Implementation and Adoption of Telerehabilitation for Treating Mild Traumatic Brain Injury : Journal of Neurologic Physical Therapy

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Research Articles

Implementation and Adoption of Telerehabilitation for Treating Mild Traumatic Brain Injury

Campbell, Kody R. PhD; Wilhelm, Jennifer L. PT, DPT; Pettigrew, Natalie C. PT, DPT; Scanlan, Kathleen T. PT, DPT; Chesnutt, James C. MD; King, Laurie A. PT, PhD, MCR

Author Information
Journal of Neurologic Physical Therapy: October 2022 - Volume 46 - Issue 4 - p E1-E10
doi: 10.1097/NPT.0000000000000409

Abstract

INTRODUCTION

Telemedicine has become an increasingly popular option, as digital technologies have advanced and become more accessible to those in rural communities and those in need of in-person alternatives due to the coronavirus disease-2019 (COVID-19) pandemic.1–4 Telerehabilitation is a subset of telemedicine in which patients requiring rehabilitation for motor, cognitive, or psychological disorders can access care remotely, via phone calls or video conferencing. Initial telerehabilitation studies focused on orthopedic pathologies.5 However, given the need for continuous access to rehabilitation in patients with chronic neurological conditions, telerehabilitation may provide a vital alternative to in-clinic care.

There is some evidence that telerehabilitation may be effective for several chronic neurological patient populations. A meta-analysis on telerehabilitation after stroke reported no significant differences between telerehabilitation and standard of care and concluded that telerehabilitation was a reasonable method for rehabilitation in this chronic population.6 Another systematic review concluded that video conferencing was the most frequently used approach and that telerehabilitation had a similar effect on activities of daily life compared with usual care in people with chronic stroke.7 Additional studies on preventing falls in multiple sclerosis, Parkinson disease, and the elderly support the use of telerehabilitation as an effective and feasible means for rehabilitation.8–10

Several studies on telehealth for mild traumatic brain injury (mTBI) have been published before and during the COVID-19 pandemic, with most describing baseline testing, diagnosis, and acute care.11–17 Telehealth assessments were effective in managing patients through return-to-learn/-play and provide similar levels of patient satisfaction compared with in-person services.13,17 One study provided assessments and prescriptions of aerobic exercise remotely to help in mTBI recovery.16 Otherwise, studies have only recommended virtual visits to specialized care when needed and none have examined the delivery of functional aspects of physical therapy intervention, such as balance training after mTBI.12,14,17 As such, there is a need for studies that can provide a framework for delivering physical therapy remotely for patients with mTBI, and studies are needed to determine its effectiveness.

Given the growing body of evidence that supports multimodal rehabilitation to address mTBI symptoms,18–20 it is unclear whether telerehabilitation could be successfully used to provide treatment across multiple domains, such as balance, walking, and aerobic exercise interventions. Several studies have shown that vestibular rehabilitation or a combination of cervical therapy and vestibular rehabilitation was effective in reducing symptom burden, facilitating a faster return to sports, and having a positive impact on health-related quality of life.21–24 Subsymptom threshold aerobic exercise has also been shown to reduce symptoms and facilitate return to premorbid activity level.25–27 In addition to targeting multiple aspects of impairment, mTBI rehabilitation programs need the appropriate frequency, intensity, duration, and progression to promote effective recovery.23,28,29 However, it remains unclear whether each of these domains is suitable for treatment using telerehabilitation after mTBI.

In this study, we adapted a multimodal physical therapy intervention that was targeted to address individuals in the subacute phase of mTBI who still reported symptoms of impaired balance and/or dizziness. This rehabilitation program was originally designed as part of a larger study that was assessing the timing of physical therapy intervention on people with a delayed recovery (2-12 weeks post-injury) from mTBI (Clinical Trial NCT03479541).30 The original protocol was intended to be performed in-person with a physical therapist that supervised and progressed the participant and was adapted to be delivered by a physical therapist remotely due to the COVID-19 pandemic preventing in-person rehabilitation. The multimodal program consisted of cervical, cardiovascular, static, and dynamic balance exercise. The goals of this pilot project were (1) to explore the feasibility of delivering all components of a comprehensive multimodal mTBI rehabilitation program remotely and (2) to discuss the pros and cons of telerehabilitation compared with regular in-person rehabilitation after mTBI.

