frequency of services, types of VADs seen in clinical practice, training in medical emergency. Based on the number of VADs implanted yearly in pediatrics, number of heart centers in the United States, survival rates, and average waiting time to heart transplant, it is estimated that the sample size of PTs working with patients in this domain is between 50-100.
RESULTS: The results of this study show that PTs working with patients with VADs are mainly in the acute care setting. Most respondents have over 13 years of experience with 60% having an ABPTS Clinical Specialty in Pediatrics or Cardiovascular and Pulmonary. PTs in larger cities are seeing over 30 patients with VADs per year. The most commonly seen VADs include Berlin Heart Excor, Heartware, Heartmate, and Abbott Centrimag. Frequency of services becomes higher after the age of 12. Greater than 70% of respondents report that they are not VAD trained.
CONCLUSIONS: This study demonstrates that children with VADs are beginning to be seen by PTs outside of the acute care setting. Frequency is set inconsistently based on age of patient, which may be due to lack of practice guidelines in this area. This study also shows that PTs working with children who have VADs lack training to prevent and management VAD emergencies, which can have detrimental consequences, especially if intervention is taking place outside of the acute care setting.
CLINICAL RELEVANCE: With mechanical advancements, children with VADs are transitioning home and presenting in settings like outpatient, school, early intervention, as well as home health. There are currently no practice guidelines for this population, which can impact consistency of frequency, interventions, as well as overall outcomes. Additionally, most PTs who work with patients with VADs are not trained to prevent or manage medical emergencies. Those that are trained in medical emergency management are trained once or yearly depending on setting. Further research is needed in order to develop guidelines for PT practice, as well as a maintenance competency for VAD emergencies.
THE EFFECTS OF YOGA THERAPY ON QUALITY OF LIFE IN PEDIATRIC PATIENTS WITH ONCOLOGICAL DIAGNOSES: A SYSTEMATIC REVIEW
Rinehimer MA, Hartz M, Tota K, Harnish T. Misericordia University
PURPOSE/HYPOTHESIS: Yoga therapies have increased in recent years as a physical therapy treatment to improve mood, anxiety, and fatigue in adolescents and adults with cancer. A pediatric cancer diagnosis is correlated with high rates of depression and anxiety and has large financial implications for parents/guardians. The purpose of this study was to examine the effects of yoga therapy on the overall quality of life in the treatment of pediatric patients with an oncology diagnosis.
NUMBER OF SUBJECTS: 89 children/adolescents, 76 parents from 9 studies
MATERIALS/METHODS: Electronic databases searched in January 2021, PubMed and EBSCO databases: Academic Search Ultimate, CINAHL Complete, and MEDLINE provided valuable studies. Science Direct, Springer, and Sage revealed no additional studies. Nine studies met inclusion criteria and were grouped according to yoga session frequency: multiple sessions per week, one session per week or studies that consisted of more than one yoga session, and single yoga session studies.
RESULTS: The most effective treatment frequency was found to be one session each week. There were 16 children and 24 parents included in the 3 studies which meet the one session per week criteria. Geyer et al used the PedsQL 4.0 to assess the effects of yoga therapy. Orsey et al used the PedsQL 4.0, the PedsQL 3.0 Cancer and the fatigue scale, a yoga satisfaction survey, health-related quality of life (HRQOL)-short form, and the Caregiver burden interview survey. Wilford et al used the PROMIS system to access parent-perceived QOL changes. These studies consistently showed positive trends in emotional, social, school function, and quality of life as reported by either parent and/or children. The one session per week studies also displayed better retention compared to the multiple session per week studies. Yoga treatment included as a component of inpatient cancer treatment may be the most effective treatment setting, as it does not add another appointment or travel obligation to the family's schedule.
CONCLUSIONS: Yoga therapy may be beneficial in the treatment for improving the psychosocial impacts of cancer by improving mood, anxiety, and fatigue in the pediatric oncology population. The benefits of yoga have been studied extensively in the adult population, and this study has revealed that yoga may have similar effects in the pediatric cancer population.
CLINICAL RELEVANCE: Yoga therapy as a component of physical therapy interventions for children with oncological diagnoses may be beneficial based on the results of this systematic review and the results of previous research with adult populations. Future research with improved randomization is needed to confirm these results and to provide more concrete exercise prescriptions for the use of yoga therapy in pediatric oncology physical therapy treatments.
