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Evidence for the Use of Telehealth in

Pediatric Occupational Therapy
a
Sheryl Eckberg Zylstra MS OTR/L
a
Occupational Therapy, Temple University, Philadelphia, PA and
Chehalis-Centralia Student Support Cooperative , Chehalis , WA
Published online: 18 Dec 2013.
To cite this article: Sheryl Eckberg Zylstra MS OTR/L (2013) Evidence for the Use of Telehealth in
Pediatric Occupational Therapy, Journal of Occupational Therapy, Schools, & Early Intervention, 6:4,
326-355, DOI: 10.1080/19411243.2013.860765
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Journal of Occupational Therapy, Schools, & Early Intervention, 6:326–355, 2013
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ISSN: 1941-1243 print / 1941-1251 online
DOI: 10.1080/19411243.2013.860765
Evidence for the Use of Telehealth in Pediatric

Occupational Therapy
SHERYL ECKBERG ZYLSTRA, MS, OTR/L

Occupational Therapy, Temple University, Philadelphia, PA and Chehalis-
Centralia Student Support Cooperative, Chehalis, WA
Downloaded by [Monash University Library] at 16:19 01 February 2015
Telehealth is becoming an increasingly used service delivery model in rehabilitation

services. There are a myriad of reasons for its use. Telehealth has the potential to alle-
viate provider shortages, decrease costs associated with providing therapy, and allow
for treatment within a client’s natural environment. The purpose of this evidence-based
practice review was to answer the question, “Are web-based rehabilitation services
effective for children under the age of 16, as measured by discipline specific outcomes
and/or satisfaction with services provided?” In regard to satisfaction with telehealth
services, it appears there is evidence to support the use of telehealth in pediatric OT.
Keywords Telehealth, teletherapy, occupational therapy, parent/therapist satisfaction
What Is Telehealth?
Telehealth is a rapidly growing area of occupational therapy and of rehabilitation ser-
vices in general. The American Occupational Therapy Association (AOTA, 2013), in its
newest position paper regarding the use of telehealth services, currently defines telehealth
as “the application of evaluative, consultative, preventative, and therapeutic services deliv-
ered through telecommunication and information technologies” (p. 1). The position paper,
entitled simply Telehealth, endorses the use of telehealth technology by occupational
therapy practitioners, stating,
Occupational therapy practitioners use telehealth as a service delivery model

to help clients develop skills; incorporate assistive technology and adaptive
techniques; modify work, home, or school environments; and create health-
promoting habits and routines . . . . Occupational therapy outcomes aligned
with telehealth include the facilitation of occupational performance, adaptation,
health and wellness, prevention, and quality of life. (AOTA, 2013, pp. 1–2)
Because telehealth is a service delivery model rather than a practice model, it has the
potential to be used in all major practice areas of occupational therapy, including early
intervention and school-based services (AOTA, 2013).
In the past 5 years, there has been an expanding body of literature to support the
use of telehealth in the rehabilitation sciences (AOTA, 2013; Cason, 2009; Heimerl &
Rasch, 2009; Hill Hermann et al., 2010; Mashima & Doarn, 2008; Tousignant et al., 2011).
Received 26 January 2013; accepted 15 August 2013.
Address correspondence to Sheryl Eckberg Zylstra, Chehalis-Centralia Student Support
Cooperative, 1265 SW Pacific, Chehalis, WA 98532, USA. E-mail: szylstra@chehalis.k12.wa.us
326
Telehealth in Pediatric OT 327
Cason (2009) writes that “research has verified the efficacy of telehealth, telemedicine, and
telerehabilitation as viable options for meeting the medical and rehabilitative needs of indi-
viduals living in underserved areas” (p. 30). Other authors, however, argue that the research
regarding the use of telehealth in rehabilitation is not yet conclusive and, therefore, contin-
ued research is needed to support its use as an evidenced-based practice (Currell, Urquhart,
Wainwright, & Lewis, 2010; Ekeland, Bowes, & Flottorp, 2010; Gibbs & Toth-Cohen,
2011; Russell, 2007).
When reading the current literature, one will note that the terms telehealth,
telemedicine, and telerehabilitation are often used interchangeably, which can lead to some
confusion. Telehealth is the most encompassing term and includes both telemedicine and
telerehabilitation within its scope (Cason, 2009). Telemedicine, which includes physi-
cian and/or nursing care is defined by AOTA as, “medical services delivered through
communication and information technologies” (AOTA, 2013). Telerehabilitation, a more
selective term, is defined by AOTA as “the application of telecommunication and informa-

tion technologies for the delivery of rehabilitation services” (p. 21). This term is usually
limited to occupational therapy, physical therapy, and speech therapy services provided via
telecommunications technologies.
AOTA initially embraced the term telerehabilitation as evidenced by the use of that
term as the title of their previous two position papers (AOTA, 2005, 2010). Cason (2012),
however, argued that the term telehealth better describes the scope of occupational ther-
apy as it is more inclusive of the ideas of health, wellness, and preventative care that
occupational therapists are embracing. AOTA listened, and the title of its newest position
paper, authored by Cason, Hartmann, Jacobs, and Richmond, has recently been changed to
Telehealth (AOTA, 2013). It should be noted that this positon paper was authored by Cason
and colleagues (AOTA, 2013). The term telerehabilitation is very limited within the paper
(AOTA, 2013). This new position paper is now available online, and is soon to be published
in the American Journal of Occupational Therapy (AJOT; AOTA, 2013).
For the purposes of this evidence-based practice (EBP) review, the term telehealth will
be used, unless the discussion is referring to a specific article in which the authors use a
different term, such as telerehabilitation, teletherapy, or telemedicine.
Why Telehealth?
Several authors write that telehealth should be a supplementary therapy service and is not
meant to fully replace face-to-face services (Heimerl & Rasch, 2009; Gibbs & Toth-Cohen,
2011), so why use telehealth at all? There are myriad reasons discussed in the current
literature to support the use of telehealth.
First and foremost, telehealth has the potential to alleviate provider shortages (AOTA,
2013; Cason, 2009, 2012; Kobak, Stone, Ousley, & Swanson, 2011; Mashima & Doarn,
2008). According to recent statistics, 16% to 20% of the U.S. population currently resides
in rural areas (Cason, 2009). Telehealth is an alternative service delivery model that can
help lessen the shortages of medical professionals in rural areas (Cason, 2009). Just as
telemedicine can help address the shortages of physicians living in rural areas, telehealth
can help address the shortages of rehabilitation specialists serving children in areas where
shortages occur. The American Association for Employment in Education (AAEE) pro-
vides statistics to document the shortages of physical, occupational, and speech therapists
in school districts around the country. The most recent report from AAEE demonstrates
that shortages of rehabilitation professionals range from moderate to considerable, with the
most severe shortages being in the south central region of the country (AAEE, 2008). The
328 S. Eckberg Zylstra
most recent available statistics show that all regions across the county are reporting short-
ages of school-based physical therapists and speech and language pathologists, while seven
regions across the country are reporting shortages of occupational therapists working in the
schools (AAEE, 2008). Telehealth services are a promising way to help alleviate these
shortages.
In addition to the shortages of medical and rehabilitation providers in the United
States, there is a tremendous shortage of rehabilitation professionals in developing coun-
tries. The World Health Organization (WHO) estimates that 15% of the world’s population
has some form of disability and that approximately 5% of the world’s children have a dis-
ability (WHO, 2011). It is also estimated that less than 5% of those who need rehabilitation
services in developing countries have access to them. The WHO recommends more train-
ing programs to address the shortages of rehabilitation personnel in developing countries
(WHO, 2011). Telehealth is one way not only to assist people in developing countries who
have rehabilitation needs but to train rehabilitation professionals and para-professionals

