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

Cognitive outcomes of the at-home brain balance program

Accessibility to developmental interventions for children and adolescents could be increased through virtual, at-home delivery of training programs. Virtual childhood training programs and their effects on cognitive outcomes have not been well studied. To that end, this study examined the effects of the at-home Brain Balance® (BB) program on the cognitive task performance of children and adolescents with baseline developmental and attentional difficulties. The study included students with reported diagnosis of ADHD, autism, anxiety, sensory processing disorder, or dyslexia, and students with no reported diagnosis (aged 4-17 years). The at-home BB program is delivered through (1) a computer-based format utilizing multimodal program activities previously studied in-center (multisensory stimulation, gross motor, coordination, balance, and nutritional recommendations); and (2) the BB app (visual motor, auditory and visual processing, and rhythm and timing training) - creating a comprehensive program experience delivered remotely. Cognitive performance was measured by six cognitive tasks from Creyos Health before and after 3 months of participation in the at-home BB program (N = 316) or in-center BB program (N = 4,232), compared to controls. Results showed that overall cognitive assessment scores (including attention, response inhibition, and working memory) improved after participation in either the at-home or the in-center program, compared to controls. Importantly, significant improvements over the controls were observed for two tasks involving attention and inhibitory control, in both programs. Further, two analyses support that the effects on cognitive performance from either delivery format, in-center or at home, are comparable in magnitude. This research: (1) presents new findings demonstrating improved cognitive performance after completing the at-home BB program; (2) replicates previous findings of cognitive improvements after completing the BB program; and (3) suggests that the cognitive effects of virtual at-home BB training are similar to those observed for in-center BB training. Overall, the results demonstrate the effectiveness of the at-home BB program in improving cognitive functioning in pediatric populations with preexisting developmental and attentional difficulties. Virtual delivery and ease of use, provide at-home programs the potential to reduce barriers of access to much-needed developmental and cognitive support, for individuals who may otherwise lack access to high-quality, evidence-based developmental programs.

Effectiveness of Telephysiotherapy in Improving Older Adults' Physical and Psychological Outcomes: A Systematic Review and Meta-Analysis

(1) Objective: to investigate the effectiveness of telephysiotherapy compared with traditional rehabilitation for elderly patients and determine the factors impacting its efficacy. (2) Method: Five online databases (PubMed, Google Scholar, Scopus, Web of Science, and Cochrane) were reviewed up to 31 July 2023. The search included the literature in English from 2014 to 2023, to capture the latest practices in telephysiotherapy for elderly patients. Data from all qualified studies were independently extracted by two authors, quantifying effect size to reflect treatment performance. (3) Results: 222 records from 19 articles were analyzed. The effect size for telephysiotherapy was 0.350 (95% C.I. = 0.283-0.416; p < 0.01). The standardized mean differences for physical and psychological outcomes were 0.406 (95% C.I. = 0.325-0.488; p < 0.01) and 0.223 (95% C.I. = 0.110-0.336; p < 0.01), respectively. (4) Conclusions: Telephysiotherapy was more effective than traditional rehabilitation, significantly improving the physical and psychological status of elderly patients. The factors influencing the effectiveness of telephysiotherapy were intervention type, intervention duration, outcome, and gender.

Telehealth in speech and language therapy during the COVID-19 pandemic: a systematic review

PURPOSE

The need for social distancing in order to reduce the prevalence of COVID-19 concomitant with the needs of patients as well as the protection of the patients and service providers which has led to the use of tele health in speech and language therapy. For this reason, we decided to review the studies that focus on tele health in speech and language therapy during the COVID-19 pandemic and the purpose of this study is to investigate the use and satisfaction of tele health in speech and language therapy.

MATERIALS AND METHODS

We conducted a systematic review of the literature in accordance with the PRISMA statement on google scholar, PubMed, Scopus, Science direct, ProQuest, Web of science, Springer and Cochrane databases between 2020 - 2021. An additional manual search was performed, taking into consideration references of the included papers, through the same eligibility criteria. Two researchers screened the titles and abstracts of articles that met inclusion criteria. The methodological quality of the included papers was evaluated using the Critical Appraisals Skills Program (CASP) checklists.

