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Virtual PT

With all the changes to the physical therapy field due to the COVID-19 outbreak, virtual physical therapy has become the up and coming way to improve continuity of care and prevent gaps in therapy plans. Telecommunication was added into the PT scope of practice in 2019, though the recent global climate has brought to light the utilization of these services to protect the health of our children, families and our community. To be classified as virtual physical therapy, we need to utilize telecommunication and it must include an audio-visual component. I have had a privilege of utilizing virtual therapy services through a private therapy model, early intervention model for direct and consultative services and in the outpatient setting. This motivated me to share my experiences as many therapists and families may be utilizing these services for the first time and want to maximize the time and participation for them and their children. I have included below tips for both parents and therapists to make the most of your future virtual therapy sessions and hope you find this helpful when embarking into this new therapy setting.

Tips for Parents:

Share your goals.

Express to the therapist what you are hoping to gain out of the therapy session. Discussion expectations can help the therapist best understand your goals and can. Match that with the goals of the therapist. Virtual therapy sessions are a new area of therapy for your therapist, so your ability to communicate your goals, will help shape your therapist’s skills both for you and for future patients. This may be your first time, and it is just as important to share that you don’t know what to expect, as this will allow your therapist to share their plan and give you an opportunity to provide feedback. Being an effective therapist is founded on family-centered care, and the therapy team is strengthened with open and honest communication. As this will help prevent getting to the end of the session and still having concerns, questions or struggles that haven’t been addressed during your virtual session.

Collect your tools and toys.

As a parent, just getting your child to attend to the computer screen during your session may be exhausting, so finding ways to increase attention and engagement will help the session stay meaningful. Ask your therapist before the session for specific items needed for your PT session. The therapist may want to use your stairs, specific chairs or a couple of toys for your session. Having everything on hand will help your child to stay engaged during the session and keep you as the parent from running around the house collecting items during the therapy session, thus maximize the therapeutic benefits of the virtual PT session.

Set up your area for success.

First, you want to feel comfortable with the computer, tablet or phone platform you are using, as you may be frequently moving the camera around for the therapist to give you feedback on facilitation or activities. Computers can be helpful in providing their own stand, though a phone or tablet may provide more flexibility in angles, so whichever mode you choose to use, practice setting it up in different areas, as previously discussed with your therapist, to maintain a smooth session. Also, consider what other children or people may be doing during this session. It is common to have multiple children at home since school is virtual as well, and thus having children set up for other activities can help to give you undivided attention to the therapy session. If that’s not possible, let your therapist know other children may be present, and they can help to set up activities that include other children so everyone will be working toward a common goal during your virtual session.

Be patient.

Be patient with yourself, your child and your therapist. Technology is amazing and progressive, but can also be frustrating when trying to set up a camera, listen to feedback from the therapist and keep your child engaged. Don’t let this process get you frustrated with yourself and always ask the therapist if you need to hear something again or missed some feedback. These virtual sessions are an opportunity for the therapist to help improve your carryover of therapy goals, so there is no need to rush. The patience you cultivate for yourself should carry over to the same patience you have for your child during this process. Your child is adjusting to this new normal as well, and releasing expectations for their performance or engagement during this session will make it enjoyable and fun; not another online assignment to be complete by a deadline. When the whole team is patient with themselves, the end result is an enriching and motivating virtual interaction that will strengthen your relationship with the therapist and your child.

Tips for Therapists:

Plan a fluid, flexible session.

A paramount part of your virtual therapy sessions is planning ahead. We need to plan ahead to maximize the time we are spending with the family and optimizing engagement for the child's attention. Comparing goals in the child's plan of care, his or her progress toward those goals during past sessions and planned future interventions should all be used to help develop treatment plans for virtual therapy sessions. This will help when communicating with parents specific items, tools or toys you may need for your session. Recognizing that families may not have everything you have in your outpatient clinic is where your creativity will be key with your planning. Communicating prior to the session with the family can give you an idea of what therapeutic activities can be set up in the home, as well as an area of creative opportunity for utilizing what they have in their home for therapeutic benefits. Part of planning these virtual therapy interventions is planning multiple options that allow for many different directions that the session may go, based on the child's interest, family goals and concerns specific to that session as well as progressions and regressions needed for success at home.

