The effectiveness of tele-rehabilitation on improvement of daily living activities in children with cerebral palsy: narrative review

Trends in Telerehabilitation Utilization in the United States 2020-2021

OBJECTIVE

To examine telerehabilitation utilization in the United States (US) during the first 2 years of the pandemic.

DESIGN

We performed a retrospective analysis of outpatient insurance claims from the IBM MarketScan Commercial Claims and Encounters Database to identify the number and proportion of patients using telerehabilitation from 2020 to 2021. Telerehabilitation was identified based on the presence of specific code modifiers and place of service.

SETTING

Retrospective claims analysis.

PARTICIPANTS

Individuals living in the United States with employer-sponsored insurance plans using outpatient physical or occupational therapy (PT/OT) (N=2,007,524).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Number and proportion of outpatient PT/OT visits completed via telerehabilitation.

RESULTS

We identified 21,026,608 PT/OT visits among 2,007,524 patients. Overall, 49,974 (2.5%) patients received ≥1 telerehabilitation visit during the specified timeframe. We observed trends in utilization over time, with utilization peaking in April 2020 when 10.9% of all PT/OT visits were conducted by telerehabilitation. We also observed geographic trends with lower rates of utilization identified in rural areas. State-by-state utilization rates ranged from 10.4% (California) to 0.3% (Wyoming).

CONCLUSION

Telerehabilitation may be underutilized as a means of improving access to PT/OT, especially in rural areas of the country. Further research is needed to examine contributing factors to low observed utilization rates, such as provider and patient perceptions of telerehabilitation.

Telehealth services for children with neuro-developmental disabilities in the Asia-Pacific region: A systematic review

BACKGROUND

In recent years telehealth became a popular and a rational health service delivery approach, especially amidst multiple challenges posed while providing health care interventions during the COVID-19 pandemic.

AIM

We synthesized available evidence on telehealth for managing children with NDDs in the Asia-Pacific region with the aim of identifying successful methods.

METHODOLOGY

We systematically reviewed six electronic databases: MEDLINE, AMED, EMBASE, PsychInfo, Web of Science, and (CINAHL plus) using the keywords and database-specific subject headings from their inception to 25th August 2021. Review findings were synthesized narratively, and harvest plots were used to demonstrate the effect of interventions. The protocol and reporting the findings of this review adhered to PRISMA 2020 guidelines. PROSPERO registration: CRD 340690.

RESULTS

We harvested 30,823 records; 17,563 duplicates were removed, and 196 full-text articles were assessed for eligibility. 16 studies with multiple research designs were included in the review. Eight were from the Pacific region and eight represented Asia. The interventions targeted families and children with a variety of NDDs (autism spectrum disorder, Down syndrome, cleft lip and palate, hearing impairment, cerebral palsy etc.) via telehealth. Telehealth packages consisted of direct and indirect methods of synchronous, asynchronous, and hybrid approaches. All studies used parent-led intervention strategies. Telehealth reported a positive effect in 7/16 studies while five showed a neutral effect.

CONCLUSIONS

According to published evidence telehealth for children with NDDs is an evolving, evidence-based service facilitation modality in the Asia-Pacific region, with only a few published randomized controlled trials. The systematic review shows promising telehealth practices emerging across the region despite the diversity in NDDs studied.

An Exploration of Tri-Axial Accelerometers in Assessing the Therapeutic Efficacy of Constraint-Induced Movement Therapy in Children with Unilateral Cerebral Palsy

This study aimed to elucidate the role of tri-axial accelerometers in assessing therapeutic interventions, specifically constraint-induced movement therapy (CIMT), in children with unilateral cerebral palsy (UCP). The primary focus was understanding the correlation between the actigraphy metrics recorded during CIMT sessions and the resultant therapeutic outcomes. Children with UCP, aged between 4 and 12 years, participated in this study from July 2021 to December 2022. In conjunction with in-clinic sessions, during which participants wore tri-axial accelerometers on both limbs, we analyzed actigraphy data over three days of routine activities pre- and post-CIMT. While not all metrics derived from the accelerometers indicated significant improvements post-intervention, there was a clear trend towards a more balanced usage of both limbs, particularly evident in Axis 3, associated with vertical movement (p = 0.017). Additionally, a discernible correlation was observed between changes in the magnitude ratio derived from actigraphy data during CIMT (Δweek3-week1) and variations in traditional assessments pre- and post-intervention (ΔT0-T1), specifically the Assisting Hand Assessment grasp and release. Using tri-axial accelerometers has helped clarify the potential impacts of CIMT on children with UCP. The preliminary results suggest a possible link between actigraphy metrics taken during CIMT and the subsequent therapeutic outcomes determined by standardized tests.

