Physiotherapy has ascended into a new era with the rise of telerehabilitation. It is a fairly young concept and many rehab centers and hospitals in India do not practice it. Let us understand what telerehabilitation is and what its potential is.

Telerehabilitation is the delivery of healthcare services through the use of telecommunication technologies such as video conferencing, online chat, and mobile applications. In physiotherapy, telehealth has become an increasingly popular way of providing remote care to patients who may not be able to attend in-person sessions due to various reasons such as distance, mobility issues, or a pandemic. Telehealth in physiotherapy allows for the delivery of a range of services, including initial assessments, follow-up appointments, exercise prescriptions, education, and advice. During a telehealth session, a physiotherapist can assess a patient’s condition by observing their movements, listening to their symptoms, and asking questions about their medical history. They can also prescribe exercises and stretches, demonstrate correct techniques, and monitor progress through video calls.

So, why is telerehabilitation important? Why do we need to acknowledge it? Well, telerehabilitation became popular during the pandemic and has been in use ever since because of convenience and efficiency. Various benefits to telerehab are, but are not limited to –

• Increased access to care: Patients who live in remote or rural areas, or who have mobility issues, can receive physiotherapy services without having to travel long distances.

 

• Convenience: Patients can receive physiotherapy services from the comfort of their own homes, which saves time and money.

 

• Improved adherence: Patients are more likely to follow through with their physiotherapy exercises when they can do them in their own homes, without the need for travel or childcare.

 

• Continuity of care: Patients can continue their physiotherapy treatment even during a pandemic or other public health crisis.

 

• Reduced costs: Telehealth sessions can be less expensive than in-person appointments, as they do not require the use of a physical clinic
• Flexibility: Tele-rehabilitation allows patients to schedule their rehabilitation sessions at a time that is convenient for them, which can be particularly beneficial for patients who have busy schedules or caregiving responsibilities.

 

• Increased patient engagement: Tele-rehabilitation can improve patient engagement in their rehabilitation process by empowering patients to take an active role in their care.

 

• Real-time feedback: Tele-rehabilitation allows clinicians to provide real-time feedback to patients during their rehabilitation sessions, which can be particularly beneficial for patients who are learning new exercises or techniques.

 

• Reduced social isolation: Tele-rehabilitation can help patients who are isolated or unable to leave their homes due to physical or mobility challenges to stay connected with their healthcare providers and other patients, reducing feelings of social isolation and improving overall well-being.

 

• Improved outcomes: Research has shown that telerehabilitation can lead to similar outcomes compared to in-person rehabilitation services, particularly for conditions such as stroke, spinal cord injury, and chronic pain.

Telerehabilitation works in a very simple way. There will be a 1:1 session where you see the therapist through any video conferencing app. Treatment sessions can last up to 30 to 45 minutes, depending on the nature of the patient’s condition.  During a telerehab session, the therapist quite literally becomes a detective, asking all the right answers to the patient. Usually, the therapist may ask a lot more questions during a tele session because he/she has to compensate for not being physically present during the examination. Observation assessment, when done virtually, will depend on the view and the angulation of the device the patient is using. Relying on observatory findings may be challenging as it requires proper alignment of the camera with respect to the body segments. Thus, it would be appropriate to ask additional questions to complement your observation. Adaptations of the regular examination and modifications of the special tests and other evaluation methods are essential.

For a session to be beneficial, the following needs to be done by the therapist and patient-

• Have a list of questions and tests on hand. When starting with telehealth you might be overwhelmed by the technology and troubleshooting and a list helps you to stay on track
• Think of additional questions to ask the patient. For instance, if you are not able to view the whole patient because of poor setup, when testing forward flexion you can ask them how far they are able to reach down – fingertips to the knees, mid-shin, ankle.
• Consider which orthopedic tests will be valuable to do over telehealth and if they can be independently performed.
• For passive and active range of motion, you need to consider the patient’s angle to the camera. Consider different ways of testing if you are unable to measure with a goniometer.
• The therapist could provide a pre-recorded video to the patient ahead of the session to teach them how to perform a specific test while in the consultation. Or to give them guidance on what is needed for the test, for example, a chair or bed. A family member can be shown how to perform passive range of motion
• Consider which tests cannot be safely or effectively performed without you directly assisting. Are these tests paramount to your clinical reasoning processes with regards to the patient’s diagnosis or treatment direction? Can a test be sufficiently replaced by another test or additional questioning? Or do you need to assess the patient in person in order to establish a clear diagnosis?

