by Felicia Sterling, DPT
First, What is Traditional?
In Texas, the standard twice a week for 60 mins has been our way of life for as long as I have been practicing- that is at least in the clinic and home health setting. This frequency of visits, even though more than what is standard in other parts of the country, still relies on the caregiver learning the strategies and implementing them into their daily routines to allow for sufficient repetition of the activity and thus stronger carryover and impact on the child experiencing a developmental delay in gross motor skills such as rolling, crawling, sitting, standing, walking or running.
What Alternatives Exist and Why?
There could potentially be more alternatives but here are the ones that from my experience, I believe would be either equally beneficial( in some cases) and possibly in other cases, more beneficial.
THE SEVERELY INVOLVED CHILD
For children who are severely involved, I believe that having a coalition between the physical therapist, caregiver and an additional caregiver tasked specifically with implementing the exercise program could be equally or more beneficial than traditional therapy in cases where the primary caregiver is unable to follow through consistently with the exercise program. This could be because the caregiver works and has other responsibilities that make incorporating the strategies daily difficult. Another reason might be that the caregiver is physically unable to follow through with the activities. By having an alternative person such as an athletic trainer, nanny or hired caretaker responsible for the daily or weekly exercise/activity program, the child is given the greatest opportunity to succeed in increasing his/her functional independence. In cases where the parent pays out of pocket for therapy or a high deductible, an alternative approach could also save money. Let's look at this example. Johnny's parents pay $80 co-pay each time he sees his physical therapist(PT). He sees PT twice a week for $160/wk. A month equals $640. The PT completed an evaluation to help guide the treatment sessions by working on activities that will lead Johnny to achieving his specific goal within 3 to 6 months. The family decides that $640 is too expensive for them at this moment so they come up with a plan to hire a personal trainer at $40/hr to implement the strategies outlined by the PT. The PT will follow up with family every two weeks ($160/mo) and the family will see the personal trainer twice a week ($80/wk or $320/mo). The PT will create a checklist, videos and any other pertinent guidance to the personal trainer to ensure that the strategies are being implemented correctly and the child is progressing appropriately. With strong collaboration, the child continues to make substantial progress towards the goals set out by the family along with the PT and the family is now paying only $480/mo.
THE MODERATELY INVOLVED CHILD
The moderately involved child might not need as much assistance as the more severe child and thus he/she may be perfectly fine with only having a personal trainer less often or even utilizing a nanny or caretaker. Perhaps the family already employs a nanny or caretaker and offers to pay an additional fee or stipend to have the caretaker implement the basic strategies suggested by the physical therapist( such as an activity diet which is a daily plan that lists functional activities and/or exercises that are to be completed daily much like a meal plan or class schedule). The PT could see the child weekly, bi-weekly or monthly to follow up with the nanny or caretaker and adjust the strategies as needed. Whereas the family would be paying the PT $100 per session (out of pocket, cash cost per session) for a total of $800/mo with the alternative plan they would be paying $400 out of pocket plus whatever the stipend were for the nanny/caretaker? In this scenario, it may cost the same or even slightly more however the difference is there is someone implementing the protocol daily vs twice a week. So now the child is experiencing the promoting behavior/function/activity each day which has a substantial impact on functional progress vs success in the clinic twice a week. This alternative set-up could also apply and be super-beneficial for the child with severe involvement as well ( actually, I like this set-up the best for the child with severe involvement because daily, functional intervention goes so much further)
THE MINIMALLY INVOLVED CHILD
For the minimally involved child, often there is a pattern in the daily routine that just needs tweaking or there is a physical issue that the child may be experiencing that is causing the motor delay or dysfunction. Once that issue is noted and addressed, often the child will soon be on his/her way towards mastery of the delayed motor skill. For example, many of times I would evaluate a child for delayed crawling and found after interviewing the parent that the child spent a great majority of the day in a child container such as a walker, bouncer, caregiver's lap, etc. Or perhaps, there was a family pet or older sibling that was keeping the child from being placed on the floor to avoid injury. Or maybe the child has slightly lower muscle tone and the parents just need strategies on how to set up the environment to encourage movement in a way that allows for success and thus stimulates that child to continue moving. A physical therapist could assess the child, provide suggestions then follow up with the parents once a week, twice a week or once a month via in person or virtual sessions. A virtual workshop could be attended by the parents to speak with a therapist, receive suggestions and have the ability to follow up with the therapist via email or chat if needed as well as remain in contact with other parents who are also working with their child on the same function thus sharing winning strategies. The workshop is a one time, nominal fee that provides access to the therapist without the necessity of regular therapy visits. The parent is able to learn the common strategies, have concerns addressed directly by the PT and have adjustments to strategies provided. The uncertainty of not knowing if you are missing something is eliminated because if the therapist feels the child needs more attention, that could be advised and followed upon. Based on the scenarios above, you could see how this example would be a less stressful and cost effective for certain families who would typically be thrust into a once or twice a week prescription.
How did I get here, advocating for a less traditional way of care?
Through my years of evaluating hundreds of children I noticed that there were many kids who demonstrated a developmental delay in motor skills but they still fell within a range of normal or only presented with mild issues of concern. Once those mild issues were addressed or simple strategies were provided to address the issues, these kids went on to progress just fine in their motor skills. Often the strategies needed, once understood, are repetitive in nature. The reason for therapy( in these situations) is simply to follow up with progress to ensure that the milestones are in fact reached, but more importantly, reached appropriately. For example, if the child not walking is a concern- as a physical therapist, I want to make sure that as the child is learning how to walk he/she is not using poor habits or dysfunctional patterns that will be problematic in the future such as a child who is seen to stand on toes often may later begin walking on toes consistently throughout the day. Therefore, I may choose to continue to see a child until he/she starts walking so that I am confident that the child has learned how to walk in an appropriate pattern. But now, with the advent of virtual therapy, constant presence is no longer necessary (in some cases) just to ensure no complications are present once the child has met his/her outcome.
I have also experienced, when working with the more severely involved child, wishing that I could provide a daily schedule that a caretaker could implement either in total or partially so that there is some form of repetition because I've seen how beneficial that particular activity is during our PT session which is only 45-60 mins and I know that follow through might be minimal due to the family's other responsibilities. It's my job as a PT to find simple ways for the family to incorporate strategies but even still it is a challenge. I am a parent and I know what it is like to get home from work and have a ton of things to do before I have to shut it down for the next day. So I understand and just think, if only. I know that many are not capable of hiring a caretaker which may cost as much as $20/hr but I know that some are. For those that are, this might be a great option for them. The caregiver could work primarily during a certain period of time such as mornings, midday or evenings for children who a home all day focusing on the daily routines within each time frame to help the child participate in activities similar to those of able bodied peers. For those that attend school, the caregiver could work during the afternoon on exercises and functional activities.
To Note:
These alternatives of care are not suggested as a permanent change to the current standard. I am only offering them as a way to think outside the box when deciding what is the best solution for each individual family especially when ability, time and money are strong determining factors. If outside the box is right up your alley, check out our upcoming workshops or contact me to discuss a personal consultation plan designed for your needs.
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