quickly and cost-effectively to meet these needs.
Another reason that telehealth is gaining popularity is its potential to decrease the costs
associated with providing therapy in remote areas, especially for therapists or clients trav-
eling long distances for services. Trevor Russell, a physiotherapy researcher, discusses the
potential for savings, not only in transportations costs but also in travel time saved (Russell,
2007). Cason (2009) further discusses how telehealth can decrease costs associated with
traveling therapists. In a recent study, she demonstrated that while 15 hours of early inter-
vention community-based occupational therapy services would cost $1,335, a comparable
level of teletherapy services would cost just $945.00, a savings of $390.00 (Cason, 2009).
Furthermore, in a recent systematic review of the cost effectiveness of telehomecare, (the
application of telemedicine technologies to the home environment), it was reported that
telehomecare was a cost-effective alternative to traditional homecare in 91% of the studies
included (Vergara Rojas & Gagnon, 2008).
Another important reason to support the use of telehealth in rehabilitation is the abil-
ity to allow for treatment within a client’s natural environment. In this regard, a telehealth
service delivery model aligns nicely with the Occupational Therapy Practice Framework:
Domain and Process (2nd ed.; OTPF-2). The OTFP-2 (AOTA, 2008) is an official document
of the AOTA designed to define and guide occupational therapy practice. The OTPF-2 man-
dates a client-centered process and discusses the importance of the environment (physical
and social) and client engagement when providing occupational therapy services (AOTA,
2008). Because a telehealth service delivery model often enables services to be provided in
a client’s natural environment (home or school), some may argue that occupational therapy
telehealth services may, at times, be better suited to a promoting a child’s engagement in
home-based daily living skills than when those services are provided in a clinic.
McCue, Fairman, and Pramuka (2010) agree, writing that although much of the lit-
erature surrounding telerehabilitation has focused on the outcomes of decreasing costs
and improving access, an equally important perspective is that, with the use of telehealth
technology, services can be implemented within the individual’s environment. These
authors discuss their belief that rehabilitation that occurs within the patient’s own home
and community has greater relevance to the patient (McCue et al., 2010). They note
that what is learned or accomplished in one setting (e.g., a clinic) does not necessar-
ily generalize to other settings and argue that “naturalistic treatment increases functional
outcomes, addresses problems with generalizability, and enhances patient satisfaction and
self-direction” (McCue et al., p. 197). Thus, if the goal of treatment is for a child to be
more successful in his or her home activities, it makes sense that therapy might be best
completed in their home environment. Russell (2007) also discusses the positive effects,
and importance, of rehabilitating patients in their own social and vocational environment.
Still another important aspect of telehealth, which lends further support to its use in the
rehabilitation services, is its ability to allow for increased collaboration and communication
between providers. Cason (2011) writes,
Use of telerehabilitation in EI services has the potential to connect team mem-

bers remotely to discuss evaluation results, treatment recommendations, and
coordinate care as well as facilitate co-treatments with specialists and local
therapists and provide access to specific disciplines not available within a local
community. (p. 20)
Recent studies by Karlsuud (2008) and Robinson, Seale, Tiernan, and Berg (2003)
examined parental satisfaction following the use of telehealth services to increase team
collaboration. Both authors found that parental satisfaction was high when team members
collaborated, via telecommunication services, for the benefit of the child (Karlsuud, 2008;
Robinson et al., 2003).
Finally, telehealth, in the form of web-based and online training, has the potential to
help keep therapists well educated and up to date on the latest research and intervention
techniques. Online education is booming. By the fall of 2010, more than 6 million college
students had registered for an online course (Whitney, 2012). Furthermore, most students
who had taken online courses reported that they found the online courses equivalent to, or
more valuable than, face-to-face instruction (Whitney, 2012). In a study by Kobak and col-
leagues (2011), it was demonstrated that web-based training could be as effective as on-site
training. In this study, professionals were trained, either in the traditional classroom format
or in a web-based format, to administer the STAT—an autism screening tool (Kobak et al.,
2011). Results demonstrated that each method was equally effective (Kobak et al., 2011).
In a similar study by Vismara and colleagues (2009), researchers found that training ther-
apists via telehealth to use the Early Start Denver Model, a model of practice for working
with children on the autism spectrum, was as effective as live trainings (Vismara et al.,
2009). These findings are especially important for those professionals practicing in rural
areas, for whom travel to traditional style trainings may be cost-prohibitive.
In addition to the literature supporting the use of telehealth, there are concerns regard-
ing its use as well (Cason, Behl, & Ringwalt, 2012; Theodoros & Russell, 2008; Tucker,
2012). Theodoros and Russell have noted such obstacles as professional portability, patient
characteristics, limited outcomes research, reimbursement, training, and the limited avail-
ability of telecommunications friendly assessment and treatment tools as barriers to the
development of telerehabilitation.
Professional portability includes the requirement by many states that therapists be
licensed not only in the state in which they reside but also in the state, or states, in which
they are providing services (Theodoros & Russell, 2008; AOTA, 2010). For occupational
therapists providing telehealth services, this may involve being licensed in multiple states,
which is an expense that may be prohibitive for some. Patient characteristics can be a bar-
rier to the successful use of telehealth if the patient presents with certain physical and/or
neurological differences making access to, or use of, the technology difficult. In all pedi-
atric online therapies, it is essential to have a parent or trained adult on the receiving end
of the therapy for safety reasons. This can add significant costs to the therapy services,
especially in school-based therapies where a therapy aide or assistant must be utilized.
Theodoros and Russell (2008) make special mention of the degree of physical con-
tact required in rehabilitation therapy as a barrier to the advancement of telerehabilitation.
They write that “The nature of the work of a rehabilitation therapist involves a hands-on
approach with significant physical contact between the therapist and the patient” (p. 200).
For example, in early intervention or school-based occupational therapy, a therapist might
perform joint compressions, passive range of motion exercises, or positioning techniques,
all of which require skilled hands-on services. It would be difficult, and potentially unsafe,
to attempt to teach these skilled techniques to an aide or parent via technology.
In addition to Theodoros and Russell (2008), other authors note reimbursement con-
cerns as a barrier to the expansion of occupational therapy telehealth services (AOTA,
2013; Cason, 2012). At this time, according to the Center for Telehealth and e-Health Law
(CTeL), 45 states already have some type of reimbursement for telehealth services (CTeL,
2011). However, AOTA notes that Medicare does not yet list occupational therapy prac-
titioners as eligible providers of telehealth services (AOTA, 2013). AOTA does note that
some states are currently providing occupational therapy telehealth Medicaid and/or pri-
vate insurance reimbursement opportunities, and they encourage each occupational therapy
provider to contact his or her state Medicaid and third-party payers to determine current
reimbursement possibilities (AOTA, 2013). Since Medicaid reimbursement is dictated by
each state, therapists using telehealth technologies should be active in petitioning their state
to authorize payment for services.
Recently, Cason and others (2012) published the results of a survey regarding the uti-
lization of telehealth services by providers of early intervention services. Multiple barriers
and concerns were expressed including security issues, privacy issues, concerns about the
quality of services provided, and the current lack of evidence to support the effectiveness of
telehealth (Cason et al., 2012). The authors recommend further policy development, educa-
tion of stakeholders, further outcomes research, and the use of secure and private delivery
platforms as a means of facilitate more widespread support for, and use of, telehealth ser-
vices in the early intervention population (Cason et al., 2012). In regard to security issues,
Watzlaf, Moeini, and Firouzan (2010) write that although VoIP technologies, such as Skype,
have a place for use in telerehabilitation, there is a high level of risk for confidentiality
and privacy breaches. They offer a privacy and security checklist to help eliminate these
risks to maintain compliance with the Health Insurance Portability and Accountability Act
(HIPAA) during use of these technologies.
In another recent study, Tucker (2012) conducted a survey of school-based speech and
language pathologists in one state, regarding their experiences and thoughts on telehealth
services. This author noted that, of the 170 survey respondents, only 1.8 % were cur-
rently using telehealth technology to provide services, and that, overall, survey respondents
expressed concerns regarding the use of telehealth services (Tucker, 2012). Concerns
included the validity of assessments administered via telepractice, whether clinicians can
adequately establish rapport with clients via telepractice, and whether teletherapy can be as
effective as in-person therapy (Tucker, 2012). On an interesting note, expressed willingness
to use telepractice was inversely related to age, “perhaps because younger members of the
profession are more accustomed to using technology” (Tucker, 2012, p. 61).
Telehealth Technology
There are a variety of ways that telehealth can be administered, depending on the needs
of the client and the provider. Increasing in popularity are the VoIP technologies (Voice
over Internet Protocol) such as Skype. This technology is relatively easy to use and can be
used in the privacy of one’s home, which is a positive for many clients and their families.
VoIP technologies are also often free of charge for those who already have computers with
Internet setup. One drawback of these systems is that some programs do not interface with
others, which can limit their use. In addition, some authors warn there is a possibility of
security breaches that could compromise confidentiality (Cason, 2011; McCue et al., 2010;
Watzlaf et al., 2010).
Other telehealth options include plain old telephone service (POTS), HDTV video-
conferencing, and videoconferencing using a videophone or a commercial videoconfer-
encing system such as Polycom or Tandberg (Cason, 2011). AOTA (2013) differentiates
between synchronous and asynchronous telehealth delivery. Synchronous delivery refers to
telehealth services delivered through interactive technologies in real time, such as a live
VoIP consultative or treatment session with a child and their family, while asynchronous
delivery refers to store-and-forward technologies, such as therapy websites offering infor-
mational videos and other tools to families, or self-paced Internet trainings for therapists
(AOTA, 2013). For a more detailed account of the various options for web-based telehealth
services, refer to Cason (2011) or McCue et al. (2010), both of whom provide a very nice
synopsis of the current technologies being used today.
Methodology
This evidence-based practice review was completed in order to answer the question, “Are
web-based rehabilitation services (OT/PT/Speech) effective for children under the age of
16, as measured by discipline specific outcomes and/or satisfaction with services pro-
vided?” This question was an expansion of the preliminary EBP question, which was
specific to the pediatric occupational therapy literature. Although there is a growing body of
literature to support the use of telerehabilitation in adult occupational therapy, there is still
limited research regarding its use in the pediatric occupational therapy population. There
is, however, a growing body of evidence in the speech and language literature on the use
of telehealth with children receiving speech and language services. Because of the close
relationship between pediatric OT and SLP services and the limited research available spe-
cific to the pediatric OT population, the EBP question was expanded to include all pediatric
rehabilitation research (OT/PT/Speech).
Search Strategies
After firmly establishing an evidence-based practice question, a formal search of the
telehealth literature was completed in order to find all studies discussing the use of
telehealth in the pediatric rehabilitation population. Extended Ovid, CINAHL, and Temple
Summons searches were initiated through Temple University’s online library. A variety of
search words and phrases were used to find all pertinent research. Initial search phrases
included telehealth, telerehabilitation, occupational therapy, children, school, and early
intervention. In attempts to obtain all articles related to telehealth and child rehabilita-
tion, the search was then expanded upon by adding the following phrases: speech, speech
therapy, and physical therapy, combined with telehealth.
Inclusion and Exclusion Criteria