DOES EXTERNAL SENSORY STIMULATION CHANGE GAIT IN CHILDREN WITH IDIOPATHIC TOE WALKING
Roberts D (Springfield College), Hurley E (Springfield College), Krovitz G (Springfield College), Mudway R (Springfield College), Smith S (Connecticut Children's Care Network)
PURPOSE/HYPOTHESIS: Idiopathic toe walking(ITW) in children is defined by lack of heel strike at initial contact and lack of full foot contact during the entirety of stance phase of gait. Children diagnosed with ITW do not have health conditions related to the gait deviation seen. It has been speculated that children with ITW have sensory processing abnormalities contributing to the gait deviations. The purpose of this systematic review is to assess the efficacy of somatosensory external stimulation(SES) on gait parameters in children with ITW.
NUMBER OF SUBJECTS: N = 137
MATERIALS/METHODS: MEDLINE complete, CINAHL, Cochrane Database of Systematic Reviews, and Physiotherapy Evidence Database(PEDro) were searched. Our final search strings, “Physical Stimulation” and toe walk*, “Sensory Threshold” and toe walk*, Idiopathic Toe Walking* were used for all databases. We included articles if subjects were < 18 years, had a formal diagnosis of ITW, an intervention using SES that was not auditory was used, and gait outcomes were measured. We excluded articles if they were non-English, if subjects had a neurological diagnosis, previous surgery for ITW, or gait deviations not related to ITW. Articles that met our criteria were appraised using the PEDro scale.
RESULTS: Six articles met criteria for inclusion. Study designs included randomized control trial (RCT)(2), non-RCT(1), case-control(2), and cohort(1). Studies used SES interventions including whole body vibration(WBV), orthoses, variable walking surfaces, and ankle taping. Mean age of subjects was 6.5 years. Intervention length varied with the longest being 6 weeks. No study did long-term follow up on gait changes. Due to heterogeneity in outcomes, a meta-analysis was not conducted. PEDro scores ranged from 3-5 with a mean of 3.8.
CONCLUSIONS: WBV done for 5 minutes before walking resulted in immediate improvements in ankle mobility and heel contact percentage that did not carry over 20 minutes post intervention. WBV of < 5 min did not change gait. Walking on noxious stimuli such as gravel resulted in a higher percentage of steps with heel contact compared to carpet or vinyl type surfaces. The percent of steps with heel vs toe contact increased when walking with stiff tape or bracing maintaining ankle dorsiflexion, or with a rigid foot orthoses inside a high top shoe compared to barefoot walking. This was seen both acutely and after a 6 week wear period, though carry over to barefoot walking was only seen after the six week intervention. Most studies assessed acute changes to gait with no long term follow up. Further, intervention parameters and outcome measures varied and not all studies assessed passive ankle mobility at baseline making comparisons between results difficult.
CLINICAL RELEVANCE: It is hypothesized that children with ITW have altered sensory processing that contributes to their gait. SES interventions that did not also influence biomechanics/structure resulted in only acute gait changes. External rigid bracing appears to be the most effective at increasing heel contact when being worn. It is unclear if rigid external bracing improves heel strike due to an altered somatosensory input or biomechanical changes.
BENEFITS OF STUDENT PHYSICAL THERAPIST INTERNATIONAL COLLABORATIVE LEARNING
Stuyvenberg C (University of Minnesota), Dhawan A (University of Minnesota), DiSpirito K (The Plaster House), Maetzold P (University of Minnesota)
PURPOSE: Physical therapy education has been greatly impacted by Covid-19. As children under age 12 years have not been vaccinated, they have been prohibited from participating in pediatric physical therapy classroom labs, demonstrations, and practical exams. To fill this void, alternate experiences were sought to excite and inspire a new generation of pediatric physical therapists. Building on the established relationship between the University of Minnesota Global Health Program and The Plaster House (a pediatric rehabilitation facility in Arusha, Tanzania), a collaboration was initiated. The aims of this union served to provide pediatric physical therapy students an engaging learning experience and to provide The Plaster House with needed resources.
DESCRIPTION: The Plaster House sought evidence-based rehabilitation protocols regarding common diagnoses seen at the facility. Highest priority was placed on rehabilitation protocols for children ages 8-16 years status-post osteotomy for the correction of genu varum/valgum related to skeletal fluorosis. The DPT students were divided into 4 groups of 3-5 students to develop exercises for four phases of post-osteotomy rehabilitation. The four phases included post-op non-weight bearing exercises, weight-bearing exercises in plaster casts, initial gait training with casts removed and knee flexion limitations, and gait training for the transition to home. The DPT students were provided with photographs and videos of the protocol currently employed at The Plaster House in addition to contact with The Plaster House local expert staff for collaboration.