Towards functional improvement of motor disorders associated with cerebral palsy

Cerebral palsy is a lifelong neurodevelopmental condition arising from non-progressive disorders occurring in the fetal or infant brain. Cerebral palsy has long been categorised into discrete motor types based on the predominance of spasticity, dyskinesia, or ataxia. However, these motor disorders, muscle weakness, hypotonia, and impaired selective movements should also be discriminated across the range of presentations and along the lifespan. Although cerebral palsy is permanent, function changes across the lifespan, indicating the importance of interventions to improve outcomes in motor disorders associated with the condition. Mounting evidence exists for the inclusion of several interventions, including active surveillance, adapted physical activity, and nutrition, to prevent secondary and tertiary complications. Avenues for future research include the development of evidence-based recommendations, low-cost and high-quality alternatives to existing therapies to ensure universal access, standardised cerebral palsy registers to harmonise epidemiological and clinical information, improved adult screening and check-up programmes to facilitate positive lived experiences, and phase 3 trials for new interventions.

Training Intervention and Program of Support (TIPS) for fostering adoption of family-centred telehealth in pediatric rehabilitation: Protocol for a multi-method, prospective hybrid type 3 implementation-effectiveness study (Preprint)

Background

Children with disability face long wait times for rehabilitation services. Before the COVID-19 pandemic, telehealth adoption was low across pediatric rehabilitation. Owing to the COVID-19 pandemic restrictions, pediatric therapists were asked to rapidly shift to telehealth, often with minimal training. To facilitate the behavior changes necessary for telehealth adoption, provision of appropriate evidence-based training and support is required. However, evidence to support the effective implementation of such training is lacking. The successful real-world implementation of a training intervention and program of support (TIPS) targeting pediatric therapists to enhance the adoption of family-centered telerehabilitation (FCT) requires the evaluation of both implementation and effectiveness.

Objective

This study aimed to evaluate TIPS implementation in different pediatric rehabilitation settings and assess TIPS effectiveness, as it relates to therapists’ adoption, service wait times, families’ perception of service quality, and costs.

Methods

This 4-year, pan-Canadian study involves managers, pediatric occupational therapists, physiotherapists, speech-language pathologists, and families from 20 sites in 8 provincial jurisdictions. It will use a multimethod, prospective, hybrid type 3 implementation-effectiveness design. An interrupted time series will assess TIPS implementation. TIPS will comprise a 1-month training intervention with self-paced learning modules and a webinar, followed by an 11-month support program, including monthly site meetings and access to a virtual community of practice. Longitudinal mixed modeling will be used to analyze indicators of therapists’ adoption of and fidelity to FCT collected at 10 time points. To identify barriers and facilitators to adoption and fidelity, qualitative data will be collected during implementation and analyzed using a deductive-inductive thematic approach. To evaluate effectiveness, a quasi-experimental pretest-posttest design will use questionnaires to evaluate TIPS effectiveness at service, therapist, and family levels. Generalized linear mixed effects models will be used in data analysis. Manager, therapist, and family interviews will be conducted after implementation and analyzed using reflective thematic analysis. Finally, cost data will be gathered to calculate public system and societal costs.

Results

Ethics approval has been obtained from 2 jurisdictions (February 2022 and July 2022); approval is pending in the others. In total, 20 sites have been recruited, and data collection is anticipated to start in September 2022 and is projected to be completed by September 2024. Data analysis will occur concurrently with data collection, with results disseminated throughout the study period.

Conclusions

This study will generate knowledge about the effectiveness of TIPS targeting pediatric therapists to enhance FCT adoption in pediatric rehabilitation settings, identify facilitators for and barriers to adoption, and document the impact of telehealth adoption on therapists, services, and families. The study knowledge gained will refine the training intervention, enhance intervention uptake, and support the integration of telehealth as a consistent pediatric rehabilitation service option for families of children with disabilities.

Trial Registration

ClinicalTrials.gov NCT05312827; https://clinicaltrials.gov/ct2/show/NCT05312827

International Registered Report Identifier (IRRID)

PRR1-10.2196/40218