The original literature search for this EBP review was completed in September of 2012.
Literature searches were limited to journal articles in the English language and articles
that were published in the past 15 years. All studies included involved direct telehealth
therapy intervention with children. The initial and expanded searches yielded five arti-
cles that met the established inclusion criteria (Gibbs & Toth-Cohen, 2011; Golomb et al.,
2010; Jessiman, 2003; McCullough, 2001; Waite, Theodoros, Russell, & Cahill, 2010).
Subsequently, a hand search of the reference lists of studies meeting the inclusion cri-
teria was conducted. This yielded one additional article (Kelso, Fiechtl, Olsen, & Rule,
2009). Finally, it was noted that several reference lists contained articles from two spe-
cific journals not showing up in the primary search engines: The International Journal of
Telerehabilitation and the journal Telemedicine and e-Health. Independent online searches
of those journals were completed. Five more articles were obtained in this manner (Cason,
2011; Crutchly & Campbell, 2010; Grogan-Johnson et al., 2011; Karlsuud, 2008; Robinson
et al., 2003). Many citations found did not provide full access to texts online, and those
articles were requested through Temple libraries ILLiad program. In July of 2013, as this
paper was being accepted for publication, a new study was published involving the use of
telehealth in school-based occupational therapy (Criss, 2013). Because of its direct applica-
tion to this EBP topic, the review was modified to include this article. Ultimately, 12 articles
were obtained that met the established criteria. The final articles selected for review, and
where they were found, are listed as follows in Table 1 and summarized in Appendix A.
Two promising articles were excluded because they did not specifically include OT,
speech, or PT interventions, but they deserve mention here. One study, by Wade and col-
leagues (Wade, Wolfe, Brown, & Pestian, 2005) examined whether children with traumatic
brain injuries could successfully use a web-based intervention to improve child adjustment
Table 1
Search Strategies
1. Cason, J. (2011) Int. Journal of telerehabilitation:

journal-specific search
2. Criss, M. (2013) Int. Journal of telerehabilitation:
journal-specific search
3. Crutchly, S., & Campbell, Int. Journal of telerehabilitation:
M. (2010) journal-specific search
4. Gibbs, V., & Toth-Cohen, S. CINAHL Search
(2011)
5. Golomb, M., et al. (2010) CINAHL Search
6. Grogan-Johnson, S., et al. Int. Journal of telerehabilitation:
(2011) journal-specific search
7. Jessiman, S. (2003) Expanded CINAHL search to include speech
services
8. Karlsuud, P. (2008) Telemedicine and e-health: journal-specific
search
9. Kelso, G., et al. (2009) From reference list in Cason (2011)
10. McCullough, A. (2001) Expanded CINAHL search to include speech
services
11. Robinson, S., et al. (2003) Telemedicine and e-health: journal-specific
search
12. Waite, M., et al. (2010) Temple Summons
and parent-child interactions. The other study examined whether children on the autism
spectrum could improve problem behavior following parent coaching/consultation pro-
vided by applied behavior analysts, via telehealth technology (Wacker et al., 2013). Both
studies showed promising results including a high level of parent and child satisfaction
and/or improved outcomes.
Participants
All rehabilitation clients in the studies contained in this review were children under the
age of 16. However, because many of the studies measured parent, therapist, or other
stakeholder satisfaction, many study participants were actually parents, family members,
therapists, or team members of the pediatric clients. The youngest children included in this
review were six children under the age of 3, receiving early intervention telehealth services
(Cason, 2011; Kelso et al., 2009), and the oldest child was 15 years of age (Golomb et al.,
2010).
Interventions
All interventions in this evidence-based practice review included some form of telehealth
with pediatric rehabilitation clients. Four articles looked at studies of telehealth specific
to pediatric occupational therapy services (Cason, 2009; Criss, 2013; Gibbs & Toth-
Cohen, 2011; Golomb et al., 2010). Five studies looked at telehealth services provided
by speech therapists (Crutchly & Campbell, 2010; Grogan-Johnson et al., 2011; Jessiman,
2003; McCullough, 2001; Waite et al., 2010). One study looked at telehealth provided by
occupational therapy, physical therapy, or speech therapy (Kelso et al., 2009), and two
studies examined telehealth provided by teams of various professionals including: parents,
psychologists, occupational therapists, speech-language pathologists, physical therapists,
physicians, nurses, teachers, dietitians, welfare officers, recreation officers, and/or social
workers (Karlsuud, 2008; Robinson et al., 2003). A matrix of the articles organized by
discipline is available in Appendix B.
Outcome Measures
Because of the variety of interventions included in this EBP review, a wide variety of out-
come measures were used as well. Although 9 of the 12 studies (75%) included in this
review attempted to measure parent satisfaction as the primary, or one of the primary,
outcomes (Cason, 2009; Criss, 2013; Crutchly & Campbell, 2010; Gibbs & Toth-Cohen,
2011; Jessiman, 2003; Karlsuud, 2008; Kelso et al., 2009; McCullough, 2001; Robinson
et al., 2003) and three of those measured therapist satisfaction as well (Kelso et al., 2009;
McCullough, 2001; Robinson et al., 2003), each study used different measures, such as
surveys and/or questionnaires, that were specific to that study to measure the construct of
satisfaction with services.
Only six studies (50%) looked at discipline specific outcomes (Criss, 2013; Gibbs &
Toth-Cohen, 2011; Golomb et al., 2010; Grogan-Johnson et al., 2011; Jessiman, 2003;
Waite et al., 2010), with three of these studies looking at satisfaction measures in addi-
tion to discipline specific outcomes (Criss, 2013; Gibbs & Toth-Cohen, 2011; Jessiman,
2003). In regard to discipline-specific outcomes, three were SLP studies that looked at lan-
guage and/or articulation outcomes (Grogan-Johnson et al., 2011; Jessiman, 2003; Waite
et al., 2010). Outcome measures used included the Goldman Fristoe Test of Articulation-2
(Grogan-Johnson et al., 2011), informal speech probes (Jessiman, 2003), and the Clinical
Evaluation of Language Fundamentals (4th edition; Waite et al., 2010). Three studies
looked at outcomes specific to occupational therapy (Criss, 2013; Gibbs & Toth-Cohen;
Golomb, 2010). Of those studies, one looked at various tests of hand function including
grip and pinch strength, ROM measures, and bone scans (Golomb et al., 2010); one looked
at handwriting outcomes using the Print Tool (Criss, 2013); and the third looked at sen-
sory processing outcomes using the Sensory Processing Measure (Gibbs & Toth-Cohen,
2011).
Data Collection and Analysis