Plan ahead, but always be flexible. This shouldn't be a novel idea for pediatric therapists, who work with the ever-changing attention of children, though, because we are not in person to help redirect that attention, having many planned activities can help keep the pivoting attention of the child on task with goals for therapy. One way to keep the child motivated can be using a visual schedule just like you might in an in person session, especially for older children, so they have an expectation of what will happen and an within session reminder of what they should be doing. Another way to maintain the engagement of the child throughout the session, especially for younger children, can be to give them child choices to make during the session. This can include choosing between two different activities but can also include within-activity choices. Choices give a child the sense that they are in control, though you are controlling the choices they are picking from and thus maintaining control in the direction of your virtual therapy session toward goals.

Interactive treatment ideas.

When giving children choices for a therapy session, make it like a video game. This means that each choice they make should layer upon previous choices and keep them coming back to you for more choices. If you think back to playing SuperMario, Spyro or Madden, you had the option to pick specific levels or pick specific quests within those levels in working toward beating the game. I have exercised this concept within my virtual sessions to keep it interactive for the child as well as decreasing the demands for the parents to keep their child on task. I have included below some of the examples of ways to create that video game feel within your virtual session:

Mystery Choices

I used the colored domes pictured below, but you could use anything that hides the options underneath, such as cups, cones, eggs or bowls. You can hide anything therapeutic under them, whether it be exercises you wrote on a piece of paper, animal figures you are using for animal walks, or numbers related to how many reps need to be done for an exercise. This mystery keeps the child on their toes and wondering what is coming next.

Motor Coordination Cards

I use resource cards with exercises on it, including online free printables, yoga pictures and animal cards all as ways to communicate exercises for children to do at home. I also use flash cards for counting and repetitions for exercises, incorporating the power of choice for the child. The cards act as an additional visual cue for the child, along with your demonstration or parent verbal and tactile cues for proper form and execution of an exercise. These cards can also be used for your home programming for the family and within the session practice to improve carryover without you there.

Scavenger Hunts

All pediatric therapists are familiar with using a scavenger hunt to promote volume and duration of an exercise within the treatment session, as searching for multiple items increases time spent working on a specific motor activity while providing purpose to that activity. Scavenger hunts can still be used as a tool in our virtual therapy sessions, we just need to be directing them for therapeutic gains. I have used scavenger hunts paired with color matching puzzles, where the child searches around the house for a specific color item, or performs a specific activity like climbing up stairs to collect the respective color crayon at the top of the stairs, based on the colored piece of the puzzle I am putting into the puzzle. Many resources online promote using a dice with colored scavenger hunts, which embodies my principle of making our session like a video game with interactive treatment ideas. Scavenger hunts don't just have to be for puzzles though, it could also be for a specific shape, number, animal or items hidden around the house, if planning and early communication was done with the family ahead of time. Use those searches to work on the same motor activities you would in the clinic, including animal walking, backwards walking, scooterboarding or skipping.

Pretend Play

Taking advantage of both you and the child being at home, you can include play with items you both have at home to entertain the child. If the family has a play kitchen, use this to have a pretend tea party or pretend meal with the child, as it can create wonder for the child when they make you "coffee" and then you have a cup of coffee that you are enjoying on your screen. You can also play doctor, pretend shop or play sports outside to match their activities at home. Mirroring the child's own environment can help to be a physical break for them but also maintain their participation in the session.

Creating Obstacles

All kids like to be part of the planning process, which compliments prior discussions on giving the child choices. Having them help with making something for the session, increases their fulfillment in the activity. This could be drawing different pictures on paper to be used as landmarks for a jumping activity or building a hurdle to jump over with pillows or blocks. There could also be a co-treat opportunity with OT in having the child cut out shapes for an obstacle course or be a co-treat opportunity with ST in working on directions like over, under, around and behind. The child will be proud of the effort put into making something for your session and this will promote that engagement and improve participation in that motor task.