METHODS

Participants

Seventy-three people with subacute mTBI were included in this analysis; 56 were enrolled into in-person rehabilitation and 17 into telerehabilitation. Participants were recruited from Oregon Health and Science University and local clinics. Inclusion and exclusion criteria and mTBI definitions have been previously described.30 Briefly, participants were included if they (1) had a diagnosis of mTBI made by a physician and were 2 to 12 weeks of their injury, (2) were between 18 and 60 years old, (3) had a graded symptom checklist total symptom severity score of 15 or more, and endorsed any symptoms on headache, nausea, dizziness, blurred vision, or balance problems from the Sport Concussion Assessment Tool version 5, and (4) no more than minimal cognitive impairment (≤8 on the Short Blessed Test).31 This study was approved by the Joint Institutional Review Board Committee of Oregon Health and Science University and Veterans Administration Portland Health Care System. The original clinical trial study enrolled participants from July 2018 to March 2020 when in-person research stopped due to the COVID-19 pandemic. To continue the clinical trial, we transitioned to a telerehabilitation program and enrolled participants from April 2020 to September 2020, before the clinical trial returned to in-person testing and rehabilitation (Table 1).

Table 1. - Participant Demographics at Study Enrollment
In-person
n = 56
Mean (SD)/n (%)
Telerehabilitation
n = 17
Mean (SD)/n (%)
Age, y 34.33 (12.23) 38.34 (12.72)
Sex, male/female 9/47 8/9
Height, cm 167.71 (9.59) 174.81 (8.95)
Body mass, kg 71.85 (14.57) 74.68 (15.96)
Days since injury before rehabilitation 66.82 (31.3) 61.06 (36.95)
Number of previous mTBIs
0 35 (63%) 13 (76%)
1 8 (14%) 2 (12%)
2 6 (11%) 0 (0%)
≥3 7 (13%) 2 (12%)
Mechanism of injurya
Bike 3 (5%) 2 (12%)
Fall 13 (23%) 2 (12%)
Motor vehicle crash 17 (30%) 4 (24%)
Sports 13 (23%) 6 (35%)
Other 10 (18%) 3 (18%)
Abbreviations: mTBIs, mild traumatic brain injuries; SD, standard deviation.
aMechanism of injury percentages add to 99% due to rounding within the In-Person column. Mechanism of injury percentages add to 101% due to rounding within the Telerehabilitation column.

Protocol

Before any rehabilitation for both in-person and telerehabilitation, participants completed a baseline patient-reported evaluation of mTBI-related symptoms using the Neurobehavioral Symptom Inventory (NSI), a 22-item test with each item rated from 0 (none) to 4 (very severe).32,33 The NSI is composed of a total score and subscale scores, including vestibular and sensory, mood and behavior, and cognitive.32 The assessment has good internal consistency and stability.34,35 Participants filled out the NSI within 7 days before starting rehabilitation. Participants who received in-person rehabilitation filled out the NSI on paper while telerehabilitation subjects were emailed an electronic version and provided verbal responses over the telephone. Within 7 days of completing rehabilitation, participants completed the NSI with similar instructions. Additionally, those who performed telerehabilitation completed a telerehabilitation satisfaction questionnaire.