RESULTS

The collection of reviewed articles included 83 articles from different countries, subsequently 8 articles (3 clinical trials and 5 experimental) were selected. The data extracted were: participations, objects, methods, tools and results.

CONCLUSIONS

According to present study, tele health can be used in diagnosis and treatment of speech-language conditions as well as educating speech and language pathology students. Moreover, these findings showed patients and therapists were more inclined to utilise tele health.IMPLICATIONS FOR REHABILITATIONReduced access to in-person rehabilitation care in covid-19 pandemic, along with changes in health care finance and delivery, contributed to an exponential increase in telehealth.Measures of quality and patient satisfaction are unknown in the model of tele rehabilitation.To date, the literature on tele rehabilitation is limited and most commonly describes treatment for an impairment within a specific disease.Beyond infection control, eliminating travel time, incorporating other health care advocates, and convenience delivering care in familiar environments to pediatric patients are all benefits that will be durable outside times of pandemic.For families who live in rural or medically underserved areas and have access to internet and technology, telemedicine is a tool to provide access to medical care. Telemedicine can also increase patient and caregiver satisfaction through reduced travel and clinic wait time and increased potential for appointment time flexibility.Tele rehabilitation medicine provides an opportunity to deliver timely, patient and family-centric rehabilitation care while maintaining physical distancing and reducing potential COVID-19 exposure for our patients, their caregivers and medical providers.Since SLP mostly relies on communication through visual-auditory and perceptual aspects, tele practice could be a proper opportunity to provide care in this field.Given the need for continuous therapy sessions in order to treat speech-language disorders, the application of tele practice may eliminate problems in this area to some extent while preventing the transmission of COVID-19.

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

A novel entry-level collaborative clinical learning experience (CLE) in pediatric physical therapy (PT) delivered via telehealth was implemented involving 12 families, 54 DPT students, and 12 clinical instructors (CIs). Children of various ages, a wide range of home environments, and diagnoses received individualized PT via telehealth during a four-week CLE. Retrospective quantitative and qualitative analyses of student documentation, video recordings of sessions, and CI, student, and caregiver survey responses were performed. All children demonstrated qualitative improvements and 73% demonstrated quantitative improvements. CIs, students, and caregivers believed the children benefited from the experience and 98% believed the children were able to work toward their goals. Most students (95%) and CIs (100%) felt that it was a valuable and effective learning experience. Most (>71%) CIs and students believed students were able to learn in all relevant domains of the clinical performance instrument. This model provides a unique CLE for students in both pediatric PT and telehealth.

Effects of the COVID-19 Pandemic on SMA Screening and Care: Physician and Community Insights

OBJECTIVE

As part of efforts to reduce diagnostic delays and enhance clinical trials, Cure SMA evaluated the effects of COVID-19 on SMA care and clinical trial conduct.

INTRODUCTION

Spinal muscular atrophy (SMA) is an autosomal recessive neuromuscular disease characterized by progressive, potentially debilitating muscle weakness and atrophy. Uninterrupted access to early diagnosis, disease-modifying treatment, and care for SMA is vital to avoiding irreversible motor neuron death and achieving optimal patient outcomes.

METHODS

Two surveys were conducted: a provider survey and a community survey. The Provider Impact Survey, distributed from November 24, 2020, through March 8, 2021, assessed COVID-19's effects on referrals for evaluation of suspected SMA, cancellations and delays of SMA-related care, and clinical trials. The Community Impact Survey was fielded in three waves between April 7, 2020 and July 19, 2021, in tandem with Cure SMA COVID-19 support programs.

RESULTS

A total of 48 completed provider surveys (22 from care sites, 26 from care-and-trial sites) reflected decreases in referrals for suspected SMA, increases in appointment cancellations and delays, and patient reluctance to attend in-person visits due to COVID-19. One-third of care-and-trial sites reported trial recruitment delays, and one-quarter reported pausing trial enrollment. Results of the Community Impact Survey, completed by 2047 individuals, showed similar disruptions, with 55% reporting changes or limitations in accessing essential SMA-related services.

