Research Award Details

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A Pilot Study for Evaluation of Parents and Patients with GMFCS Level II Cerebral Palsy Satisfaction and Comfort with Home Physical Therapy through Tele-Therapy

Grant Recipient: Selina Poon, MD

Co-Investigators:
Institution:
Shriners Hospital for Children
Presentations & Publications:
Further Funding:
Additional Information:

Part A:  The Project and Investigator(s)

 
  1. Project Title: A Pilot Study/Evaluation of the Satisfaction and Comfort with Home Physical Therapy through Tele-Therapy by Parents and Patients with GMFCS Level II Cerebral Palsy

2. Investigator(s) and Academic Department/Units Involved

 
Research Team Name Department/Institution
Principal Investigator Selina Poon Pediatric Orthopedic
Co-investigator Christine Caron Physical Therapy
Co-investigator Robert Cho Chief of Staff
 
 
  1. Project Duration
 
  Original
Project Start Date 9/1/2017
Project Completion Date pending
Duration  (in months) 12
  1. Project Expenditure
 
Sources of funding
 
POSNA funded amount: US$:      $1,000      
 
Expenditure to date: US$  $1,000
 
Balance:  US$ 0
 

Part B:  Report on Project Progress

 
5.  Project Aims
 
Specific aims of the project as per original application (please list):
1. To explore the parent and patient’s level of comfort with the assigned home physical therapy exercises, if they were able to communicate with the therapist via two way, real-time interactive video communication (Tele-Therapy).
 

6. Research Activities

While telehealth is an accepted practice in medicine, use of telehealth in rehabilitation is far less defined in practice and outcome. Paucity of studies determining the effect of telehealth in physical therapy restricts acceptance of this practice particularly in pediatrics.
 
A startup grant was used to initiate a study of efficacy of telerehabilitation in international patients with Cerebral Palsy. Four patients diagnosed with Cerebral Palsy and classified as GMFCS II were identified to participate. Two lacked the necessary access to Facetime to participate. Of the two remaining patients, one completed baseline and follow up testing (HL). The other completed baseline, but has not been able to be reached for follow up.
Patient HL:
  • 17 y/o Male
  • Spastic Diplegic CP GMFCS II
  • Developmental Milestones:
    • Independent sit at 1 year
    • Walking at 3.5 years
  • Surgical History:
    • 2005:  Bilateral Adductor Tenotomies
    • 2009: Bilateral Perc Tendo Ahilles Lengthening, Bilateral Open Hamstring Lengthening, Bilateral Grice procedures
    • 2017:  Botox Bilateral Hamstrings
  • Last Reported Objective Deficits:
    • ROM:
      • Knee Extension: -10˚
      • Bilateral Adduction: 15˚
•     DF: 15˚/5˚
  • Pop angle: 60˚
  • MMT:
    • Abdominals3+/5
    • Trunk extension 4/5
    • Hip Flex & Ext, Abd 3+/5
    • Hip add 4/5
    • Knee Flex & Ext 3-/5
    • Ankle DF/PF 2+/5
  • SCALE: 4 Bilaterally
  • Modified Ashworth:
    • Hip Flex & Ext 1
    • Knee Flex & Ext 1+
    • Ankle DF 1
    • Ankle PF 0
  • Last Reported Functional Profile
    • Modified Independent  bed mobility and transfers
    • Limited community amb with lofstrand crx
    • 5-6 blocks on fairly even surfaces
    • Does not work
    • Does not play sports
    • Plays computer games as primary hobby/entertainment
 
  Task Baseline score 1 week follow up score 1 month follow up score
 
Likert Scale of family perception of comfort with completing exercise program Hamstring stretch -1 0 +1
Adductor stretch -1 0 +1
Plantarflexor stretch -1 0 +1
Straight Leg Raise -2 -1 +2
Hip Abduction -2 -1 -1
Hip extension -1 0 +1
Bridging -2 0 -1
Standing deadlift -2 -1 +1
TOTAL GAS SCORE: -12 -3 +5
Likert Scale of family perception of comfort with completing exercise program   3 2 4