Coach families.

Coaching may be the most important skill for therapists during a virtual therapy session. Similar to when you are coaching a student therapist leading a PT session, giving them the tools, cues and guidance to maintain control of the session, we, as therapists, need to give parents that same sense of empowerment during our virtual therapy session. Coaching families will help to create motor learning opportunities and gross motor progression for the child in their own environment. Utilizing the plan you have created for the session, help give parents tips for where to set the camera up, where toys need to be placed and how they can help their child, whether that is specific verbal cues or movement facilitation. The set up of the camera is crucial for coaching the family, as you have to see the full picture to give feedback on how to maximize motor learning during your activity. Keep in mind, multiple angles for the activity, similar to multiple planes of motion, can all give you different information for movement analysis, so asking the camera be moved during multiple reps of an activity, not only increases the practice for the child, but also allows multiple opportunities for feedback for the family. Coaching during your session requires use of motor learning principles, not only for the child, but also for the family members assisting in the session. Consider learning styles, feedback timing and practice scheduling to maximize learning and carryover of home programming. Utilizing part practice for complex tasks, distributed practice when tasks may be fatiguing or blocked practice when learning a new skill can help to improve practice for the parents and improve the quality of your coaching for the family. Lastly, monitor the attention and focus of the family during your session, as the attention location in relation to the performance of the task may be different than yours as the therapist. Helping to direct attention to your specific area of opportunity from the motor analysis of the task will optimize communication and make sure you and the family are both on the same page when coaching during your session.

Have a model - person or doll.

In line with coaching the family, visual demonstration can be one of the most effective ways to communicate facilitation or give feedback on performance. Having a baby doll, or using someone as a model can help to give visual cues for positioning, movement facilitation and hand placement. Using a doll will also decrease the verbal cues you may be using when coaching, and help to decrease overall verbal feedback during the session, as the family will also be interacting with their child. The visual demonstration with your doll or model may serve as the first step in a family member's learning for your planned activity and this foundation will be built upon throughout your session. The doll or model can also serve as visual confirmation of performance within the session or activity as well as visual feedback when something needs to be changed. Your doll acts as another tool in your PT skill toolbox to maximize your virtual therapy session when we can't be hands on ourselves.

Document with clarity.

A therapist's documentation should always be thorough, clear and accurate. Documentation for virtual therapy sessions needs to embody those same principles, though it may seem unclear what to write within your SOAP note format when we are not facilitating movement ourselves or in-person with the child. The Subjective portion of your note will be an easy section in the virtual session format, though not all the information belongs in this section. In the objective portion of your note, identify motor skills you see the child perform or motor activities that your coach the family to assist the child on. Specifically identifying verbal cues for the family or child, visual model with demonstration either from you own body, your model or doll, and motor activity set up will help to explain how family training was effectively communicated and translated into the child's natural environment. In the assessment portion of your note, make sure to include your clinical decision made during that session, including plan of care (POC) programming changes, positioning adjustments, activity modification recommendations and home exercise modifications. Continue to utilize the plan section for overall POC plans, and also update to include future activities for virtual therapy sessions, family goals for future sessions and what coaching and modeling techniques were most beneficial for your current session. It is of utmost importance to look up insurance and reimbursement regulations for documentation to insure inclusion of important information. This can include patient/parent consent, patient location, specifically identifying you are in the same state as the patient, and the platform used for your audio-visual component, as this needs to be HIPPA compliant. Create a checklist if you need when writing notes for your virtual therapy sessions that meet state and federal expectations to ensure reimbursement and maximize value of your time.

I found great success as a therapist when keeping each of these tips in the forefront of my virtual therapy sessions and it has helped me continue to grow as a physical therapist in this new treatment setting. Communication, planning and creativity are the foundations for successful virtual therapy for both the parents and therapists. The combination of these essential elements will continue progress toward therapy goals, until therapy can be continued in your respective setting. Sharing ideas with other therapists and families can help grow the tools in your toolbox for success, and I hope this has helped guide you for future virtual therapy sessions.

Caroline Ubben, PT, DPT, PCS


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