CONCLUSIONS

This research evaluates the pandemic's interruption of SMA care and research. These insights can help mitigate and increase preparedness for future disruptive events. Expanded use of virtual tools including telehealth and remote monitoring may enhance continuity and access. However, additional research is required to evaluate their effectiveness. While this research was specific to SMA, its findings may have relevance for other patient communities.

Delivery of School-based Physical Therapy via Telehealth: Perceptions and Attitudes of School-based Physical Therapists

AIMS

School-based physical therapists (SBPTs) rapidly transitioned to telehealth during the pandemic. This study explored the perceptions of, and strategies utilized by, SBPTs delivering therapy via telehealth.

METHODS

Using a grounded theory qualitative design, semi-structured interviews were completed with 13 SBPTs. Interviews were transcribed and theme coded until saturation was achieved.

RESULTS

The following themes emerged: supports and education, challenges, strategies promoting success, and the outcomes of telehealth. SBPTs overcame challenges including those associated with technology, communication, space, equipment, and examination. Coaching techniques, incorporation into the daily routine, and the sharing of demonstrations promoted success. Telehealth service delivery was perceived to improve communication with educational teams and families, improve efficiency and productivity, increase access to students, promote an appreciation of the family and home context, and enhance family engagement. SBPTs believe incorporating elements of telehealth in conjunction with in-person delivery is ideal.

CONCLUSIONS

While the COVID-19 pandemic forced a rapid transition to telehealth for SBPTs, lessons learned could have a long-lasting positive impact on school-based services. The benefits of telehealth should be considered in the delivery of school-based physical therapy services.

Evolution of a System to Monitor Infant Neuromotor Development in the Home: Lessons from COVID-19

In the nine months leading up to COVID-19, our biomedical engineering research group was in the very early stages of development and in-home testing of HUGS, the Hand Use and Grasp Sensor (HUGS) system. HUGS was conceived as a tool to allay parents' anxiety by empowering them to monitor their infants' neuromotor development at home. System focus was on the evolving patterns of hand grasp and general upper extremity movement, over time, in the naturalistic environment of the home, through analysis of data captured from force-sensor-embedded toys and 3D video as the baby played. By the end of March, 2020, as the COVID-19 pandemic accelerated and global lockdown ensued, home visits were no longer possible and HUGS system testing ground to an abrupt halt. In the spring of 2021, still under lockdown, we were able to resume recruitment and in-home testing with HUGS-2, a system whose key requirement was that it be contactless. Participating families managed the set up and use of HUGS-2, supported by a detailed library of video materials and virtual interaction with the HUGS team for training and troubleshooting over Zoom. Like the positive/negative poles of experience reported by new parents under the isolation mandated to combat the pandemic, HUGS research was both impeded and accelerated by having to rely solely on distance interactions to support parents, troubleshoot equipment, and securely transmit data. The objective of this current report is to chronicle the evolution of HUGS. We describe a system whose design and development straddle the pre- and post-pandemic worlds of family-centered health technology design. We identify and classify the clinical approaches to infant screening that predominated in the pre-COVID-19 milieu and describe how these procedural frameworks relate to the family-centered conceptualization of HUGS. We describe how working exclusively through the proxy of parents revealed the family's priorities and goals for child interaction and surfaced HUGS design shortcomings that were not evident in researcher-managed, in-home testing prior to the pandemic.

Use of Telemedicine Healthcare Systems in Pediatric Assistance at Territorial Level: Consensus Document of the Italian Society of Telemedicine (SIT), of the Italian Society of Preventive and Social Pediatrics (SIPPS), of the Italian Society of Pediatric Primary Care (SICuPP), of the Italian Federation of Pediatric Doctors (FIMP) and of the Syndicate of Family Pediatrician Doctors (SIMPeF)

Technological innovation can contribute to a reorganization of healthcare, particularly by supporting the shift in the focus of care from the hospital to the territory, through innovative citizen-centered models, and facilitating access to services in the territory. Health and social care delivery modalities, enabled by telemedicine, are crucial in this regard. The objective of this Consensus document, written by the main Italian Scientific Societies involved in the use of telemedicine in pediatrics, is to define a standard for its use at the territorial level in various declinations in the pediatric field; this paper also identifies priority areas for its application and the types of services that most require intervention and investment. The changes that are underway in digital transformation in all sectors are unstoppable, and for the digital transformation to take place in a productive sense, the contribution of not only all health professionals, but also of patients, is necessary. From this perspective, authors from different backgrounds were involved in the drafting of this Consensus and, in the future, other figures, primarily patients, are expected to be involved. In fact, this belongs to the vision of connected care, in which the citizen/patient actively participates in the treatment path so that they are assisted in a personalized, predictive and preventive way. The future scenario must be able to provide for the involvement of patients from the initial stages of planning any treatment path, even in the pediatric age, and increasing, where possible, the proximity of the health service to the families.