 
 
 
 
GOAL ATTAINMENT SCALE (GAS)
Level of Expected OUTCOME Behavioral Statement of Expected Outcomes Competence of Exercise Completion
MUCH MORE THAN EXPECTED (+2) Patient will complete exercise using cueing/assist from parent with notable alterations to exercise to reflect patients performance (i.e. increase isometric hold time if patient completing exercise too easily)
MORE THAN EXPECTED (+1) Patient will complete exercise using cueing/assist from parent without need to stop exercise to consult written instructions
EXPECTED (0) Patient will complete exercise using written instruction and cueing/assist from parent without additional cues from therapists
LESS THAN EXPECTED (-1) Patient will complete exercise using written instruction and cueing/assist from parent with 1-2 additional cues from therapists
MUCH LESS THAN EXPECTED (-2) Patient will complete exercise using written instruction and cueing/assist from parent with 3+ additional cues from therapists
 
Likert Scale of family perception of comfort with completing exercise program
 
SCALE
Behavioral Statement of Expected Outcomes
Patient and Parent Comfort Level of Exercise Program Performance
5 Patient and Parent feel that they are able to complete exercises and progress exercise program without therapist intervention/ cueing
4 Patient and Parent feel that they are able to complete exercises without therapist intervention/ cueing, but need therapist cueing/ intervention to progress exercises
3 Patient and Parent feel that they are able to complete exercises without therapist intervention/ cueing
2 Patient and Parent feel that they are able to complete exercises with therapist intervention/ cueing
1 Patient and Parent feel that they are not able to complete exercise without therapist intervention
 
 
Scores indicate that patient and parent felt comfortable completing exercises following baseline instruction in exercises, but at the one week follow up, felt that they needed more instruction.
However, at the one month follow up, family felt confident in completing the exercises, but believed they needed skilled intervention to advance the exercise program. Pt’s mother stated that she liked having access to therapy and would like the Facetime appointments to continue. Therapist scoring of patient/parent competence in completing exercises, however reflect a contrary perception. Low scores in all exercises demonstrate the need for therapist instruction/cueing for completion of all exercises despite the family perception that they were comfortable completing all exercises without therapist assistance/cueing. Yet, at the one week follow up, the therapist felt that the patient and parent were progressing well with less cueing needed despite the family feeling that they needed more cueing and intervention from the therapist. Ultimately, at the one month follow up, the therapist and patient/parent perceptions aligned reflecting that both patient/parent and therapist felt that the family demonstrated competence in completing exercises in general, but benefitted from skilled intervention to progress the exercise program.
Discrepancy of patient/parent and therapist perceptions and demonstrated scoring patterns indicate a benefit in home follow up for exercise program interventions. Greater patient/family confidence and competence in completing exercise programs will result in improved compliance and benefit of home exercises programs resulting in functional gains while decreasing medical costs. Use of telerehabilitation to maximize gains appears feasible, but does come with barriers. Despite the success in data collection of this one subject, barriers culminated in multiple dropped calls requiring the 30 minute follow up to take several hours to complete. Diminished bandwidth results in multiple dropped calls and grainy images with multiple “freeze frames”. Additionally, filming completed by patient as parent assists in performing exercise prevented the patient from adequately participating in the exercise and ultimately resulted in needing an additional person to assist. Also, poor lighting makes distinguishing fine points of technique difficult and the home environment could not be altered to improve lighting.  Further, due to space constraints of home

environment, determination of functional limitations and progress are nearly impossible to complete outside of relying on patient/parent interview.
In conclusion, use of telerehabilitation shows great promise in promoting competence, confidence, and compliance with home exercise programs. It can be a valuable tool in motivating patients for improved functional outcomes while streamlining costs, but continued research is needed to promote minimal bandwidth, space, and lighting guidelines for participation.
 

Part C:  Research Output to date

 
 
  1. Conference(s)
Date/Mont h/Year/ Place Title Conference Name
April 2018, Pasadena California Challenges and lessons learned through providing teletherapy for GMFCS II CP patients 27th  Annual G.
Wilbur Westin Lectureship