SUMMARY OF USE: This learning opportunity was unique in exposing pediatric student physical therapists to global health. The students were charged with adapting evidence-based practices to low-resource settings and developing culturally/linguistically appropriate exercises while honoring societal differences in pediatric developmental expectations. Students also applied family-centered practices to the unique child, family, and extended family dynamics present in Tanzanian culture. Exercise protocols were generated in conjunction with local occupational and physical therapists at The Plaster House as procedures and tools may differ from US standard practice for practical reasons.
IMPORTANCE TO MEMBERS: We hope to find this partnership serves to excite the next generation of pediatric physical therapists during a difficult historical time while providing beneficial resources to the children and families receiving post-operative rehabilitation at The Plaster House.
STRESS, TRAUMA, AND BURNOUT EXPERIENCED BY NEONATAL THERAPISTS
Tenenholtz S (Brigham and Women's Hospital), Sweeney J (Rocky Mountain University of Health Professions)
PURPOSE: Stress, trauma, and burnout are recognized concerns in healthcare professionals but have not been reported in Neonatal Therapists. The purposes of this project were to explore the presence and pattern of workplace stress, trauma, and burnout in Neonatal Therapists and to identify support resources and workplace modifications for the Neonatal Intensive Care Unit (NICU) setting.
DESCRIPTION: A survey was distributed electronically through four primary sources: 1. social media (APTA Pediatrics Academy's Neonatology Special Interest Group and National Association of Neonatal Therapists); 2. specialty newsletter (APTA Pediatrics Academy); 3. Neonatology Fellowship Director panel (to reach fellowship graduates and colleagues); and 4. direct e-mails to Neonatal Therapist colleagues. Respondents included 69 participants with full survey completion and 79 participants with partial (>50%) completion. The multidisciplinary Neonatal Therapists represented physical therapy (47.9%), speech-language pathology (27.4%), and occupational therapy (24.6%). The majority (63.9%) worked in a Level III NICU with under 10 years of experience (25.6% 0-4 years; 25.6% 5-9 years).
SUMMARY OF USE: Neonatal Therapists reported stress, trauma, and burnout experiences across all NICU Levels of care. The pattern from the majority of participants was moderate physical and emotional fatigue in their respective occupation with slight burnout experienced. Neonatal Therapists identified the rate of frustration at work between 1-3 times per week. Neonatal Therapists indicated an emotional burden of feeling the full weight of clinical care on their shoulders while the primary NICU nursing and medical team members only moderately understood their therapy roles. Neonatal therapists revealed occasional (40.6%) stress related to workplace bullying and sometimes (42.0%) experienced that the NICU work environment as toxic, condescending, intimidating, or manipulative. Most Neonatal Therapists (63.2%) noted that caregiving modifications related to the COVID-19 pandemic contributed to further stress and new clinical challenges. Resource components identified as priorities for Neonatal Therapy workplace enhancement included increased communication and assistance from NICU leadership, expanded clinical training opportunities, and conflict management education and support. Future research is needed to explore potential changes in stress, trauma, and burnout experiences after implementing specific workplace support and resources for Neonatal Therapists.
IMPORTANCE TO MEMBERS: This exploration of NICU workplace stress, trauma, and burnout provides a beginning understanding of stress patterns experienced among Neonatal Therapists and reinforces the need to develop enhanced support resources. Neonatal Therapists may use these findings in strategic communications with hospital managers, including NICU leadership staff and rehabilitation managers, to create and increase support resources to decrease levels of workplace stress, trauma, and burnout.
TEST RETEST RELIABILITY OF THE HEAD CONTROL SCALE
Thomas J, Hudson B, Hoag N. Texas Woman's University
PURPOSE/HYPOTHESIS: Difficulty obtaining head control is often one of the first signs of aytpical development in the pediatric population and is often a target of intervention by pediatric physical therapists. However, no assessment tool is available that measures only head control, making it difficult for improvements in this area to be detected. The HCS was developed in 2019 and has been shown to have good interrater reliability. The purpose of this study is to establish the test retest reliability of the HCS, further establishing its psychometric properties. Significant changes in head control would not be expected in a week's time, so this study's hypothesis is that HCS scores will be consistent between the first and second test administrations.
NUMBER OF SUBJECTS: There were 31 participants who participated in the first administration of the HCS. Of those, 21 returned for a second visit, which was required due to the test retest format.