Each article in this review was critically appraised using the hierarchy presented by Moore,
McQuay, and Gray (1995) in order to determine the strength of the evidence presented.
This hierarchy provides a system for rating the strength of evidence presented in a research
study. The rating system ranges from level I, the most rigorous research, to level V, the
least rigorous research, and has been used to rate the strength of evidence presented in the
occupational therapy literature (Holm, 2000).
Because 75% of the studies in this review measured parent satisfaction, data were pri-
marily collected in survey or interview format. Studies involving survey and interview data
are level-V studies—the weakest level of evidence for evidence-based practice. Qualitative
studies are also considered level-V evidence (Holm, 2000). Eight of the 12 studies in this
review were considered level-V studies (Cason, 2009; Crutchly & Campbell, 2010; Gibbs
& Toth-Cohen, 2011; Jessiman, 2003; Karlsuud, 2008; Kelso et al., 2009; McCullough,
2001; Robinson et al., 2003).
Four studies in this review (25%) were categorized as level III-evidence, which
includes evidence from well-designed trials without randomization, single-group pre-post
test studies, and cohort studies (Criss, 2013; Golomb et al., 2010; Grogan-Johnson et al.,
2011; Waite et al., 2010). Although the four studies were categorized as level-III stud-
ies because they included pre-post testing, it is important to note that three of the four
studies had sample sizes of 13 or fewer, significantly impacting the ability to general-
ize results. There were no studies in this review that fell under the criteria for level-I or
level-II evidence, the highest levels of evidence for evidence-based practice, which include
large sample sizes, randomized controlled trials, meta-analyses, or systematic reviews of
the literature (Holm, 2000).
Results
The purpose of this evidence-based practice review was to answer the question, “Are web-
based rehabilitation services effective for children under the age of 16, as measured by
discipline specific outcomes and/or satisfaction with services provided?” In regard to par-
ent and therapist satisfaction with telehealth services, I believe there is sufficient evidence
in the literature to answer this question in the affirmative.
In this review of the literature, 9 of the 12 articles (75%) measured parent satisfaction
with pediatric telehealth (Cason, 2009; Criss, 2013; Crutchly & Campbell, 2010; Gibbs &
Toth-Cohen, 2011; Jessiman, 2003; Karlsuud, 2008; Kelso et al., 2009; McCullough, 2001;
Robinson et al., 2003). Of the nine articles that looked at parent satisfaction outcomes,
eight (89%) found a high level of parent satisfaction with the telehealth process (Cason,
2009; Criss, 2013; Crutchly & Campbell, 2010; Gibbs & Toth-Cohen, 2011; Jessiman,
2003; Karlsuud, 2008; McCullough, 2001; Robinson et al., 2003). Only one study (Kelso
et al., 2009) demonstrated mixed results, with the responses of parents being either some-
what satisfied or somewhat dissatisfied with services. In addition to parent satisfaction,
three of the satisfaction studies also looked at therapist satisfaction with telehealth services
(Kelso et al., 2009; McCullough, 2001; Robinson et al., 2003). All three of those studies
(100%) demonstrated a high level of therapist satisfaction with the provision of telehealth
services.
According to the data included in this review, there is a clear indication that parents
and therapists are highly satisfied with the provision of telehealth services. This evidence
correlates strongly with the published literature for adult telehealth services, where there is
generally evidence of high patient satisfaction ratings for adult telerehabilitation (Ekeland
et al., 2010).
Although evidence is emerging, there does not yet appear to be the same level of
evidence available to support the use of telehealth in the pediatric rehabilitation pop-
ulation when examining discipline specific outcomes. Only six of the studies in this
review (50%) looked at discipline specific outcome measures (Criss, 2013; Gibbs & Toth-
Cohen, 2011; Golomb, et al., 2009; Grogan-Johnson et al., 2011; Jessiman, 2003; Waite
et al., 2010 ). Three of these studies specifically looked at pediatric occupational ther-
apy outcomes (Criss, 2013; Gibbs & Toth-Cohen, 2011; Golomb et al., 2010). Criss
(2013) noted improvements in handwriting skills among 6- to 11–year-olds attending
an online public school, when provided OT intervention through telehealth technology.
Golomb and colleagues (2010) noted improvements in fine-motor outcomes in children
with hemiplegia following a virtual reality video game intervention. Gibbs and Toth-
Cohen (2011) looked at sensory processing outcomes in four children with autism and
noted that three of the children either improved, or made no changes, in their sensory pro-
cessing following telehealth intervention, while one child’s sensory processing outcomes
worsened.
In this review, there were three articles that looked specifically at speech and language
outcomes (Grogan-Johnson et al., 2011; Jessiman, 2003; Waite et al., 2010). Although
all (100%) showed positive outcomes, each study included different outcomes measures,
making results difficult to compare and generalize. Waite and colleagues (2010) used an
assessment measure to determine the accuracy of assessing language deficits via telehealth.
They found that assessment via telehealth was as effective as face-to-face assessment
using the Clinical Evaluation of Language Fundamentals (4th edition; Waite et al., 2010).
Grogan-Johnson and colleagues (2011) looked at ongoing speech therapy services and also
found no significant difference between face-to-face and telehealth services. Both groups
in that study showed significant improvements (Grogan-Johnson et al., 2011). Jessiman
(2003) completed a small study with more mixed results. Jessiman found that both clients
included in a single-subject design study improved in their speech and language goals. She
also found, however, that problems with hearing certain sound classes over the telehealth
technology resulted in assessment errors when compared to an in-person assessment three
days later (Jessiman).
Finally, two articles in this review looked at cost savings (Cason, 2009; Kelso et al.,
2009). Both supported the theory that telehealth services can be cost-effective. Cason
(2009) found that telehealth services could result in savings at the state level, while Kelso
and colleagues (2009) found that virtual home visits resulted in an average savings of
$42.52 per visit and a potential savings, on average, of $510.27 per year per child.
Discussion
Based on the articles included in this review, it appears that there is now sufficient evidence
in the pediatric rehabilitation literature to demonstrate a high level of parent and therapist
satisfaction with telehealth services, thus supporting the use of these services in our daily
practice. However, there are a couple of caveats to making such a claim. As previously
mentioned, 89% of studies looking at parent satisfaction, and 100% of studies looking at
therapist satisfaction demonstrated positive responses. Each of these studies, however, had
a different set of criteria for measuring the construct of “satisfaction.” Because the survey
questions and ratings in each of the nine studies measuring satisfaction were quite varied, it
is difficult, if not impossible, to directly compare the results. For example, one study used
open-ended, qualitative questions to determine parent satisfaction levels (Cason, 2009),
while another used content analysis of videotaped sessions to determine satisfaction with
services (Gibbs and Toth-Cohen, 2011). Another study used a 5-point Likert scale to answer
survey questions with ratings from 1 (strongly disagree) to 5 (strongly agree; Crutchley &
Campbell, 2010), while yet another used a 4-point scale, with 1 being satisfied and 4 being
dissatisfied (Kelso et al., 2009). One study reported using a parent satisfaction survey but
gave no further description of the measures used (Jessiman, 2003).
To further add to the confusion, it could be argued as to whether the same construct of
satisfaction was even being measured in each study. One study (Kelso et al., 2009) specif-
ically used the word satisfaction, asking parents and therapists to rate their “satisfaction”
level on a 4-point scale. Others, however, did not specifically, or consistently, use the word
satisfaction in their surveys, instead using words thought by the researchers to be indicative
of the construct of satisfaction (Criss, 2013; Crutchley & Campbell, 2010; Karlsuud, 2008,
McCullough, 2001). For example, one study used statements such as, “My expectations for
the TeleSpeech Therapy program have been met,” and “I would recommend TeleSpeech
Therapy to other school districts” (Crutchley & Campbell, 2010). These statements were
rated highly by study participants, so the authors concluded that there was a high level of
satisfaction with the telehealth project (Crutchley & Campbell, 2010). Many authors who
reported on satisfaction did not report on the specific terminology used in the questions
or statements included in their data collection process (Cason, 2009; Gibbs & Toth-Cohen,
2011; Jessiman, 2003; Robinson et al., 2003). Because each study used a different means to
measure satisfaction with services and appeared to have different definitions of satisfaction
altogether, there must be caution in interpreting the results.
One final caution in interpreting the results of the satisfaction studies is the fact that
six of the nine studies (67%) in this review looking at parent satisfaction with telehealth
services also incorporated some form of face-to-face services (Cason, 2009; Gibbs & Toth-
Cohen, 2011; Jessiman, 2003; Kelso, et al., 2009; Karlsuud, 2008; Robinson et al., 2003).
Keeping this in mind, a more appropriate conclusion of this review might be that parents are
satisfied with telehealth services when they are provided in combination with face-to-face
services. Karlsuud, (2008) goes so far as to recommend that families have a face-to-face
meeting with team members prior to instigation of the telehealth intervention. I believe that
parents may be more willing to accept telehealth services if they have met the therapist
on at least one occasion in order to establish a therapeutic rapport. One suggestion for
future study would be to measure satisfaction of services when the therapist providing the
telehealth services is previously unknown to the family and when there is no face-to face
contact during the data collection period. This would help to eliminate possible biases that
might otherwise occur. Criss (2013) accomplished this in her pilot study, but more, larger
studies are needed.
Even with the caveats discussed above, I believe a sufficient number of studies have
been done to demonstrate a consistently high level of satisfaction with pediatric telehealth
that such services can be recommended for use as evidence-based practice. In addition,
I believe it is time to take telehealth research in a new direction. Although parent and
therapist satisfaction is essential to a positive therapeutic outcome, it is also imperative that
children are meeting their therapy goals and demonstrating progress on outcome measures.
Typically, in pediatric occupational therapy, we would expect that progress to be in the
area of motor skills or sensory processing. Physical outcomes simply were not sufficiently
addressed in the current literature. There were only three pediatric OT telehealth studies
looking at physical outcomes, with an average sample size of five. Theodoros and Russell
(2008), who have written extensively about telerehabilitation, support this argument by
stating
The literature is primarily composed of case reports or small pilot studies and
while much of the research is encouraging there is an obvious lack of highly
controlled and large scale research studies to demonstrate improved patient
outcomes or cost effectiveness. (p. 193)
Clinical Implications
Implications for Occupational Therapy Practitioners

The results of this evidence-based practice review have considerable implications for
occupational therapy practitioners, especially for those working in early intervention or
school-based settings. Results confirm that parents and families are satisfied with telehealth
services, at least in combination with face-to-face services. This research opens the door for
pediatric occupational therapy practitioners, especially those in rural or high-needs areas,
to confidently incorporate telehealth services into their practice. Practitioners who decide
to incorporate this service deliver model into their practice are encouraged to participate in
future research in order to further add to the current knowledge base.
As stated previously, occupational therapists must work within the Occupational
Therapy Practice Framework: Domain & Process (AOTA, 2008). The OTPF-2 describes
the defining contribution of occupational therapy as “the application of core values, knowl-
edge, and skills to assist clients (people, organizations, and populations) to engage in
everyday activities or occupations that they want and need to do in a manner that supports
health and participation.” Based on the results of this review, and given the right circum-
stances, it is felt that pediatric occupational therapy practice that aligns with the guidelines
of the OTPF-2 can be accomplished via telehealth technologies.
In addition, it should be noted that AOTA requires the same professional and ethical
standards when using a telehealth service delivery model as when providing face-to-face
occupational therapy. AOTA notes that each therapist is required to ensure his or her own
competence in any area in which they choose to provide services, including telehealth
(AOTA, 2013). AOTA writes, “This requirement reinforces the importance of careful con-
sideration about whether evaluation or intervention through a telehealth services delivery
model will best meet the client’s needs and is the most appropriate method of providing
services given the client’s situation” (AOTA, 2013). AOTA also notes that occupational
therapy practitioners are to abide by the HIPAA by maintaining the security, privacy, and
confidentiality of all client records and interactions. Clearly, it is the responsibility of
each occupational therapy practitioner to ensure that all services provided via telehealth
technologies are appropriate, safe, private, and secure and fall within the realm of the
occupational therapy practice framework (AOTA, 2013).
Implications for Researchers

