Analysis of the motor development of at-risk infants who received face-to-face and remote assistanceABSTRACT
’Early intervention programs have continuously treated infants and their families during the lockdown caused by the COVID-19 pandemic via online platforms. Such remote treatment aimed to minimize the deleterious effects social isolation could bring to subjects in full development. Yet the results of this process ’were unknown, including toward a new approach to care. Thus, this study aimed to assess whether the positive effects of face-to-face early motor intervention on the motor development of at-risk infants mirror those in remote sessions. This comparative ex-post-facto study evaluated the motor development of at-risk infants by the Alberta Infant Motor Scale. All subscales showed significant differences from pre-to-post treatment in both groups, which were not different from each other. However, evaluating percentiles showed a statistically significant difference in the remote group. In the sample, 15 infants received face-to-face treatment and 15, remote care. This study aimed to investigate remote early physical therapy interventions due to the efficacy the home environment and the remote physical therapy guided by a professional.
Keywords:
Child Development; Early Intervention; Premature Newborn; Telerehabilitation; COVID-19
RESUMO
Sabe-se que os serviços de intervenção precoce (IP) trabalharam de forma contínua para atender remotamente bebês e suas famílias durante o confinamento causado pela pandemia de covid-19. O atendimento não presencial veio para minimizar os efeitos deletérios que essa limitação social pôde trazer aos sujeitos em pleno desenvolvimento, mas não se conhecia o resultado desse processo, nem mesmo para torná-lo uma nova abordagem de atendimento. Assim, o objetivo do estudo foi verificar se os efeitos positivos produzidos no desenvolvimento motor de bebês de risco pela intervenção motora precoce presencial foram os mesmos produzidos pela forma remota. Foi realizado um estudo ex-post-facto comparativo. Para avaliar o desenvolvimento motor dos bebês de risco, foi utilizada a Alberta infant motor scale (Aims). Pode-se observar em todas as subescalas que a diferença do pré para o pós foi significativa em ambos os grupos, que não diferiram entre si. No entanto, quando avaliado o percentil, a diferença é estatisticamente significativa no grupo remoto. Destes, 15 bebês faziam parte do grupo presencial e 15 bebês do grupo remoto. Os achados deste estudo propõem investigar os atendimentos de fisioterapia precoce no contexto remoto, uma vez que o ambiente domiciliar e a fisioterapia remota guiada por um profissional mostraram-se eficazes.
Descritores:
Desenvolvimento Infantil; Intervenção Precoce; Recém-Nascido Prematuro; Telerreabilitação; Covid-19
RESUMEN
Se sabe que los servicios de intervención temprana (IP) trabajaron continuamente en la asistencia remota a bebés y sus familias durante el confinamiento provocado por la pandemia de la covid-19. La atención no presencial pudo minimizar los efectos deletéreos que esta limitación social podría implicar a los sujetos en pleno desarrollo, pero no se conoce el resultado de este proceso, ni siquiera para convertirlo en un nuevo enfoque de la atención. Así, el objetivo de este estudio fue verificar si los efectos positivos producidos en el desarrollo motor de los bebés en riesgo por la intervención motora temprana presencial eran los mismos que los producidos en forma remota. Se realizó un estudio ex-post-facto comparativo. Se utilizó la escala de motricidad infantil de Alberta (AIMS) para evaluar el desarrollo motor de los bebés en riesgo. Se puede observar en todas las subescalas que la diferencia de pre- a pos- fue significativa en ambos grupos, que no difirieron entre sí. Sin embargo, cuando se evalúa el percentil, la diferencia es estadísticamente significativa en el grupo remoto. De estos, 15 bebés formaron parte del grupo presencial y 15 bebés del grupo remoto. Los hallazgos de este estudio proponen evaluar la atención temprana de fisioterapia en el contexto remoto, ya que el entorno domiciliario y la fisioterapia remota guiada por un profesional demostraron ser efectivos.
Palabras clave:
Desarrollo Infantil; Intervención Temprana; Recién Nacido Prematuro; Telerrehabilitación; Covid-19
INTRODUCTION
The rapid emergence and demand due to the COVID-19 epidemic has made necessary to introduce many control measures at once (including social distancing), with varying acceptance across countries1. Early intervention services (EIS) have continuously worked to serve children and their families during the lockdown due to the pandemic via online platforms. Thus, the COVID-19 pandemic offered health workers the opportunity to introduce telerehabilitation strategies in families’ daily lives2.