MATERIALS/METHODS: Participants were recruited from two outpatient pediatric physical therapy facilities, one privately owned and one hospital-based. Participant age ranged from 5 months to 10 years, 4 months (average 50.7 months). The most common diagnosis of participants was congenital/genetic disorders (n = 6). Other diagnoses included cerebral palsy (n = 5), anoxic or traumatic brain injury (n = 3), general developmental delay (n = 3), and other (n = 4). The HCS measures head control in prone, supine, pull to sit, and supported sitting; each dimension is measured on a 0-4 scale. The HCS was administered to each participant during the course of their regularly scheduled physical therapy session with the child's physical therapist helping the child obtain the positions and the researcher observing and documenting on the HCS form. The test was administered a second time 6-7 days later under similar conditions.
RESULTS: Due to missing data from 10 participants, 21 scores for the HCS were included in data analyzation. Cohen's Kappa was utilized to determine the agreement between participants' scores on the first and second administration, for each position. For prone, substantial agreement was obtained (k = .646); for supine, agreement was almost perfect (k = 1) and for both pull to sit and supported sitting, agreement was moderate (k = .613 and k = .533 respectively). Intraclass Correlation Coefficient (ICC model 3) with absolute agreement was used to compare total scores from the first administration to the second. ICC was .982, which indicates excellent reliability.
CONCLUSIONS: The HCS was developed to fill a gap in current assessment tools available to pediatric physical therapists. After its initial development, it is important for its psychometric properties to be established. This study shows that the HCS has good test retest reliability, indicating this assessment tool would be helpful in measuring head control in the pediatric population.
CLINICAL RELEVANCE: The HCS was developed to give clinicians a quick, easy-to-use, reliable tool by which to assess head control with the ultimate goal of using it to document changes over time. The results of this study show that a clinician can reliably use the HCS in clinical practice.
DEVELOPING AND ADDRESSING STUDENT GOALS THROUGH ONLINE AND HYBRID SCHOOL-BASED THERAPIES DURING COVID-19
Wynarczuk K, Bawayan R, Sanders E, Burmeister S, Milstrey B. Moravian University
PURPOSE/HYPOTHESIS: Beginning in March 2020 and extending through the 2020 – 2021 school year, many school-based therapists who had worked in in-person school settings quickly changed to online and hybrid service delivery due to the COVID-19 pandemic. The purpose of this research was to describe how school-based physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) develop and address goals for students who receive school-based related services via online or hybrid formats, particularly due to COVID-19.
NUMBER OF SUBJECTS: Twenty school-based therapists (7 PTs, 7 OTs, 5 SLPs, and 1 Certified Occupational Therapist Assistant) participated in an semi-structured interview. Participants had an average of 15.0 years working in school-based practice (range = 2 to 28 years). Eleven participants considered themselves “expert” therapists in school-based practice and 9 considered themselves “intermediate-level” therapists. Participants worked in 10 different states across the United States; 10 worked in primarily suburban schools, 5 in urban schools, and 5 in rural schools.
MATERIALS/METHODS: This study used a qualitative descriptive research approach. Interviews were conducted between October 2020 and March 2021. During the interview, participants were asked to describe how they developed and addressed student goals prior to COVID-19, and how they adapted those practices when they changed to online or hybrid service delivery. Researchers analyzed interview transcripts using an iterative thematic analysis approach.
RESULTS: Prior to COVID-19, 18 participants' school-based workloads were 100% in-person, 1 was 100% online, and 1 was hybrid. During initial COVID-19 shut-downs (April to May 2020), 17 participants' school-based workloads were 100% online and 3 were hybrid. At the time of their interview, 4 participants' school-based workloads were 100% online, 15 were hybrid (mean of 51.3% of workload online, range of 4-90% of workload online), and 1 had stopped working to care for her own children. Seven themes emerged related to developing and addressing student goals for students who receive school-based related services via online or hybrid formats: 1) Do we redefine school-based practice? 2) Do we redevelop IEP goals? 3) Do we change expectations? 4) How do we redefine priorities? 5) How do we define boundaries? 6) How do we collaborate with the educational team? and 7) How do we address inconsistent state, team, and contract expectations?
CONCLUSIONS: Therapists' comments reflected a great amount of grappling with how to approach school-based therapy for online and hybrid school formats and a striving toward identifying and following new best practices.
CLINICAL RELEVANCE: This study helps therapists identify and reflect on how school-based practices changed during the unanticipated move from in-person to online and hybrid schooling due to the COVID-19 pandemic, and how student goals may be developed and addressed for students who receive school-based related services via online or hybrid formats.