Measures

Feasibility

Feasibility was assessed by comparing groups according to the number of participants who withdrew from the study, adverse events, rehabilitation session attendance, home exercise adherence, and level of exercise progression throughout rehabilitation. Physical therapists determined attendance based on the number of visits during the intervention (target attendance was 8 sessions over 6 weeks). To determine participant satisfaction with telerehabilitation, we used a satisfaction questionnaire that incorporated components and themes recommended for acquiring telemedicine use satisfaction.36 Participants completed the satisfaction questionnaire after they finished rehabilitation and rated their satisfaction with the ease of use, level of care, level of convenience, level of comfort, and whether it helped with their recovery on a 5-point Likert scale (1 = “strongly disagree”, 5 = “strongly agree”). Additionally, we asked participants whether they had used some form of telehealth before.

Intervention

Interventions for both groups consisted of 8 visits with a licensed physical therapist, either in-person or virtually, completed over 6 weeks. The frequency of visits began with 2 visits in the first 2 weeks, and then reduced to once per week for the remaining 4 weeks. Each visit was 60 minutes and included subcategories of (1) cervical spine, (2) cardiovascular, (3) static balance, and (4) dynamic balance with approximately 15 minutes devoted to each subcategory (Figure 1). We chose to include all 4 subcategories as well as to standardize the timeframe for physical therapy, since this intervention was part of a larger randomized controlled trial.30 Our inclusion criteria ensured that all people had some level of balance and/or dizziness complaints and in order to continually challenge participants who did not show obvious deficits in each of the 4 subcategories, we designed the intervention to include increasingly complex exercises tailored by the physical therapists to avoid a ceiling effect. Furthermore, there is typically considerable overlap in each of the areas and most mTBI patients demonstrate deficits in more than 1 category.20,37,38 All participants started the exercises at the first level for each subcategory and were progressed based on the quality of movement as observed by the physical therapist and reported symptoms.

F1
Figure 1.:
Overview of the rehabilitation program for in-person care with included exercises and progressions. Bolded text indicates aspects of the in-person rehabilitation that was modified for telerehabilitation. Bolded text and circled in gray text indicate aspects of the program that were removed completely. Modifications for telerehabilitation are provided.

The in-person rehabilitation took place within an academic hospital setting while the telerehabilitation protocol was provided to participants virtually through internet-based video conferencing (Webex). This platform allowed physical therapists to see the participant performing the exercises in the participant's home environment and monitor performance. Physical therapists asked the participant to position themselves in front of their computer cameras to allow for a view of their eyes during ocular motor exercises and postural sway during balance exercises.

Participants were asked to perform a daily home exercise program (HEP) and completed a log to track their adherence. The HEP consisted of similar intervention subcategories and levels of difficulty (see supplementary appendix from Parrington et al30). The HEP was progressed based on patient performance during rehabilitation and reported symptoms (headache, dizziness, nausea, and fogginess indicated on a visual analog scale). The following sections explain the components of the subcategories and how each was adapted for telerehabilitation (Figure 1).

Cervical

Cervical treatment included stretching, joint position sense exercises with a laser light, strengthening, and motor control exercises.21 In addition, manual therapy, including joint and soft tissue mobilization, was performed as needed for pain management and to improve active range of motion.17 Cervical treatment was modified for telerehabilitation by removing manual therapy and joint position sense training. Participants were instructed on cervical stretching, strengthening, and motor control exercises, similar to the in-person sessions. Self-mobilization techniques were added in place of manual therapy.

Cardiovascular

Participants were assessed using the Buffalo Concussion Treadmill Test (BCTT) Protocol.22 They were then prescribed to walk or jog on a treadmill at 80% of their symptom-provoking heart rate (HR) for each session as determined by their initial visit BCTT results.26 Participants were progressed by increasing their HR 5 beats/minute (bpm) every 5 minutes by increasing either treadmill speed or incline with minimal increase in symptoms (≤2 points).26 In place of the BCTT for telerehabilitation, the physical therapist assessed the participant's current cardiovascular fitness program and symptom provocation through a structured interview. Questions regarding exercise frequency, intensity, time, type, and if or how exercise provoked mTBI symptoms helped the physical therapist tailor instructions on cardiovascular exercise performance to the patient. Participants exercised outside of the telerehabilitation session according to the feedback provided during the structured interview. If the patient had access to an HR monitor, they were instructed to use it during exercise and to maintain a given HR zone based on their symptom reports. This was progressed based on symptom response by 5 to 10 bpm per week. If the participant did not have an HR monitor, they were instructed to use the Borg Rating of Perceived Exertion Scale (6-20), and exercise intensity was progressed with this instead. Each subsequent visit included this structured interview and verbal instruction in the progression of exertional level (either HR or Borg level) based on reported symptom provocation. Finally, if the patient did not have symptoms with cardiovascular exercise, they were instructed to exercise at 85% of their age-predicted maximum HR as it has been shown that high-intensity exercise may contribute to mTBI recovery.39