Various attempts have been made to try to compensate for the lack of the physical presence of the therapist. Tom Murray et al have put forward a musculoskeletal framework for assessment during a telerehab session. 

Firstly, a patient teleconsultation advice sheet must be given to the client, which is a sheet consisting of important information the client should know in order to begin the session.

Other aspects the patient should keep in mind are

Patient Environment and Attire – It is advisable that the patient is located in a quiet room of adequate size for a range of movement tests. The patient should be positioned with an uncluttered background and appropriate front lighting to avoid glare into the camera. A number of references also suggested the benefit of a trusted volunteer being available to help with camera positioning in order to maximize consultation efficiency by positioning the device (ideally laptop or tablet) to view the required examination joint; this may be particularly relevant with elderly patients or those with a disability, e.g., visual impairment. The requirement for appropriate attire to allow visual access for remote examination is vital. 

 

Technical Set-Up – While online platforms may vary between practices, it is strongly recommended that information detailing the function of the chosen software is sent to patients in advance. This should include information on how to access the teleconsultation. It is essential that this information is clear and coherent, perhaps in the form of a pictorial diagram or a link to an explanatory video; the technical set-up can have a significant effect on the accuracy of teleconsultation. The creation of a frequently asked question list is also recommended. Where there is a personalized link for the patient’s teleconsultation, it is important that this link is sent to the patient’s device being used for the consultation, e.g., send the link via email, text or both. With elderly patients, third-party input may be helpful, so consider sending the link to a friend or relative (with the appropriate consent in place) if the patient does not have an appropriate internet connection. Similarly, a third party may also be beneficial where visualization is needed from an awkward angle or for taking photographs – as has been found with dermatological telemedicine.

 

Share Screen Function – A share screen function is a tool that allows the meeting host to present a document or image so that others can view it. This could be useful in a primary care setting using pre-prepared photos or videos to show patients how to perform MSK tests which may otherwise be complicated to describe. Examination photos that may be helpful to demonstrate this for patients are discussed later under remote MSK examination.

 

Contingency Plan – Although technological developments are rapid, there is still a potential risk of technical failure. Therefore, having a plan to manage this is recommended, such as changing to an audio consultation via telephone. At the start of the teleconsultation, this contingency plan should be agreed upon. 

 

Like the client, the therapist must also follow a certain set of instructions/advice –

 

As a practitioner, it is important to ensure that the video consultation still feels personal for the patient. Methods such as a ‘virtual handshake’ and making eye contact with the camera whilst introducing yoursel help to strengthen the doctor-patient relationship. It is also important to recognise the potential for audio delays, so giving time for the patient to reply is vital. Pacing cues such as gestures can also be useful for this. A number of authors also recognise the need to summarize the consultation at the end; this gives the patient the opportunity to ask questions that can be difficult to ask during the consultation.

It is advised that health care providers wear smart or professional attire. As with patients, a plain background with adequate front lighting is essential. It is also recommended to sit about 2-feet (60 cm) away from the camera, placing yourself centrally to the screen. Gestures that are commonplace in a face-to face consultation, for example, leaning in, can reduce the clarity on screen due to changes in focus. 

 

Now, coming to the actual framework for examination. 

By following these steps, a telerehab session becomes more valid and the lack of the therapist’s presence doesn’t affect the whole process of examination. 

Using this MSK examination framework, primary care practices should be able to conduct MSK video consultation more effectively and efficiently. 

Telehealth is a budding concept and is expected to create a revolution in the field like none other. It is important to understand the limitations of the concept, but those limitations should in no way shadow the amazon benefits it brings to the table. Telerehab has not only been proved through evidence, but it is reassuring for the patients as they will be able to get treated at the comfort of their own home.