November 15, 2021 by Steve Kerschke, PT
Although telemedicine has been around since the beginning of the 20th century, resistance to widespread adoption remains, especially when considering clinical applications that traditionally involve a “hands-on” component. Telerehabilitation involving physical, occupational, and speech-language therapy is a perfect example. For many years, leaders in these professions have touted the value of in-person interaction and “personal touch” to deliver successful outcomes. Whether someone is dealing with a simple or complex condition, visiting a brick-and-mortar clinic for therapy has been and still is viewed as the most effective and often the only option for care.
Maybe this conceptualization is incorrect, however. The term “early adopters” was popularized by the 1962 book, Diffusion of Innovations , written by Everett Rogers, a professor of communications at Ohio State University. He suggested that adoption of new technologies, solutions to problems, or approaches to service delivery are often best represented on a normalized curve. Only 16% of the population falls into the “early adopters” category. These are people who quickly recognize the potential value of innovations.
Early adopters, as Simon Sinek puts it, are those “who just get it. They understand what is happening, they see the value, and they are here for it.” Early adopters have an optimistic enthusiasm and a higher tolerance both for financial and social risk. The further one moves away from the early adopters end of the curve to engage the early majority and eventually the laggards, the more you need to convince people to join the new movement.
Over the past three years, adoption of telerehabilitation has been pioneered by those innovating in the space as well as early adopters. Many providers were ahead of the curve and already gearing up to deliver care using video technology prior to the onset of the COVID-19 pandemic. These were people who recognized the many indicators supporting the use of telerehabilitation.
One major factor prompting remote delivery of rehabilitation services was limited access to experienced providers and rehabilitation services. For example, access to physical therapy (PT) was substantially below average in some geographical areas. According to data from the Bureau of Labor Statistics, large parts of the country experience shortages in physical therapists. For example, large metropolitan areas in New York, California, Texas, and Illinois have below-average PT coverage.
Access to occupational therapy poses similar concerns. Occupational therapists play a pivotal role in promoting an independent lifestyle. Their tasks include helping to improve in-home accessibility, developing strategies to simplify self-care activities, and helping with post-surgical care, and other age-related conditions such as dementia, stroke, and arthritis. While the occupational field has grown almost 25% in the past decade, Gertrude Robertson claims many states are dealing with professional shortages. It is estimated that by 2030, the US will experience significant shortages of occupational therapists and their services. Recent reports also show that the states with the greatest shortest ratios will be Arizona, Hawaii, and Utah, while the states with the lowest number of OT jobs will be California, Florida, and Texas.
In both cases, the problem is most pronounced in rural and remote areas. This severely limits the ability of patients to receive the care they require.
Early access to therapy has proven to have a positive impact on outcomes. In one study, healthcare costs for individuals with lower back pain who received early PT were as much as $1,500 less than those who delayed care or did not get PT. Furthermore, Thackeray et al. found that participation PT was associated with decreased opioid use in patients with lower back pain. This research suggests important personal and societal advantages from the improved access to PT offered by remote service delivery options.
Evidence also suggests that PT delivered via telerehabilitation can be as efficacious as in-person PT in reducing readmissions, alleviating pain, and improving patient function. Researchers at the University of Alabama have demonstrated that telerehabilitation can reduce readmission rates from 18% to 6% in patients with pulmonary disease. Cotrell et al. analyzed 13 studies comparing PT delivered through telerehabilitation versus in-person. They found that PT provided virtually is comparable and, in some cases, better than in-person PT in reducing pain and improving function in people with musculoskeletal conditions.
Similarly, Hung et al. conducted systematic reviews of 15 articles, which indicated positive therapeutic effects of using telerehabilitation in occupational therapy practice, and Mashima, et al. completed an extensive literature review that supported efficacy of speech-language pathology delivered virtually.
The COVID-19 pandemic encouraged—or forced—greater and faster adoption of telerehabilitation, but many consumers still do not appreciate ALL of the benefits, understand HOW the service is delivered, and most importantly, do not BELIEVE it can be a long-term option for care. Despite evidence supporting the effectiveness of telerehabilitation, it has continued to be viewed as an approach reserved for use when there are no other options.