Static Balance

Static balance exercises included quiet stance with feet together with varying sensory information (eyes open/closed and stance on firm/foam (Airex) surfaces). We incorporated head turns, oculomotor exercises (smooth pursuit and saccades), gaze stabilization exercises (vestibular-ocular reflex and visual motion sensitivity), and cognitive dual-task training. Exercise progressions included increasing the head velocity and altering sensory conditions. The static balance component of the telerehabilitation protocol remained largely unchanged other than adaptations for safety and equipment (Figure 1). Exercises were adapted to start with standing with feet apart for additional safety (for in-person rehabilitation, these exercises began in a narrow stance). These exercises were then progressed to a narrow stance based on observed postural stability. Exercises originally performed on an Airex foam surface were adapted to standing on a compliant surface in the subject's home (ie, a pillow or folded yoga mat).

Dynamic Balance

Dynamic balance exercises included walking with head turns, with eyes open or closed, and on firm or foam surfaces. Dynamic balance progressions incorporated gaze stabilization, backward walking, cognitive dual tasks, tandem walking, and various bending, squatting, and lunging exercises. The dynamic balance domain was significantly modified for telerehabilitation due to safety concerns over performing walking with eyes closed without in-person supervision. All exercises that involved a foam-compliant surface for walking and eyes closed were removed from the protocol.

As an additional safety measure for telerehabilitation, participants were instructed in the adaptation of their home environment. Patients were instructed to perform exercises near a wall, corner, or chair for balance support. They were also given information to help with screen sensitivity related to computer use for the web-based sessions. These instructions included steps for lowering contrast and brightness, using a blue light filter program, moving computers away from windows and using shades to reduce glare, and using tabletop lighting instead of fluorescent lighting.

Statistical Analysis

Descriptive statistics were calculated for demographic, feasibility measures, and NSI data for both in-person and telerehabilitation groups. To explore symptom resolution for each group, we estimated Hedges' g effect sizes on changes in the NSI questionnaire. We interpreted the magnitude of the effect sizes as none (g < 0.2), small (0.2 < g < 0.5), medium (0.5 < g < 0.8), and large (g > 0.8). Effect sizes were calculated using the Measures of Effect Size Toolbox in MATLAB (Version 2020b).40

RESULTS

Feasibility

Seventy-three participants were enrolled: 56 in the in-person group and 17 in the telerehabilitation group. Of the 73 enrolled participants, 9 people withdrew with a similar rate between the in-person (13%) and telerehabilitation (12%) groups (Table 2). The study flow for in-person and telerehabilitation with participant reasons for withdrawing from the study is provided in Figure 2. Both telerehabilitation (97% ± 7%) and in-person (92% ± 13%) had similar and high intervention attendance, but the telerehabilitation group adhered less to the HEP (38% ± 28%) compared with the in-person group (61% ± 29%). Participants in the telerehabilitation group completed less of the intervention for the cervical stretching and range of motion, dynamic balance eyes closed firm, eyes open foam, and eyes closed foam subcategories compared with the in-person group (Figure 3). Neither group reported any adverse events during the intervention (Table 2).