Relationship-driven, family-centered care via TelePT: Reflections in the wake of COVID-19

In response to the throttling of children’s therapy programs precipitated by COVID-19 shutdowns, interest in the use of telehealth has increased among service providers at both the clinical and administrative levels. TelePT promises to be particularly appropriate in devising programs of on-going, therapeutic exercise interventions for children with neuromotor disorders. From the lay perspective, physical/physiotherapy (PT) which is seemingly characterized by the “hands-on,” and corrective approach to managing impairments, makes it a counter-intuitive candidate for delivery over telehealth. Over the past decades, however, PT as a discipline has increasingly adhered to a relationship-driven, family-centered model of intervention. This model is “hands-off,” figuratively if not always literally, and hence is not necessarily disconsonant with delivery mediated by telehealth technology. The current study explores in-depth the experiences and reflections of seven practicing therapists, on the impact of telehealth, telePT on the operationalization of relationship-based, family-centered methods into therapy. Interpretative phenomenological analysis was selected as the analytic method for understanding participants’ experience providing services using both distance and standard face-to-face practice modalities. Results identified eight principal themes emerging from participants’ descriptions of their experience of delivering therapy over telePT. Four of these themes correspond to the tenets of relationship-driven, family-centered care identified across four frameworks applied to pediatric rehabilitation. The remaining four themes focus on the particularities of the telePT modality and its viability in clinical practice. The ability telePT afforded to “see into the child’s environment” emerged arguably as the greatest value of the modality in patient care. It revealed to therapists so much that they did not know about their patients’ progress and, more strikingly, had not realized they did not know. TelePT provides a unique window into the child’s functioning in the hours he is not in therapy. Given its potential in parent–therapist relationship building, assuring the ecological validity of therapy programs, and the empowerment of families who seek it, telePT is likely to be part of the future of PT and one driver of its evolution as a profession. There is a compelling case to retain telePT modalities offering them alongside in-person formats for convenience, safety, and service quality enhancement.

[Telerehabilitation of Subjects with Neurodevelopmental Disorders During Confinement due to COVID-19]

Introduction

Social distancing measures due to the COVID-19 pandemic prevented many children with neurodevelopmental disorders from accessing face-to-face treatments. Telerehabilitation grew at this time as an alternative therapeutic tool. In this study we analysed remote cognitive rehabilitation in neurodevelopmental disorders.

Methods

This was a prospective, quasi-experimental (before-after) study that included 22 patients (mean age 9.41 years) with neurodevelopmental disorders who had telerehabilitation for over six months.

Results

After six months of telerehabilitation, a statistically significant improvement was found with a large effect size in these areas: attention (sustained, selective and divided), executive functions (verbal and visual working memory, categorisation, processing speed), visuospatial skills (spatial orientation, perceptual integration, perception, simultanagnosia) and language (comprehensive and expressive). On the Weiss Functional Impairment Scale, all areas (family, learning and school, self-concept, activities of daily living, risk activities) improved with statistical significance. We found a positive correlation between the number of sessions and the improvement observed in executive functions (visual working memory, processing speed), attention (sustained attention, divided attention) and visuospatial skills (spatial orientation, perceptual integration, perception, simultanagnosia). We did not find statistical significance between the family structure and the number of sessions carried out. A high degree of perception of improvement and satisfaction was observed in the parents.

Conclusions

Telerehabilitation is a safe alternative tool which, although it does not replace face-to-face therapy, can achieve significant cognitive and functional improvements in children with neurodevelopmental disorders.