The results of this EBP review confirm that further research is needed. Currell and col-
leagues (2010) write that “as with any other form of health technology there is a need
to assess the effectiveness, efficiency and safety of telemedicine, before it is brought
into widespread use.” (p. 3). Most notably, more research is needed to demonstrate that
discipline-specific outcomes can improve with telehealth services (Grogan-Johnson et al.,
2011; Kelso et al., 2009; Wade et al., 2005; Waite et al., 2010).
One important area that needs to be addressed before telehealth will be a fully accepted
part of occupational therapy practice is the reimbursement of services. Unless services are
covered at, or near, the same rates as face-to-face services, charges will be too high for
some families, and therapists will not be able to recoup their costs, limiting telehealth as
a feasible option for families. Susan Palsbo (2004) completed a review of states providing
Medicaid coverage for telemedicine services. According to her report, in 2002, 24 states
had Medicaid programs that reimbursed for telemedicine services, while only 5 states
had Medicaid programs that reimbursed for telerehabilitation services (Palsbo, 2004). Just
9 years later, the CTeL completed a 50-state survey that reviewed each state’s Medicaid
telehealth reimbursement policies (CTeL, 2011). They found that, as of 2011, 45 states
already had some type of Medicaid reimbursement for telehealth services. Although these
results are not specific to OT or rehabilitation services, they demonstrate that Medicaid is
rapidly accepting increasing telehealth service claims.
Theodoros and Russell (2008) argue that the major barrier to reimbursement is the cur-
rent lack of strong outcome data supporting telerehabilitation. They challenge therapists to
provide the clinical evidence needed. Palsbo (2004) also noted the importance of continued
research to support the use of telehealth in order to increase Medicaid coverage. The results
of this EBP review call for a large, level-III or higher, randomized, multi-site study looking
specifically at whether physical outcomes can be improved with telehealth services in the
pediatric population.
Implications for Consumers

Because these results support the use of pediatric telehealth services, we will likely see
these services continue to increase in availability to consumers. I believe that pediatric
telehealth services have the potential to improve the quality of care for consumers and their
children, especially for those in rural areas who currently might have to drive significant
distances, or those in urban areas who are on wait lists for services due to a lack of suf-
ficient providers in their area. Choice is an extremely important component of consumer
satisfaction. It is important that parents of children with therapy needs have a variety of
options for seeking care. The increased availability of telehealth services will add to the
choices for consumers, when seeking rehabilitative care for their children.
Summary of the Recommendations for Best Practice