Telerehabilitation services are growing exponentially, having a broad scope. Telerehabilitation has overcome temporal, geographical, social, and financial barriers3. Thus, this study sought to assess whether early remote motor physical therapy would have significant gains for infants’ motor development since its implementation could circumstantially make life easier for their parents.
The continuous process of development of the human brain is based on a constant interaction between infants’ genes and environment. Humans have an increased rate of neurogenetic events during fetal development up to the second year of life, including greater neuroplasticity and brain reorganization capacity4. This evinces the importance of EIS in infants at risk of poor development and the importance of new channels that can facilitate parents’ access to EIS, such as telerehabilitation, a way to meet this demand in the future regardless of confinement.
Infants at risk are those newborns under situations with a greater risk of unfavorable evolution and who have a greater chance of mortality and morbidity5. The Brazilian Ministry of Health deems children with low birth weight, preterm (less than 37 weeks of gestational age), severe asphyxia, hospitalization, or complications in the maternity ward, who are born from adolescent mothers or those with low education, in a risk area, or with a history of death of children in the family as at risk6.
EIS programs are essential to prevent damage or the worsening of the developmental evolution of at-risk infants since their families alone are unable to guarantee adequate stimulation during the first years of their infants’ life. Thus, physical therapy plays an important role by promoting targeted and appropriate stimuli and fostering new neural connections7. Thus, telehealth is indispensable as it facilitates the care of families who live far from EIS centers and enables the participation of the entire family by making the hours of service more flexible, saving time and money by eliminating the need for parents and infants to travel2.
Therefore, analyzing the motor performance of infants cared for remotely can yield scientific evidence to enhance and establish this practice if it such assessments obtain positive results. Thus, this new scenario of care has elicited a comparison of the effects on the development of infants undergoing face-to-face and remote physical therapy in the early motor intervention project at the physical therapy clinic at Universidade Federal do Rio Grande do Sul. For this, this study formulated its guiding question: would early remote motor interventions show results resembling those of previous studies on face-to-face interventions? Thus, this study aimed to assess whether early remote interventions on the motor development of at-risk infants obtained the same positive effects as those in face-to-face interventions.
METHODOLOGY
A comparative ex-post-facto study was carried out. Its population was composed of infants of both sexes at risk of motor delay-initially classified by the Alberta infant motor scale (AIMS)-who were aged up to 18 months and who received physical therapy within the Universidade Federal do Rio Grande do Sul early motor intervention project.
All medical records with complete data spanning from 2016 to 2019 on infants’ initial evaluation and an assessment after three months of the beginning of face-to-face care at the early motor intervention project (final evaluation) (control group = face-to-face group) were included in this study. The medical records of all infants who were treated in the telerehabilitation/telephysical therapy format (online group = remote group) in 2020, 2021, and up to the first semester of 2022 were included. Infants cared for remotely should also have undergone an initial evaluation and another assessment three months after the beginning of their care (final evaluation). The final evaluation did not necessarily end infants’ care since the project routinely evaluates them every three months. However, the analyzed data were collected from their final evaluation (three months after the initial one) for both groups. Such choice was only used to organize this study as all infants currently remain in face-to-face services.
Infants with incomplete data in their medical records, those whose families had dropped the intervention, infants who were absent for more than three consecutive times, or those who missed their appointments were excluded from this research.
Sample size was calculated on Programs for Epidemiologists for Windows, version 11.43, based on Gerzson et al.8 and Valentini et al.2 A minimum of 14 infants in each group was obtained for a 5% significance level, 80% power, and a standardized effect size of about one standard deviation between measurements.
The measurement instruments used were the anamnesis file and AIMS. The anamnesis file contained data from medical records with the following information: name of the infant described by a code, sex, corrected age, date of the first evaluation, date of the second evaluation, and AIMS scores9,10.
AIMS has been translated and validated for the Brazilian population. It is used in infants with corrected ages from birth to 18 months regardless of whether they are full-term or preterm. This observational assessment scale was developed to measure gross motor maturation in infants from birth to independent gait, making it possible to find motor delays10. AIMS consists of 58 items in four postures, 21 items in prone, 12 items in supine, 12 items sitting, and 16 standing. With the items, one is ablet to assess infants’ antigravity activity in order to analyze components for other acquisitions via free movement2 and seek to find signs and changes in motor development delay. The scale generated a raw score that was transformed into a percentage. Scores below 5% were classified as motor delay; from 5 to 25%, as development with possible delay; and above 25%, as typical development2,10,11.