Voices of Teens and Young Adults on the Subject of Teleconsultation in the COVID-19 Context

This article describes the perceptions of adolescents and young adults aged 14 to 25 years who live in Québec (Canada) and obtained health services via teleconsultation for the first time, owing to the COVID-19 pandemic. Eleven young people who had received physical health services (medicine, physiotherapy, speech therapy, or nutritionist) participated in virtual semi-structured interviews. These interviews shed light on how these adolescents and young adults experienced the adaptation of the intervention and how effective they perceived the intervention to be. The article concludes with some thoughts for practitioners.

A post pandemic roadmap toward remote assessment for neuromuscular disorders: limitations and opportunities

Recent advances in technology and expanding therapeutic opportunities in neuromuscular disorders has resulted in greater interest in and development of remote assessments. Over the past year, the rapid and abrupt COVID-19 shutdowns and stay-at-home orders imposed challenges to routine clinical management and clinical trials. As in-person services were severely limited, clinicians turned to remote assessments through telehealth to allow for continued care. Typically, disease-specific clinical outcome assessments (COAs) for neuromuscular disorders (NMD) are developed over many years through rigorous and iterative processes to fully understand their psychometric properties. While efforts were underway towards developing remote assessments for NMD before the pandemic, few if any were fully developed or validated. These included assessments of strength, respiratory function and patient-reported outcomes, as well as wearable technology and other devices to quantify physical activity and function. Without many choices, clinicians modified COAs for a virtual environment recognizing it was not yet known how they compared to standard in-person administration. Despite being able to quickly adapt to the demands of the COVID-19 pandemic, these experiences with remote assessments uncovered limitations and opportunities. It became clear that existing COAs required modifications for use in a virtual environment limiting the interpretation of the information gathered. Still, the opportunity for real-world evaluation and reduced patient burden were clear benefits to remote assessment and may provide a more robust understanding and characterization of disease impact in NMD. Hence, we propose a roadmap navigating an informed post-pandemic path toward development and implementation of safe and successful use of remote assessments for patients with NMD.

Social media and the practice of pediatric physical medicine and rehabilitation in the COVID-19 pandemic: A new era in patient-care

Social media represents a significant source of health information for the public, especially during the COVID-19 pandemic where gatherings are limited. It is important for pediatric physical medicine and rehabilitation physicians to understand how their patients use these platforms in order to educate the public and provide sound medical advice on social media. Given the lack of current guidelines on medical education through social media, the purpose of this paper is to provide an overview of various online social media platforms and describe how they can be utilized to enhance pediatric patient education. It is necessary to understand the different educational functions and limitations of the various social media platforms. This text provides a comprehensive overview of different social media platforms, their educational uses, limitations, and sample accounts. Relevant to the COVID-19 pandemic, social media can improve the efficiency of educational delivery and clinic workflow. Although social media is not meant to replace physician-patient relationships, it can be used as a surrogate for health information and improve- even start- physician-patient relationships. Despite the benefits of social media, pediatric physiatrists may be hesitant to utilize these platforms for several reasons. This text provides an overview of common barriers to social media usage by physicians and recommendations to overcome them. Given that the pandemic has led to increased social media usage, physicians should be aware of its implications on patient care and how they can be used to enhance the practice of pediatric physical medicine and rehabilitation. As social media usage by both patients and physicians grows, more research is needed to create recommendations on how pediatric physiatrists can best utilize social media to educate the public in an enjoyable manner while maintaining a professional image.

Telehealth Program for Infants at Risk of Cerebral Palsy during the Covid-19 Pandemic: A Pre-post Feasibility Experimental Study

Aim: To verify the effects of a telerehabilitation program for infants at high risk for Cerebral Palsy (CP) during the COVID-19 pandemic.Method: Longitudinal study. Infants were aged 3-18 months corrected age, at risk of developmental delay. The General Movement Assessment or a neurologic examination were performed to identify the risk of CP. Motor function was assessed using the Gross Motor Function Measure-88 (GMFM-88) and the Alberta Infant Motor Scale (AIMS). Caregivers of infants at high risk of CP applied a home-based program supervised by a Physical therapist, five times a week over 12 weeks. The program included guidance for optimal positioning, optimization of goal-directed activities, environmental enrichment, and educational strategies.Results: 100 infants at risk for delayed motor development were recruited. Eighteen infants were classified at high risk of CP, and 10 families completed telerehabilitation (83% final retention rate). No adverse events were reported. Adherence to the telecare program was high (90%). The costs were low. We found increased scores for all dimensions and the total score of the GMFM-88, and the AIMS percentile at the end of the intervention. Most infants presented a clinically significant change for the GMFM-88.Conclusions: The telecare program was feasible.