Table 2. - Feasibility for Participants Receiving Rehabilitation Through In-person or Telehealth
In-person Telerehabilitation
Total enrolled, n 56 17
Total withdrawing from study of enrolled, n (%) 7 (13%) 2 (12%)
Total completing rehabilitation of enrolled, n (%) 49 (88%) 15 (88%)
Rehabilitation attendance, mean (SD), % 92% (13%) 97% (7%)
Home exercise adherence, mean (SD), % 61% (29%) 39% (28%)
Adverse events, n 0 0
Prior telehealth use of completed rehabilitation, n (%) 10 (67%)
Satisfaction questionnaire, mean (SD)
0 = strongly disagree, 5 = strongly agree
Easy to use 4.27 (1.10)
Satisfied with care 4.73 (0.46)
Convenient to use 4.67 (0.49)
Comfort with using 4.53 (0.64)
Helped recovery 4.73 (0.59)
Abbreviation: SD, standard deviation.

F2
Figure 2.:
Study flow diagram for participants who were enrolled, withdrew, completed, and were analyzed for the current study according to in-person rehabilitation and telerehabilitation. The reasons for participants who withdrew from the study are provided.
F3
Figure 3.:
Average exercise progression within each subcategory for in-person (gray) and telerehabilitation (white). Dashed lines indicate ±1 SD. EC, eyes closed; EO, eyes open.

After completing rehabilitation, the telerehabilitation group rated their satisfaction with receiving their rehabilitation virtually and indicated whether they had telehealth experience. Sixty-seven percent indicated that they had used some form of telehealth previously. On average, the telerehabilitation group found the program easy to use, were satisfied with the level of care, were comfortable using the virtual methods, and thought it helped with recovery (Table 2).

Postrehabilitation Symptom Changes

All pre- and postrehabilitation measures and subscales for the NSI for both groups are presented in Table 3. On average, both groups reported a decrease in symptoms following their respective rehabilitation programs (Table 3). However, the in-person group had a large effect size (−0.94) in decreases in symptoms following rehabilitation, while the telerehabilitation group had a moderate effect size (−0.73; see effect sizes in Table 3).

Table 3. - Means and Standard Deviations for the Neurobehavioral Symptom Inventory and Their Subscales at Pre- and Postrehabilitation Time Points on Participants Receiving In-person or Telerehabilitation Carea
NSI In-person Telerehabilitation
Prerehabilitation
Mean (SD)
Postrehabilitation
Mean (SD)
Effect Size (95% CI) Prerehabilitation
Mean (SD)
Postrehabilitation
Mean (SD)
Effect Size (95% CI)
Vestibular and sensory (out of 44) 14.77 (7.16) 8.82 (5.43) −0.91b (−1.20, −0.68) 12.80 (5.86) 9.73 (5.40) −0.52c (−1.04, −0.08)
Mood and behavior (out of 28) 12.19 (5.85) 7.16 (5.18) −0.88b (−1.24, −0.61) 10.93 (5.55) 7.33 (4.03) −0.72c (−1.22, −0.35)
Cognitive (out of 16) 7.38 (3.81) 4.73 (3.53) −0.69c (−0.98, −0.45) 7.67 (2.29) 5.47 (3.81) −0.67c (−1.58, −0.25)
Total score (out of 80) 34.33 (15.24) 20.71 (12.70) −0.94b (−1.27, −0.70) 31.40 (11.79) 22.53 (11.46) −0.73c (−1.32, −0.31)
Abbreviations: CI, confidence interval; NSI, Neurobehavioral Symptom Inventory; SD, standard deviation.
aEffect sizes from pre- to postrehabilitation and 95% CI are presented for each group.
bLarge effect.
cMedium effect.

DISCUSSION

In this pilot study, we demonstrated that an evidence-based, multimodal physical therapy program to treat people in the subacute recovery phase from mTBI could be safely delivered through virtual means with minimal required materials for treatment. The telerehabilitation sessions utilized a protocol similar to the in-person program, but some components were modified or completely removed due to safety concerns and the lack of equipment/materials. These changes required for telerehabilitation provide insight for clinicians who may need to shift to remote therapy to treat patients. The development of safe and challenging exercises related to cervical, cardiovascular, static, and dynamic balance to administer virtually may be important for an effective mTBI rehabilitation program. We found that the in-person group that had a more comprehensive rehabilitation program with more challenging exercises also demonstrated a larger reduction in symptoms. However, we cannot determine with certainty what accounts for this observation.