As vaccination rates rise and communities across the country continue to assume a “new normal,” returning to “the old way of doing things” simply out of habit would be easy. Beyond the normal routine, significant data supporting in-person care drives this behavior, with concerns remaining around personal connection, sub-optimal outcomes, and adoption of technology as arguments against virtual care.
Telerehabilitation is certainly a great option when in-person care is not available or possible, but the service delivery option does not have to remain the second choice. Increasing use of telerehabilitation has provided more and more data supporting it. As a result, there are several reasons telerehabilitation should remain a desirable and viable option.
Virtual care allows access to clinical expertise regardless of location while also limiting interruptions at work, school, or home. Commute times and reduced time in waiting rooms is also a benefit. Millennials in particular place high value on convenience. They make up the largest segment of today’s workforce, and 40% of them say access to telehealth is “extremely important”.
A biproduct of convenient access to services is increased engagement. One study noted that the no-show rate of telehealth visits was 7.5%, lower than in-office now-show rates of 29.8%. Further, surveyed patients who experienced telehealth visits had similar satisfaction compared to those who attended in-office visits.
While concerns about COVID-19 persist, at-home rehabilitation options have the advantage of limiting community exposure for people who are at high risk for infection or who prefer to limit contact with others. One study reported that 71% of respondents were fearful of visiting an in-person clinic due to risk of infection.
Another benefit of telerehabilitation is cost savings. Beyond the cost of transportation, providers are aggressively finding innovative ways to deliver effective care at lower cost. The use of asynchronous therapy is one way to allow access to care in an “on demand” way while also ensuring an appropriate level of guidance throughout the rehabilitation journey. For consumers who are more financially savvy, cash-based options further decreasing the cost of care are often available.
Despite the benefits, whether supported by research or anecdotal experience, adoption of telerehabilitation remains limited. The following sections describe common reasons and/or misconceptions about telerehabilitation.
As with any service delivery method, the customer service, quality of care, and outcomes of telerehabilitation vary widely; however, these problems are likely to be of the same caliber as occurs during in-person rehabilitation experiences. Because telerehabilitation is new, providers are still learning how to maximize effectiveness. They are responding and continue to establish new practice standards to promote competency throughout the industry. At the same time, having consumers who are appropriately tolerant of the learning curve and are also willing to provide constructive feedback will drive greater quality in the long run.
A common misperception is that a condition must be “simple” to consider telerehabilitation. Sprains, strains, basic fitness training, simple speech impairments, and caregiver training are certainly achievable. At the same time, complex conditions—like brain injury, spinal cord injury, limb loss, or chronic pain—can also be addressed; they likely will require additional expertise compared to more basic problems, however. As with anything, providers must take care to educate prospective clients about what can or cannot be addressed appropriately through telerehabilitation, but, as time goes go by, the effectiveness of this approach continues to exceed expectations.
Technology can be scary for those who are unfamiliar with recent advances. Accessing video technology only takes a few clicks on a computer, tablet, or smartphone, and telerehabilitation providers are committed to offering easily accessible care. Troubleshooting is typically available for anyone experiencing technology problems, so this should not be a deterrent from giving telerehabilitation a try.
There is no doubt that some treatment strategies are more effective in-person than through remote services. Manual therapy and physical support for safety are examples that are difficult to achieve through virtual treatments. However, an increasingly small percentage of treatment strategies fit into this category. Skilled clinicians often have creative solutions to deliver traditionally hands-on therapy techniques. To name just a few…self-mobilization techniques, gait training, vision therapy, and basic swallowing techniques are all possible.
Telerehabilitation has been catapulted to the forefront because of the COVID-19 pandemic, and it shows great promise as a solution to address many healthcare-related problems. Wide adoption by consumers, payers, and practitioners is likely as familiarity with the practice grows.
However, education alone will not drive long-term utilization. Sinek—an expert storyteller—popularized the idea that a company must have a purpose for doing business. Their communication should start with communicating their purpose, and only later should the message shift to how and what they do. Numerous examples from Apple, Martin Luther King, Jr., and the Wright brothers illustrate that people don’t buy ‘what’ you do, they buy ‘why’ you do it.
Providers must find a way to accomplish this. The features and benefits of telerehabilitation vary from the obvious to the abstract, and they’re all important aspects of navigating the normal adoption curve that comes with innovation. However, connecting consumers to the people behind the therapy and the purpose behind the company will have the greatest impact on creating Raving Fans and widespread adoption.
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