Effectiveness and Acceptability of Telerehabilitation in Physical Therapy during COVID-19 in Children: Findings of a Systematic Review

The goal of this systematic review was to determine the efficacy and acceptability of telerehabilitation in physical therapy (PT) and parental acceptance during the COVID-19 pandemic in children. In 2021, an electronic search of academic articles was performed using databases such as Embase, PubMed and Scopus. One-hundred and one articles did not satisfy the eligibility criteria after deleting duplicates and reviewing abstracts, while 16 papers did not meet eligibility after reviewing complete texts. Hence, full texts for 13 articles were retrieved, which were incorporated in the review. All these studies were observational studies assessing the effectiveness and acceptability of telerehabilitation in PT required for diverse conditions in children during the COVID-19 pandemic. All included studies revealed a positive effect of telerehabilitation in PT during the COVID-19 pandemic in children with different conditions. Moreover, the included studies revealed that both rehabilitation professionals and parents or caregivers of children were satisfied with the telerehabilitation services provided remotely. Thus, telerehabilitation appears to be a suitable and convenient strategy to offer remote services to children in need but cannot visit in person due to COVID-19. The existing evidence shows that telerehabilitation can be considered effective for children who need PT for any health condition mainly during the pandemic. However, due to the dearth of studies in this area, exploring this topic is recommended mostly in low-middle-income countries with poor access to health care services and limited resources.

The Telemedicine-Based Pediatric Examination of the Neck and Upper Limbs: A Narrative Review

With the COVID-19 pandemic hastening the adoption of telemedicine into clinical practice, it has also prompted an abundance of new literature highlighting its capabilities and limitations. The purpose of this review is to summarize the current state of the literature on telemedicine applied in the context of a musculoskeletal examination of the neck and upper limbs for children 3 to 18 years old. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. General examination components including inspection, guided self-palpation, range of motion, sensory and motor examination, as well as special testing are described. Although the literature is focused mainly on adult populations, we describe how each component of the exam can be reliably incorporated into a virtual appointment specific to pediatric patients. Caregivers are generally needed for most consultations, but certain maneuvers can be self-performed by older children and adolescents alone. There is general feasibility, validity, and substantial reliability in performing most examination components of the upper limbs remotely, except for the shoulder exam. Compared to those made in person, clinical diagnoses established virtually were found to be either the same or similar in most cases, and management decisions also had high agreement. Despite this, there is evidence that some pediatric providers may not be able to collect all the information needed from a telemedicine visit to make a complete clinical assessment. Lastly, currently available smartphone applications measuring joint range of motion were found to have high reliability and validity. This narrative review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase physicians' confidence in incorporating telemedicine into their standard of care.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.

Lessons Learned during a Naturalistic Study of Online Treatment for Pediatric Rehabilitation

The COVID-19 pandemic forced many health care providers to modify their service model by adopting telehealth and tele-rehabilitation with minimal time to plan for its execution. ALYN-Pediatric Rehabilitation Hospital in Jerusalem, Israel, responded with alacrity by providing a broad range of rehabilitation services to young people via online therapy during the first 5 months of the pandemic. The objectives of this naturalistic study were: (1) to monitor usage and user experience of online rehabilitation provided to young people receiving out-patient sessions of physical therapy, occupational therapy, speech and language therapy and psychology and (2) to consider the advantages and disadvantages of retaining this model of online treatment in full or in part post-COVID-19. The online rehabilitation treatment program was provided to 147 young people, aged 3 months to 20 years (mean 8.5 y; SD 5.3), and monitored and evaluated via data from the medical records as well as interviews, questionnaires and focus groups. The results use descriptive and inferential statistics to analyze data on the types and frequencies of therapy provided to 147 young people. Over a five month-period, 2392 therapy sessions were provided, 61 therapists from four disciplines were involved and 56.4% of the young people received two or more types of therapies via online rehabilitation. A repeated measures ANOVA showed significant differences over time per therapy. Feedback and recommendations about the process from therapists, parents and young people were collected during two focus groups of the professional staff (n = 12), parents and young people (parents n = 5, young people n = 3). Tele-rehabilitation services were perceived to be beneficial and effective by the great majority of young people, their parents and the healthcare professionals. The results are discussed within the context of conventional therapy as well as in comparison to reports of other online services for similar populations. We conclude that a hybrid approach in which in-person therapy sessions are coordinated with synchronous, online sessions, will provide a best-case fit for young people with chronic disabilities.