Regarding procedures in the medical records, all infants had a file containing an initial evaluation, the evolution of their sessions, and an evaluation three months after the beginning of care. The interventions were carried out once per week for both groups for 50 minutes. The families were instructed to stimulate their children during the week. In the sessions, visual tracking, postural control, and fine motor skill stimuli were performed based on a previous study12. Stimuli included three to five minutes of visual tracking since it encourages manipulation: a visual tracking toy was offered to the infants so they could manipulate it with some nuances, such as hiding it, setting objects between it and the toy, putting it inside containers, etc. The manipulation activity lasted around 20 minutes. For the remainder of the time, activities were offered in several decubitus positions, posture changes, seating, cat pose, kneeling, half-kneeling, and standing depending on infants’ development stage.
The routine evaluations were carried out by physical therapists who had been trained by physicians in the area in the face-to-face and remote phases of this study. The difference is that the teleservice was evaluated remotely since AIMS enables this.
Data were analyzed on Statistical Package for Social Sciences, version 27.0. The numerical variables were described by means and standard deviations or medians and interquartile ranges. Categorical variables were described by absolute and relative frequencies. The Shapiro-Wilk test was used to check data normality, finding an abnormal distribution. Thus, the Mann-Whitney was used to compare AIMS scores between the groups. The Wilcoxon test was used to compare pre- and post-treatment in each group. Proportions were compared by Pearson’s Chi-squared test. A 5% significance level was adopted (p<0.05).
RESULTS
The sample consisted of 30 infants aged from 20 days to 18 months, of whom 15 participated in the face-to-face group and 15 in the remote group. This study found no significant differences between the mean ages of the groups and the time between assessments, evincing similar groups in these variables. Regarding infants’ sex, girls predominated in the face-to-face group and boys in the remote group (p=0.027). Regarding infants’ data, six and 13 infants were born premature in the face-to-face and remote groups, respectively (Table 1).
Table 2 describes the intra- and intergroup evaluations. In all postures, intragroups differed pre- and post-treatment as infants naturally tended to evolve over the months in both groups. However, comparing percentiles (which does not directly depend on age as it stands on a scale with a raw score x age), only the remote group showed significant results; that is, those who stood at 0% evolved to 1% in the face-to-face group, representing a delay between pre- and post-treatment. The median of the remote group went from 2 to 23%, evolving from delay to possible delay in classification (p=0.003).
Postures remained similar, but the percentile changed when comparing the difference between the groups (p=0.003).
Although the groups did not show statistically significant differences regarding postures, the infants in the remote group improved their percentile and thus their classification. The face-to-face group averaged 0%, evolving to 1%, configuring an important delay in development. On the other hand, the remote group, which also obtained a low percentile in the pre-intervention (2%), improved in this average percentile (23%), being classified as at risk of delay. The remote group shows more pronounced differences, with the reduction of delay going from 60 to 26.7% (Figure 1).
DISCUSSION
Child development is critical to the continued progress of human development. Before a child is born, a mold of brain structure is formed according to genetic influences and their relationship to the environment in the early years of life. Thus, the maturation of the central nervous system enables the progression of motor development over time13. Subjects’ movements begin in the fetal phase after the eighth week of gestation, showing variety, complexity, and fluidity. Such movements happen due to synaptic activities in the cortical subplate, the neural substrate responsible for the complexity of general movements4. Changes during the embryonic process can lead to complications, damaging infants’ ideal development. The factors that place this development at risk include prematurity, low birth weight, decreased blood oxygen concentration, bronchopulmonary dysplasia, prolonged use of oxygen therapy, mechanical ventilation, congenital malformations, maternal infections, among other factors. These factors can change infants’ development and growth and cause deficits or delays in language, cognition, socialization, and learning14.
Thus, it is important to diagnose alterations in motor development (one of the first signs of an unhealthy nervous system) as early as possible. Physical therapists are one of the most important professionals in this early stage of infants’ life when something unexpected happens. Given this scenario, evaluations must be specific to infants’ age and, as with interventions, should occur as early as possible so they have an adequate development14.
Thus, we were very concerned due to the confinement caused by COVID-19. Outpatient clinics were unable to care for at-risk infants, who could outgrow their learning window, causing them future problems in global development. So, the Federal Council of Physical Therapy and Occupational Therapy allowed remote care for these infants15. However, the effectiveness of remote care has been questioned since physical therapy must be evidence-based. We were aware of the positive effects of face-to-face early motor interventions, but those of remote care remained unknown, justifying this study.
