July 15, 2022 by Steve Kerschke, PT
During the COVID-19 pandemic, telerehab served as one of the only solutions to accessing physical therapy. While this exposed many patients to virtual care and encouraged providers to respond to the constraints of social distancing, the initial response to the removal of COVID-19 restrictions has been to return to in-person care giving the impression that online physical therapy is simply a temporary fad. Not only does the familiarity of in-person care drive consumers to the clinic, but also, skeptics continue to question patient satisfaction and outcomes related to an online approach. This is also compounded by many misconceptions and a lack of clarity around when it is appropriate to consider virtual care.
Despite this, telerehab continues to challenge the traditional approach to delivering physical therapy services. Previously, we explored several benefits of telerehabilitation suggesting it should remain a desirable and viable option. In this post, we will dive deeper into common misconceptions and offer a basic framework for determining when online physical therapy is appropriate.
Hospital closures, clinician shortages, and the absence of specialty services often means increased travel time for rural patients. There’s no doubt virtual care offers unprecedented access to care, and this is where telehealth has had the greatest impact. On the contrary, specialty providers are more prevalent in urban areas, which often makes in-person care the first choice. While there are many scenarios where this is what is best for the patient, the density of traffic can hinder one’s ability or desire to access care in a clinic.
For many patients, the choice to use telerehab boils down to convenience. A survey conducted by the American Telemedicine Association found convenience to be the top motivator for consumers interested in complementing or replacing their in-person care. Depending on the type of injury, convenience is even more valuable. For example, patients who have mobility issues or other physical and/or cognitive deficits often require physical assistance, support for transportation, or additional time to complete daily routines.
The severity, nature of the injury, and other complications impact whether telerehab is an appropriate approach. Heavy care needs, significant safety concerns, manual therapy, or specialized equipment are just a few considerations that may impact service delivery. For example, telerehab is frequently effective for treatment of basic musculoskeletal injuries as well as online education, home exercise supervision, and discharge and transition.
Unfortunately, many providers and patients remain narrow minded when faced with challenges that are more complex in nature. Beyond minor injuries and consultation, telerehab is also indicated for pain management, treatment of movement disorders, and gait, mobility, and endurance training. Although considered less frequently, treatment of complex injuries associated with traumatic brain injury, spinal cord injury, limb loss, and chronic pain is on the rise.
Telerehab is an effective way to support transitions between levels of care, especially when going from an inpatient rehabilitation center to a community-based setting. Scenarios for this could include returning home after elective surgery, such as a total hip or knee replacement all the way to discharge from an interdisciplinary rehabilitation center after a catastrophic brain or spinal cord injury. Regardless of the severity of the injury or how prepared someone is to return home, there are always unpredictable challenges that arise. Telerehab is a way to support the caregiver and the patient as they reacclimate to a real-world environment.
However, telerehab is not just for transitional purposes. It is also an effective long-term solution, and with the right provider and in the right circumstances, it can be a replacement for in-person care. As mentioned previously, there are a range of diagnoses and deficits that can be managed with this approach, and patients should expect a similar if not superior experience and comparable outcomes.
Consider someone who is recovering from a total knee replacement. Initially, therapy might be focused on safely accessing the home, pain management, and active/passive mobility. As the person moves through the recovery process, the clinician can easily add new exercises that incorporate strengthening and more complex functional mobility with the goal of returning to full function.
Similarly, an individual returning home from an inpatient rehabilitation program after a more severe injury often benefits from similar training and support. In cases like these, functional mobility, balance training, strength and endurance training, and community reintegration are top priorities and can be adjusted as needed depending on the needs of the patient.
Assuming there are no unexpected issues along the way, a skilled clinician should be able to navigate all aspects of care virtually. In doing so, the only reason a transition to an in-person clinic would be necessary is if safety becomes a concern, caregiver demands increase to an unmanageable level, or hands-on care becomes indicated.
Technology can be “scary,” but implementing basic education during onboarding, providing ongoing IT support, and arming clinicians with troubleshooting strategies are just a few ways to reduce apprehension. In fact, video conferencing platforms usually have a function that allows for the clinician to call the patient, which transfers most of the ownness to the clinician. Assuming the patient and their family acquire some basic skills, access to virtual care is as simple as the click of a button.
One point of caution – If challenges around service delivery arise, take the time to understand if it is a skills or buy-in issue. These are different. Usually, added support or education is sufficient to overcome a lack of technological skill or comfort. On the other hand, a lack of buy-in is a red flag that may indicate the need for a different approach to service delivery and a transition to an in-person clinic.
Physical therapists rely on what they hear, what they see, and what they feel to gather information, evaluate, and plan their patient’s care needs. Of course, hands-on care is not possible with virtual care, and this remains a limitation in some cases. However, standardized tools are available to illustrate current abilities and track progress. Among these are:
Additionally, wearable devices as well as sensor less technology can be used to detect movement and provide real-time feedback. In both cases, clinicians have greater access to diagnostics and predictive analytics that contribute to better outcomes.
Telerehab generally offers greater access to expertise, is highly convenient to access, and provides a clear picture of the demands of the real-world compared to in-person care.
Alternatively, a brick-and-mortar clinic may be a nice option if transportation is available, the clinic is located close to the patient’s home, and when hands-on care is needed. Additionally, some patients can apply skills from the clinic to the real-world, especially when no cognitive deficits are present.
The decision between in-person and virtual care is never going to be completely black and white. Here are some helpful logistical and clinical considerations to help determine the best approach.
To what degree does the patient value convenience?
Does the patient have adequate transportation?
What expertise is available? Is there a local clinic with comparable service offerings compared to a virtual clinic?
Is there any special equipment or hands-on therapy needs?
Does the patient understand the therapy approach, the expectations, and the behaviors and actions they need to adopt to reach their goal(s)?
Does the patient buy-in to the approach and have the desire to participate in the therapy approach?
Does the patient have the physical, cognitive, and emotional capacity and/or support necessary to participate safely and at an intensity that promotes recovery?
Does the plan of care and associated therapy activities match the specific demands of the real-world?
Is the patient capable of applying the skills being practiced in formal therapy to the real world?
In-person care remains the most common approach when addressing physical impairments, but online physical therapy has been shown to be effective in treating many of the same diagnoses and conditions. Yet, telerehab has not been widely adopted. Ongoing dialogue, further research, and greater clarity supporting the decision-making process are all necessary to eliminate misconceptions and guide consumers, payers, and providers towards the best therapy option.
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