Occupational therapy telehealth services are not coming: They are already here. A quick
search of the Internet by this author found nine service providers/companies that are cur-
rently providing pediatric telehealth services in this country. It is the opinion of this author
that once the literature is able to clearly document improvements in physical outcome mea-
sures with pediatric occupational therapy telehealth services, insurance companies will
increase their payment for these services, and the demand for services will grow expo-
nentially. In the meantime, I believe the current literature supports the cautious use of
telehealth as a viable service delivery option in pediatric occupational therapy, including
in early intervention and school-based settings, especially when used as a supplement to
face-to face services.
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Appendix A
Matrix
Design/ ∗ Level
of Outcome Conclusions/
Reference Purpose Population Evidence Measures Intervention Results Recommendations
Cason, J. (2009). To develop and Pilot study/ Level V ∗ Parent Two rural Both parent Telerehabilitation
A pilot implement the Qualitative interview Kentucky participants has the potential
telerehabilitation enTECH design ∗ Cost-savings families with reported a to meet the
program: telerehabilitation N = 2 Families analysis young children high level of therapy needs of
Delivering early Program of children rec’d satisfaction children in rural
intervention (ETP); and to receiving EI consultative OT with areas.
services to rural evaluate ETP services early telerehabilitation. A cost-savings
families program intervention A cost-savings analysis supports
International results in order services over a analysis the use of
Journal of to determine if 12-week period, demonstrated telerehabilitation
Telerehabilitation, early for a total of that utilization to meet the needs
1(1), 29–37. intervention 6 telehealth of of children in
OT services visits each. telerehabilitation rural areas.
could be In-depth phone services where Recommendations:
delivered interviews were provider The author
342
effectively completed with shortages exist recommends a
using advanced the parents would result in larger research
telecommuni- following the a cost-savings project that
cations completion of for the state of incorporates
technology. treatment. Kentucky. multiple therapy
disciplines and
participants from
more
geographical
regions across
the state -
including
pre/post testing
with quantitative
assessments to
further document
the efficacy of
telerehabilitation.
Criss, M. (2013). To determine the Pilot study; Level III ∗ The Print Evaluation and Five out of eight The author notes
School-based effectiveness Pretest/Post Tool (HW post-testing, students had that the results
telerehabilitation of occupational test with Tears plus six 30-min. HW test complement the
in occupational therapy intervention assessment tx. sessions via scores that existing literature
therapy: Using telerehabilitation N = 8 Children tool) telerehabilitation increased at which supports
telerehabilitation to improve ranging in ∗ Satisfaction technology. least 5% from the effectiveness
technologies to handwriting age from 6 to survey A learning pretest of
promote skills in 11 years old completed coach (which scores. Three telerehabilitation.
improvement in children and having by learning was each students Two students’
student attending FM and HW coach and student’s demonstrated scores decreased.
performance. Connections needs student mother) was an 11% The author notes
International Academy - an identified on present for each increase in test that these
Journal of online public an IEP session and was scores. students did not
Telerehabilitation, school open to encouraged to Learning appear motivated
5(1), 39–46. children in continue coaches and during
doi:10.5195/ multiple states. activities students were posttesting which
IJT.2013.6115 throughout the highly may have
343
week. Each satisfied with impacted their
student rec’d the OT scores.
the same “tool telerehabilitation The author notes
kit” with program. the small sample
therapy band, 100% size and short
manipulatives, satisfaction intervention
Wikki Stix, with the period are study
playdoh, pencil overall quality limitations.
grip, HWT of the program Future
workbooks, etc. was reported. randomized
86% of controlled trial
respondents research was
revealed they suggested.
were happy
that services
were provided
online.
∗
Levels of evidence are based on the hierarchy presented in Moore et al., 1995; bolded statements are related to outcomes of satisfaction.
Appendix A
(Continued)
∗
Design/ Level of Outcome Conclusions/
∗
Crutchley, S., & To investigate Cross-sectional Level V Satisfaction SLP services Survey return rate Overall parents,
Campbell, M. parent, teacher, descriptive survey were ranged from 24% teachers, and
(2010). and administrator design – (Likert provided via for parents to 65% administrators
Telespeech therapy satisfaction with a One site scale) teleconfer- for teachers. appeared to find
pilot project: year-long trial of n = 59 parents, encing from Overall there was telepractice a highly
Stakeholder telespeech teachers, March 2008- high level of satisfactory model
satisfaction. teletherapy and/or February reported satisfaction for delivering SLP
International services. administra- 2009 to with the TeleSpeech services.
Journal of tors of preschool and Program. Recommendations:
Telerehabilitation, 23 preschool elementary Administrators scored The authors
2(1), 23–30. and children in the project with the recommend further
344
doi:10.5195/ elementary rural North highest ratings of research measuring
IFT.2010.6049 children at Carolina. survey participants. satisfaction with
one school A paraprofes- speech teletherapy
sional was (specifically
present at therapist
each session. satisfaction), and
suggest additional,
and more specific,
information be
collected.
This author notes that
the poor survey
return rate cautions
against
generalizability.
∗
Gibbs, V., & To describe and Qualitative and Level V Parent The Qualitative piece: Findings suggest that
Toth-Cohen, S. explore the use of Pre-test/post interview intervention Therapy progress telerehabilitation
(2011). a collaborative test design recorded in phase of this notes indicated that may serve as a
Family-centered telerehabilitation n = 4 families narrative study parent- therapist supplementary
occupational program used to with children format involved collaboration, method of service
∗
therapy and help parents w/ASD’s Content clinic based parental stress, delivery for families
telerehabilitation improve sensory between analysis of OT 1X/wk parental feelings of with children on the
for children with based home 5–12 yrs. of archived for 4 weeks, competence, and spectrum.
autism spectrum programs for age webcam followed by family interaction Improvements in
disorders. children with sessions teletherapy improved for most SPM scores cannot
∗
Occupational ASD’s. SPM - for 4 sessions participants. be attributed to
Therapy in Sensory over a 6-week Pre/Post test: Three telerehabilitation as
Health Care, Processing period. children’s SPM face-to-face visits
345
25(4), 298–314. Measure - Teletherapy scores either were also part of the
doi:10.3109/ Home sessions were remained the same study.
07380577 Form in the form of or improved. One Recommendations:
.2011.606460 collaboration child’s scores The authors
with parents worsened following recommend further
to address the treatment/parent research in the use
sensory diet collaboration phase. of telerehabilitation
needs of the in OT, specifically
children. including its use as
a supplement to
school based
services.
∗
Levels of evidence are based upon the hierarchy presented in Moore et al., 1995; Bolded statements are related to outcomes of satisfaction.
Appendix A
(Continued)
Design/ ∗ Level
Golomb, M., et al. To investigate One group/ Level III ∗ BOT Subjects used a All 3 subjects Use of remotely
(2010). whether Non-random/ ∗ Grip strength videogame showed monitored
In-home virtual in-home Pre-Post test ∗ Pinch system (that improved videogame
reality videogame remotely 3 month strength included a function of telerehabilitation
telerehabilitation monitored proof-of- ∗ Finger ROM 5DT 5 Ultra the appears to
in adolescents with videogame concept ∗ DXA/pQCT Glove and a hemiplegic produce
hemiplegic based pilot study. – (bone PlayStation hand, improved hand
cerebral palsy. telerehabilitation N = 3 (ages mineral 3 game improved function in teens
346
Arch Phys Med could improve 13–15) density console to finger ROM, with CP.
Rehabil. 91, 1–8. hand function tests) play games and Recommendations:
doi:10.1016/ and forearm ∗ fMRI requiring improved Further studies
j.apmr.2009.08.153 bone health in finger flexion/ fMRI with larger
teens with extension or readings. sample sizes are
hemiplegic CP. thumb needed in order
movement. to generalize
Average practice results.
was
20 minutes per
day for
36–67 days.
Grogan-Johnson, To determine Pre/post test Level III ∗ Goldman Traditional There was no Telehealth appears
S. et al. (2011). whether design Fristoe Test speech therapy significant to be a viable
A pilot children make n = 13 K-6th of was carried difference method for
exploration of similar grade Articulation-2 out in two between the delivering
speech sound progress when students at (GFTA-2) groups groups in intervention for
disorder they receive two (telehealth vs. terms of speech sound
intervention web-based elementary face-to-face), amount of disorders to
delivered by telehealth schools in according to change. Both children in a
telehealth to speech therapy rural Ohio each student’s groups rural, public
school-age services as with speech IEP, and using showed a school setting.
children. compared to sound TinyEYE significant Recommendations:
International face-to- face disorder Speech improvement Further research
347
Journal of services. goals on an Therapy in was
Telerehabilitation, IEP Software. performance recommended
3(1), 31–41. doi: An e-helper on the including
10.5195/ escorted GFTA-2 as recruitment of
IJT.2011.6064 students to the measured by students matched
therapy room, the Wilcoxon on important
but did not Signed -Rank characteristics,
participate in Test. and random
the assignment of
intervention. students to
intervention
groups.
∗
Levels of evidence are based upon the hierarchy presented in Moore et al., 1995.
Appendix A
(Continued)
Design/ ∗ Level
Jessiman, S. To determine Single subject Level V∗ Post treatment Assessments Parents reported The effectiveness of
(2003). whether design/Post (Although this telehealth were satisfaction telehealth
Speech and telehealth test only is a single satisfaction completed with the gains technology
language technology is n = 2 school- subject survey face-to-face their child appears
services using an effective aged design – the Informal prior to twice made and the promising.
telehealth method of children post test speech per week telehealth Concerns: Very
technology in speech and living in only survey probes telehealth services small sample size;
remote and language remote design was speech therapy overall. Children, parents,
underserviced services in a communi- weak so it sessions Clients were and therapist were
areas. Journal of remote area of ties in was ranging from seen much bothered by the
Speech- Canada. Alberta, categor-ized 30 to more quickly audio time delay.
Language Canada as 60 minutes for w/ telehealth Recommendations:
Pathology and level V vs. a 2-month than if they The author
348
Audiology, 27(1), level III period. had been recommends
45–51. Retrieved Families brought required to further research
via Temple children to the travel to the with good-quality
Ginsburg Library satellite site in SLP. equipment and
Iliad search. rural Alberta. Both clients optimal room set
progressed up, including
quickly in head mounted
their SLP microphones,
goals over highly adjustable
12 sessions. cameras, monitors
with split-screen
capability, visually
and acoustically
treated room, and
an on-site
facilitator.
Karlsudd, P. To describe the Descriptive Level V Likert style An “e-room” The majority of Results indicate that
(2008). development research survey ques- was set up users were an application like
E-collaboration and evaluation survey tionnaire for each child positive CIDS can improve
for children with of an IT based design/ Follow-up (n = 8). The about the use care.
functional system (CIDS) Qualitative interview administrator of the e- Parents were the
disabilities. aimed at interview (often the collaboration most positive
Telemedicine and facilitating n=8 parent) then system. responders and
e-Hhealth, 14(7), communica- families/8 invited team Average reported increased
687–694. tion, “e-rooms” members e-room quality of care,
doi:10.1089/tmj information, 47 of 62 (MD, OT, scores on coordination of
.2007.0112 documentation, (76%) SLP, teacher, 5 point scale treatment, and
and possible psychologist, ranged from continuity.
collaboration users etc.) to join. 3.6 – 4.4 Recommendations:
349
for families of completed All members (with 1 = For higher
disabled the primary could then low score utilization, a
children; and question- plan, discuss and 5 = high physical
to determine naire - and score introductory
whether such a Parents, implement a Parent led meeting is
system makes teachers, child’s care. “e-rooms” preferable. The
rehabilitation OT’s, had higher authors also
work more SLP’s, etc. usage (vs. recommend the
effectively. physician or program be
other led). translated to
English (currently
in Swedish only).
∗
Appendix A
(Continued)
∗
Kelso, G. et al. To test the Pilot study/ Level V Questionnaire 4 children rec’d Seven therapist The virtual home
(2009). The feasibility of Descriptive with satis- EI services in and 6 parent visit videoconfer-
feasibility of receiving Survey faction the form of question- encing system for
virtual home early design and SLP, OT, or naires were early intervention
visits to provide intervention n=4 usability PT. Children returned. proved to be both
early services over children ratings had a history Therapists usable and
intervention: A the Internet under using a of mean ratings satisfactory to
pilot study. (Virtual Home 3 yrs. of 4 point face-to-face were most participants.
Infants and Visits or age scale treatments 1.7 indicating Per the authors,
Young Children, VHV’s) 2 rec’d SLP An from the they were some technical
22(4), 332–340. 1 rec’d OT additional treating either problems were
1 rec’d PT open- therapist. satisfied or experienced
ended Each family somewhat which could be
350
question- rec’d satisfied with solved through
naire 1–3 VHV’s in services. the use of higher
to address addition to Parents mean resolution
parent regularly ratings were cameras and
reactions scheduled 2.7, meaning additional
to the on-site visits. they were troubleshooting
experi- Following either resources.
ence each virtual somewhat
Therapist home visit satisfied or
interview therapists and somewhat
with open families filled dissatisfied
ended out a with services.
questions questionnaire A cost savings
re: the regarding of $42.52 per
experi- usability and visit was
ence satisfaction. calculated.
McCullough, A. To investigate Non- Level V Pre-trial/ Three children Parents and Results suggest
(2001). the feasibility randomized trial/post received therapists that teletherapy
Viability and of utilizing feasibility trial 1 telehome reported the telecommunica-
effectiveness telehealth study/ satisfaction visit and one system was tions is a viable
of teletherapy within a Simple survey tele-school very useful. and effective
for pre-school community survey question- visit per Parents treatment option
children with care setting to design/Likert naire week, while reported that for preschool
special needs. meet the scale Informal one child they felt that children with
International needs of a n=4 picture received their child’s special needs.
Journal of preschool preschool naming and 1 teleschool communica- Parents were
Language and special needs children vocal visit per tion skills pleased with
351
Communication population. with imitation week only. had greatly services. They
Disorders, 36, special alluded to, improved. especially noted
321–326. needs but not Therapists that they were
formally also noted able to
discussed substantial participate more
improve- fully in their
ments in the child’s therapy
children’s program.
communica-
tion
skills.
∗
Appendix A
(Continued)
∗
Robinson, S. et al. 1. To improve patient Descriptive Level V Pre/post Evaluation was The ability to The authors noted
(2003). Use of care for special survey trial provided by a evaluate and that after the
telemedicine to needs children in research survey/ team in recommend initial excitement
follow special underserved areas. Pre/post question- Galveston treatment was period wore off
needs children. 2. To increase trial naire TX, including judged highly there was almost
Telemedicine communication Survey (as needed), satisfactory no change in the
Journal and with local question- the by the MD, number of missed
e-Health, 9(1), providers/team naire pediatrician, PT, OT, SLP appointments for
57–61. members and n = 269 OT, PT, SLP, dietitian, and those attending
Retrieved from improve local health dietitian, nurse psycho- the teletherapy
http://online. services. nurse psycho- analyst. sites as those
liebertpub.com. 3. To improve the analyst, Patient/family driving to the
libproxy.temple. referral base for psychologist satisfaction main site. They
edu/doi/pdfplus appropriate referral and/or social was high on surmised that this
352
to the tertiary care worker, for various issues might mean that
center in Galveston, children in (except for people were not
TX. more rural feelings of as satisfied with
4.∗ To evaluate the use parts of anger and the telemedicine
of telemedicine to Texas. frustration as they initially
provide for special Treatment goals which were reported on their
needs children. were not addressed satisfaction
5. To provide needed established as well in surveys.
clinical teaching for with the telemedicine
health related family, local as in the
(nursing) students therapists, traditional
in the state system. and clinics).
consulting The most
therapists. satisfactory
component
was reduced
travel.
Waite, et al. To validate the Clinicians Level III CELF-4 Language was No significant Results support the
∗
(2010). assessment of were Random (The Clinical evaluated difference validity and
Internet-based childhood randomly assign- Evaluation either by an was found reliability of
telehealth language assigned ment was of online or between scoring the
assessment of disorders via role of noted Language face-to-face telehealth CELF-4 via
language using internet based assessor or however Fundamentals – SLP while and telehealth/the
the CELF-4. telehealth rater, and sample 4th edition) being simul- face-to-face computer.
Language, services. children sizes were taneously scores on Recommendations:
Speech, and were small for rated by the CELF- The authors
Hearing randomly each both an 4 assessment recommend
353
Services in assigned to group. online and of children future studies
Schools, 41, administra- face-to-face with speech with larger
445–458. tion type SLP. Testing and sample sizes and
doi:10.1044/ (online vs. took place language within other
0161-1461 face-to between two needs. environments
(2009/08-0131) face) rooms at the such as the
n = 25 U. of child’s school
children Queensland. and home.
ages 5–9
∗
Appendix B
Outcomes Matrix (Ordered by Discipline)
∗
Face-to-face assessments, prior
Parent Therapist Discipline Specific Cost meetings, or simultaneous mtgs.
Discipline Author Satisfaction Satisfaction Outcomes Savings existed
1. OT Cason, J. (2009) X X X
USA
2. OT Criss, M. (2013) X X
USA
3. OT Gibbs, V., & Toth-Cohen, X X X
S. (2011)
USA
4. OT Golomb, M., et al. (2009) X
USA
354
5. SLP Crutchly, S., & Campbell, X
M. (2010)
USA
6. SLP Grogan-Johnson, S., et al. X
(2011)
USA
7. SLP Jessiman, S. (2003) X X X
Canada
8. SLP McCullough, A. (2001) X X
Ireland
9. SLP Waite, M., et al. (2010) X
Australia
10. OT/SLP/PT Kelso, G., et al. (2009) X X X X
USA
11. Team: Karlsuud, P. (2008) X X