This study had two groups with similar variables in pre- and post-treatment, except for sex since the face-to-face group had more girls and the remote group, more boys.
In Rosa and Dionisio16, the intervention group had more girls and the control group, more boys. Tabile et al.17 analyzed the characteristics of preterm births and the prematurity of these infants in southern Brazil. Males were predominant on their sample, with 572 boys (50.5%) born preterm, whereas 561 infants (45.5%) were girls. Ferreira Junior et al.18 analyzed the epidemiological profile of mothers and premature infants in a referral hospital for high-risk obstetrics and neonatology in northern Ceará State (Brazil), finding that most preterm newborns were boys (53.3% males versus 46.7% females). Souza et al.19 sought to analyze the prevalence of prematurity in the state of Rio Grande do Sul and its associated factors. They observed that, of the 143,290 newborns in 2014, 11.48% had been born prematurely, with 11.72% and 11.46% prevalence of prematurity for boys and girls, respectively.
In our study, 66.7% of the infants were girls in the face-to-face group, with six premature infants; whereas 80.0% were boys in the remote group, totaling 13 premature infants. The data show a greater presence of boys, which reinforces the aforementioned studies and indicate that boys suffer greater impairement due to prematurity since most children in the face-to-face group were girls, including fewer premature infants. On the other hand, analyzing the remote group shows a greater presence of boys and, thus, more premature infants. Previous research confirms our findings, in which the remote group had an 80.0% prevalence of boys, who usually show greater vulnerability to prematurity and a greater likelihood of delays than girls.
Regarding motor development, our results showed that both groups’ postures evolved from pre- to post-treatment. However, assessing their percentiles showed that the face-to-face group improved less than the remote one. A possible explanation may stem from Oliva-Amanz et al.20, who studied the influence of exclusive parental stimulation during the pandemic. Those authors evaluated motor development by the Ages and Stages Questionnaires, 3rd edition; quality of life, by the Pediatric Quality of Life Inventor; and other variables, such as stimulation during lockdown. The study found no deficits in motor development or decline in the quality of life. Although they had no contact with the external environment, the infants interacted with their families, who belong to their most immediate environment.
However, science deems that the bodily distance separating physical therapists from children and their families can negatively affect evaluations as the family can neither fully perceive an asymmetry in their infants’ bodies nor a slight increase in stiffness, which may hinder screen-based evaluations. Our biggest concern is the non-early detection of cerebral palsy; face-to-face would be essential for that. However, we noted a family participation (perhaps up to now unnoticed) during the pandemic.
Bronfenbrenner21 mentions the ecological theory in which the family comprises the child’s microsystem. It configures itself in the interaction of the home environment with the involved subjects. According to this theory, such reciprocal interaction is important because development follows the playful relationships with the family, which introduce the child’s socialization via affective processes, such as empathy, attachment, and friendship. Parents have this important role, which reflects itself on the infant’s development at home. Thus, the guidance in this study empowered the parents as they understood the relevance of their stimulation of their infants, thus involving themselves in their children’s daily life. We also asked for videos of their children and their evolution with words of motivation, answered questions, and corrected any mishandling.
On the other hand, Shuffrey et al.22, in a larger sample (114 individuals who had been exposed to SARS-CoV-2 within the womb, 141 unexposed ones, and 62 infants who were born before the pandemic), found that six-month-old infants born before and after the pandemic had lower scores in the gross and fine motor, personal-social subdomains of the Ages and Stages Questionnaires regardless of whether they had had contact with the virus. In line with this, Huang et al.23 compared infant neurodevelopment of infants born from 2015 to 2020 (3,009 at six months and 2,214 at one year) with infants born during the pandemic (546 at six months and 285 at one year). They found a higher risk of neurodevelopmental delay in the communication and fine motor domains, which was worse in only children. The authors found no differences in infants at six months23.
In another investigation, Rosa and Dionisio16 analyzed two groups of infants. One received face-to-face physical therapy care based on the Bobath Concept. The other only received guidance in a booklet containing instructions for exercises. The comparison of the results found a significant difference from pre- to post-treatment in postures and in the total score in the two groups but a greater improvement in the face-to-face intervention group. However, analyzing the data separately by a percentage gain graph found no difference between the groups, as in this research.
