Telerehab: Beyond Virtual Visits

Why the Buzz…

Telerehab is newer to the telehealth/telemedicine scene, but it continues to grow in popularity due to benefits like:

• Ease of access for remote populations
• Reduced energy expenditure through eliminating transport to a clinic
• Potential cost reduction for both patients and providers

What this article is NOT about…

One of the first things you may think of when you hear telerehab is making virtual therapy visits. And that is a very important spoke in the wheel that is telerehab; but that’s not what this article is about. There’s already a lot of great information out there on that topic and I don’t have much I can add to that.

What this article IS about…

My goal is to open you up to the bigger picture of what telerehab is and can be. By definition, telerehabilitation refers to “the delivery of rehabilitation services via information and communication technologies”. This includes the well-known virtual visit, but also includes so much more!

Below is a list of modes of telerehab delivery that were either new to me or that I found interesting information on during my research. I’ve included potential benefits, example methods of performing each, and things to consider. Keep in mind as you read through that the benefits may be validated for only certain patient populations or types of equipment. Links to research have been included throughout the article, as well as additional resources at the end.

Virtual Reality Based Rehab (VRBR)

Virtual reality is when software creates an artificial environment that the user accepts as real. Ok, so maybe you already knew that; but how effective is it in improving patient outcomes and is it something most clinics can really afford?

Computerized Training:

Computerized training can include anything from computerized cognitive training (CCT) and speech training to HEP software that aims to improve compliance with therapy home programs; which I have to say have come a long way from my stick figure drawings 15+ years ago. Oh, and I forgot AI powered digital therapists – what are your thoughts on that?

Patient Portals

Patient portals are secure online websites that provide patients with 24-hour access to personal health information from anywhere with an Internet connection. I was familiar with hospitals and large organizations having patient portals but wanted to know if smaller practices would be able to have a similar experience. You guessed it…there’s an app for that!

Wearables

Wearables are tech devices that are worn to track information often related to health and fitness. So I understand that if I wear one, I’m using it at my own risk regarding privacy, etc. But what if I’m collecting data from my patient’s device? (Let the rabbit hole begin!)

What’s Next?

Although there are known-unknowns (expected risks) and unknown-unknowns (unexpected risks) regarding telerehab, there are also known and unknown opportunities! As this area becomes more mainstream, there will be more research available to help guide our practice. Despite how much awesome information we collect though, there will always be individual organization thought and effort required to successfully roll out a new program.

Deciding on the appropriate mode of delivery for your setting and patient population, researching and finding a vendor if needed, researching the regulations, creating protocols, updating policy, training staff and patients, and on and on and on…Deeeeeeeeep breath!

This is where using some basic practices of project management will guide you through a successful implementation.

How to Implement Telerehab

As a PT-turned-project manager (PM), my bias is less toward fast-forwarding to the final outcome and more on the preliminary steps of ‘how are we going to get there?’. In researching telerehab, I noticed there wasn’t a lot of material targeted toward education on best practices of implementing a new telerehab program. Regarding improving approaches and devices for telerehabilitation, one literature analysis from 2017 stated,

• “…patient’s feedback may be more important to adapt rehabilitation techniques and approaches to their needs, which would subsequently help to improve quality of rehabilitation in the future. The need for proper training and education of people involved in this new and emerging form of intervention for more effective treatment can’t be overstated.”
• “…at present there are no standard procedures or protocols…”

Similarly, one VRBR study noted a lack of standardized VR subprotocols. It also goes on to recommend professional specialization for clinicians treating with VRBR interventions.

I understand everyone considering starting a program like this may not have an onsite formal project manager at their fingertips; but for my fellow PMs-by-default, there are some great resources out there and I’ve included a few here:

• 10 Steps to Starting a Telehealth Physical Therapy Practice – an overview of implementation considerations
• ATPA Telehealth

Please comment below to share your thoughts on telerehab equipment or modes of delivery you’ve used, what worked really well, any barriers you ran into, and how you overcame them. I’d love to hear your feedback!

And best of luck on your journey!

References:

1. ^{Peretti, A., Amenta, F., Tayebati, S. K., Nittari, G., & Mahdi, S. S. (2017). Telerehabilitation: review of the state-of-the-art and areas of application. JMIR rehabilitation and assistive technologies, 4(2), e7. - https://www.ncbi.nlm.nih.gov/pubmed/28733271}
2. ^{https://eyesoneyecare.com/resources/pt-telehealth-rob-vining-pt-mspt/}
3. ^{Richmond, T., Peterson, C., Cason, J., Billings, M., Terrell, E. A., Lee, A. C. W., ... & Brennan, D. (2017). American Telemedicine Association’s principles for delivering telerehabilitation services. International journal of telerehabilitation, 9(2), 63. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716618/}
4. ^{Massetti, T., da Silva, T. D., Crocetta, T. B., Guarnieri, R., de Freitas, B. L., Bianchi Lopes, P., ... & de Mello Monteiro, C. B. (2018). The clinical utility of virtual reality in neurorehabilitation: a systematic review. Journal of Central Nervous System Disease, 10, 1179573518813541. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262495/}
5. ^{Spiegel B, Fuller G, Lopez M, Dupuy T, Noah B, Howard A, et al. (2019) Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial. PLoS ONE 14(8): e0219115. - https://doi.org/10.1371/journal.pone.0219115}
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8. ^{Veisi-Pirkoohi, S., Hassani-Abharian, P., Kazemi, R., Vaseghi, S., Zarrindast, M. R., & Nasehi, M. (2020). Efficacy of RehaCom cognitive rehabilitation software in activities of daily living, attention and response control in chronic stroke patients. Journal of Clinical Neuroscience, 71, 101-107. - https://www.sciencedirect.com/science/article/pii/S0967586819314195}
9. ^{https://eyesoneyecare.com/resources/online-hep-hack-way-better-outcomes/}
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14. ^{https://www.healthit.gov/faq/what-patient-portal}
15. ^{Dendere, R., Slade, C., Burton-Jones, A., Sullivan, C., Staib, A., & Janda, M. (2019). Patient portals facilitating engagement with inpatient electronic medical records: a systematic review. Journal of medical Internet research, 21(4), e12779. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482406/}
16. ^{https://www.capterra.com/p/130710/SimplePractice/}
17. ^{https://www.capterra.com/p/80068/My-Clients-Plus/}
18. ^{https://go.caspio.com/build-a-patient-portal-without-coding-video-guide?utm_source=adwords&utm_medium=ppc&utm_term=patient+portal+vendors&utm_campaign=US+-+Hipaa&gclid=EAIaIQobChMIpKe0qp-J6AIVi4CfCh3B1QVlEAAYASAAEgJ94fD_BwE&r=https://www.google.com/&s=1037&d=709}
19. ^{Vallati, C., Virdis, A., Gesi, M., Carbonaro, N., & Tognetti, A. (2019). ePhysio: A wearables-enabled platform for the remote management of musculoskeletal diseases. Sensors, 19(1), 2. - https://www.mdpi.com/1424-8220/19/1/2/htm}
20. ^{F. Donovan. How Does HIPAA Apply to Wearable Health Technology?. HIPAA and Compliance News. Health IT Security. - https://healthitsecurity.com/news/how-does-hipaa-apply-to-wearable-health-technology}
21. ^{E. Snell. Health Data Privacy Risks Created with Wearable Devices. Mobile News. Health IT Security. - https://healthitsecurity.com/news/how-does-hipaa-apply-to-wearable-health-technology}
22. ^{Cano Porras, D., Sharon, H., Inzelberg, R., Ziv-Ner, Y., Zeilig, G., & Plotnik, M. (2019). Advanced virtual reality-based rehabilitation of balance and gait in clinical practice. Therapeutic advances in chronic disease, 10, 2040622319868379. - https://journals.sagepub.com/doi/full/10.1177/2040622319868379}
23. ^{https://eyesoneyecare.com/resources/telehealth-practice/}
24. ^{https://nxtgenpt.com/product/introduction-to-telerehab/}
25. ^{http://www.apta.org/Telehealth/}

^{Additional Resources:}

1. ^{Darestani, A. A., Davarani, M. N., Hassani-Abharian, P., Zarrindast, M. R., & Nasehi, M. (2020). The therapeutic effect of treatment with RehaCom software on verbal performance in patients with multiple sclerosis. Journal of Clinical Neuroscience. - https://www.sciencedirect.com/science/article/abs/pii/S0967586819318399}
2. ^{Varley, R., Cowell, P. E., Dyson, L., Inglis, L., Roper, A., & Whiteside, S. P. (2016). Self-administered computer therapy for apraxia of speech: two-period randomized control trial with crossover. Stroke, 47(3), 822-828. - https://www.ncbi.nlm.nih.gov/pubmed/26797664}
3. ^{Morone, G., Tramontano, M., Iosa, M., Shofany, J., Iemma, A., Musicco, M., ... & Caltagirone, C. (2014). The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial. BioMed research international, 2014. - https://www.ncbi.nlm.nih.gov/pubmed/24877116}
4. ^{Mohammadi, N., Hadian, M. R., & Olyaei, G. (2020). The Effects of Wii Fit Plus Training on Functional Ability in Athletes with Functional Ankle Instability. Sports Orthopaedics and Traumatology. - https://www.sciencedirect.com/science/article/abs/pii/S0949328X2030003X}
5. ^{Song, J. J. (2019). Virtual Reality for Vestibular Rehabilitation. Clinical and Experimental Otorhinolaryngology, 12(4), 329-330. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787470/}
6. ^{Dias, D., & Paulo Silva Cunha, J. (2018). Wearable health devices—vital sign monitoring, systems and technologies. Sensors, 18(8), 2414. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6111409/}
7. ^{Veisi-Pirkoohi, S., Hassani-Abharian, P., Kazemi, R., Vaseghi, S., Zarrindast, M. R., & Nasehi, M. (2020). Efficacy of RehaCom cognitive rehabilitation software in activities of daily living, attention and response control in chronic stroke patients. Journal of Clinical Neuroscience, 71, 101-107. - https://www.sciencedirect.com/science/article/pii/S0967586819314195}
8. ^{Feyzioğlu, Ö., Dinçer, S., Akan, A., & Algun, Z. C. (2020). Is Xbox 360 Kinect-based virtual reality training as effective as standard physiotherapy in patients undergoing breast cancer surgery?. Supportive Care in Cancer, 1-9. - https://link.springer.com/article/10.1007/s00520-019-05287-x}