Including∗∗ Sweden
OT/SLP
12. Team: Robinson, S., et al. (2003) X X X
Including∗∗∗ USA
OT,SLP,PT
355
TOTALS: 9 3 6 2 6
∗
In these studies, some level of face-to-face services existed. This level ranged from face-to-face assessment prior to telehealth services to face-to-face and telehealth
services being carried out with the same client simultaneously, therapies completed face-to-face with online collaboration between team members.
∗∗
An example of team members included in this study was reported as parent, psychologist, doctor, SLP, OT, teacher, welfare officer, and recreation officer.
∗∗∗
Team members in this study were reported as including pediatrician, OT, PT, SLP, dietitian, and a psychologist or social worker when appropriate. In both studies,
teams were selected based on individual client needs, so not every intervention included every member.

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This article was downloaded by: [Monash University Library]

On: 01 February 2015, At: 16:19

Journal of Occupational Therapy,

Evidence for the Use of Telehealth in

To link to this article: http://dx.doi.org/10.1080/19411243.2013.860765

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Evidence for the Use of Telehealth in Pediatric

SHERYL ECKBERG ZYLSTRA, MS, OTR/L

Telehealth is becoming an increasingly used service delivery model in rehabilitation

Keywords Telehealth, teletherapy, occupational therapy, parent/therapist satisfaction

Occupational therapy practitioners use telehealth as a service delivery model

selective term, is defined by AOTA as “the application of telecommunication and informa-

have rehabilitation needs but to train rehabilitation professionals and para-professionals

Use of telerehabilitation in EI services has the potential to connect team mem-

Inclusion and Exclusion Criteria

1. Cason, J. (2011) Int. Journal of telerehabilitation:

Data Collection and Analysis

Implications for Occupational Therapy Practitioners

Implications for Researchers

Implications for Consumers

Summary of the Recommendations for Best Practice

American Occupational Therapy Association. (2005). Telerehabilitation position paper. American

11. Team: Karlsuud, P. (2008) X X

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