Transition to Multidisciplinary Pediatric Telerehabilitation during the COVID-19 Pandemic: Strategy Development and Implementation

Telerehabilitation offers a unique solution for continuity of care in pediatric rehabilitation under physical distancing. The major aims of this study were to: (1) describe the development of telerehabilitation usage guidelines in a large hospital in Israel, and to (2) evaluate the implementation of telerehabilitation from the perspectives of healthcare practitioners and families. An expert focus group developed guidelines which were disseminated to multidisciplinary clinicians. Following sessions, clinicians filled The Clinician Evaluation of Telerehabilitation Service (CETS), a custom-built feedback questionnaire on telerehabilitation, and parents completed the client version of the Therapist Presence Inventory (TPI-C) and were asked to rate the effectiveness of sessions on an ordinal scale. Four goals of telerehabilitation sessions were defined: (1) maintenance of therapeutic alliance, (2) provision of parental coping strategies, (3) assistance in maintaining routine, and (4) preventing functional deterioration. Principal Components Analysis was used for the CETS questionnaire and the relationships of CETS and TPI-C with child’s age and the type of session were evaluated using Spearman’s correlations and the Kruskal–Wallis H test. In total, sixty-seven telerehabilitation sessions, with clients aged 11.31 ± 4.8 years, were documented by clinicians. Three components (child, session, parent) explained 71.3% of the variance in CETS. According to therapists, their ability to maintain the therapeutic alliance was generally higher than their ability to achieve other predefined goals (p < 0.01). With younger children, the ability to provide feedback to the child, grade treatment difficulty and provide coping strategies to the parents were diminished. Families perceived the therapist as being highly present in therapy regardless of treatment type. These results demonstrate a potential framework for the dissemination of telerehabilitation services in pediatric rehabilitation.

Consensus Statement on the Management of Duchenne Muscular Dystrophy in Saudi Arabia During the Coronavirus Disease 2019 Pandemic

Background: The coronavirus disease 2019 (COVID-19) pandemic has caused overwhelming challenges in healthcare worldwide. During such an outbreak, some needs of high-risk groups who require regular follow-ups and long-term management are not met. The vulnerable populations include patients with Duchenne muscular dystrophy (DMD). Duchenne muscular dystrophy is characterized by respiratory complications caused by muscle weakness. Hence, patients with this condition are at high risk of severe diseases including COVID-19. Methods: To standardize care and provide optimal treatment to DMD patients in Saudi Arabia during the COVID-19 pandemic, a panel of experts including neurologists and pediatricians consolidated recommendations for healthcare professionals and caregivers. Results: During this pandemic, substituting unnecessary clinic visits with virtual clinic services was highly recommended, if possible, without compromising clinical outcomes. Duchenne muscular dystrophy patients with respiratory complications should be closely monitored, and those with cardiovascular complications must continue taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Moreover, individualized home-based rehabilitation management was preferred. Glucocorticoid and new gene correction therapies should be continued. However, new gene correction therapy must be post-poned in newly diagnosed patients. A multidisciplinary decision was required before the initiation of hydroxychloroquine based on the COVID-19 treatment protocol. Conclusion: COVID-19 has caused challenges and transformed access to health care. However, these limitations have provided opportunities for the health care system to adapt. Further, telemedicine has become a reliable platform for follow-up appointments that should be conducted by a multidisciplinary team including physicians, dieticians, and physical therapists.