Hadders-Algra et al.4 and Straathof et al.24 have reported that EIS and combinations of developmental stimulation at home with the guidance of a physical therapist (COPing with and CAring for infants with special needs - COPCA) include learning by trial and error in a challenging and enriched environment, promoting interactions between parents and infants, which may serve as the best way to promote infants’ motor and cognitive development, correcting their developmental delays. The Netherlands has used this approach for many years. They believe that the interaction between parents and infants configures a great ally for the latter’s motor evolution, as in both groups of studies. However, based on the final percentile, the remote group obtained better results than the face-to-face group since the interaction between parents and infants is much more significant, and parents are responsible for learning and performing the techniques and exercises that facilitate their infants’ motor evolution. Formiga et al.25 also observed that the motor development of preterm infants who participated in an EIS group with guidance and mothers’ training were significantly more benefitted than the control group; corroborating our findings, which had effective parental training and guidance. Remote EIS offered an alternative for those infants who required external motor stimuli, parents felt more welcomed and empowered.
Remote care was important for improving the infants’ motor performance. Also, we can extrapolate our findings and suggest remote care for other cases, such as for newborns referred by institutions and who are unable to travel to face-to-face care, for very frail infants as in extremely premature infants, or for those who await care. Thus, this remote intervention avoids infants losing a precious period of development in their first year of life25,26.
Post-hospital discharge follow-up for at-risk infants is very important and should be carried out by multidisciplinary health teams, with early detection of developmental delays. However, most neurodevelopmental surveillance is planned for face-to-face follow-up, recommending direct interaction between patients/families and health teams, but when barriers/obstacles occur in this system, an adaptation of neurodevelopmental care becomes essential27. The network can remotely provide the necessary healthcare services without the physical presence of professionals. Thus, these technologies can economically improve children’s access to needed medical services. Such technologies can also use other methods, helping to improve these children’s health28. According to this scenario, we sought to research and assess the effectiveness of remote therapy since it may offer a new method to be improved that can help improve these children’s health toward less damage to the central nervous system since the interventions can be carried out as early as possible.
Sarti et al.29 has shown that children with specific learning disorders and cerebral palsy, regardless of the telerehabilitation, had higher scores in the learning dimension than those who underwent no telerehabilitation. Similarly, in Spain, researchers in EIS practices have reported that telehealth has configured a very useful tool in these situations, especially to rehabilitate children30.
Despite the availability of remote physical therapy and its relevant role in improving children’s health and well-being, especially during the COVID-19 pandemic, professionals still find themselves in the early stages of implementing and using these services. Moreover, although the literature highlights this service as important, no current reviews or meta-analyses have compared face-to-face care with neurofunctional telerehabilitation in children during the COVID-19 pandemic28.
Thus, despite conflicting results, remote physical therapy can be comparable to face-to-face physical therapy or better than none. However, relevant results regarding remote physical therapy in pediatric physical therapy require better clinical trials and systematic reviews and comparative research between the results of remote and face-to-face care, especially regarding the early stimulation of motor development in at-risk infants25.
This study has raised great questions for future research, but some limitations require consideration. Although AIMS evaluation are versatile in a video call, it is impossible to state that it can identify every detail. A face-to-face evaluation is essential for physical therapists. It is difficult to find studies on online pediatric physical therapy services as few studies have researched this modality. Another limiting factor refers to families’ access to internet since the signal and quality of the online platform impaired the sessions. We also acknowledge the lack of equipment and accessories at the time of the remote consultations as parents/caregivers performed the sessions without the help of other family members, thus needing to show themselves performing the exercises with their children via cell phones, making it difficult to see and assess the activities for future corrections. Notably, some infants in remote care underwent multiple hospitalizations, spending four weeks without care and thus being disqualified from this research, considerably limiting its sample. Finally, this study lacked comparative data between groups’ previous characteristics other than AIMS.
CONCLUSION
This study aimed to investigate if the positive effects of face-to-face early motor interventions on the motor development of at-risk infants would mirror those in remote sessions since the infants remained confined to their home; it and professional-guided remote physical therapy seemed effective, as proved in this sample. Thus, providing further evidence on the effectiveness of remote physical therapy for professionals, especially physical therapists, will impact decision-making and bring patients better clinical outcomes. This study aimed to increase accessibility and improve continuity of care in vulnerable populations, those in geographically remote areas, and those with disabilities, which may save time and resources in health care, assisting parents to care for their at-risk children. Remote physical therapy should not be exclusive as face-to-face anamnesis with families would still help patient’s care.
DATA AVAILABILITY
The data underlying this study are available in the published article.
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