Telerehabilitation Pros and Cons—the Patient Perspective

We found that telerehabilitation had both benefits and barriers to care for the patient. Benefits included reduced travel time for appointments as participants could attend sessions from home, work, or vacation.12 This level of convenience was confirmed in our telehealth satisfaction survey. Additionally, travel by car may be unsafe at times as a previous study demonstrated slower response times during driving simulations.41 Therefore, telerehabilitation allows patients to avoid driving when symptomatic. On the other hand, treating virtually could be seen as both a barrier or benefit depending on the conditions. Some participants may have found the home or workplace to be a quieter environment more conducive to easing concussion symptoms than the typical busy physical therapy clinic.12 In contrast, some homes were filled with many distractions in the form of work, pets, children, and roommates, which increased attentional demands and may have made session participation more difficult. While access to digital technologies that enable telerehabilitation has increased in the last decade,1,2 geographic and socioeconomic factors can both influence access to adequate WiFi broadband and smartphones, tablets, or computers required for telerehabilitation.42,43 First, adequate broadband access is often limited in rural and underserved settings, with 33% of rural Americans lacking access to high-speed broadband internet to support video-based telehealth visits.44 Second, low median household income can limit access to both the necessary broadband access and technologies needed for virtual visits. Previous research has shown that 29% of adults living with annual household incomes less than $30 000 do not have smartphones, 44% do not have home broadband, and 46% do not have computers.43 The shift to telehealth and reliance on virtual visits during social distancing for those in rural locations and the economic hardships experienced during the COVID19 pandemic may have created additional health disparities for these groups of people.42,43 Further research would be needed on how access to telerehabilitation technologies can be improved for those in rural areas and urban low-income settings.45

Telerehabilitation Pros and Cons—the Physical Therapist Perspective

Telerehabilitation allowed mTBI specialists to treat patients with limited access to care due to transportation barriers, rural locations, or without access to specialization.12,43,46 Another benefit of telerehabilitation was that the therapist could provide more customized instruction in performing home exercises by seeing precisely what space and equipment were available to patients.47,48 While this should, in theory, reduce barriers to adherence to the HEP, this was not reflected in the HEP adherence of the telerehabilitation group. The low HEP adherence could have been due to the emailed compliance log versus the printed version for the in-person rehabilitation group. It is difficult to know whether the HEP was performed less or whether the method of reporting contributed to the lower compliance. Alternatively, a decrease in HEP performance may have contributed to a smaller reduction in symptoms in the telerehabilitation group. One potential downside to telerehabilitation was the limited ability to progress patients to more challenging exercises. The physical therapists were more cautious in advancing exercises due to concerns of falls. In addition, several exercises were removed entirely from the telerehabilitation program due to safety and equipment concerns (Figure 1). While the number of exercises in static balance performed was similar in the 2 groups, the inability to utilize a high-density foam with eyes closed conditions likely decreased sensory weighting and isolating the vestibular system, which decreased the challenge of the exercises. Fifty percent of the possible exercises were removed from the dynamic balance portion due to safety concerns, which may explain the reduction in total exercises performed and progressed in the telerehabilitation group (Figures 1 and 3). The additional presence of a support person in the home may allow for exercises of greater difficulty to be performed safely. Limited equipment was a barrier for cardiovascular assessment and progression. However, personal HR monitors have increased in popularity and may aid in the prescription of cardiovascular exercise in rehabilitation.16,39 While there have been concerns about access to and use of telehealth technology,12 we found that only one participant had difficulties downloading the application, and that was resolved with support provided over a phone call.

Symptom Reduction After Interventions

While symptoms improved for people receiving telerehabilitation, there was less reduction than the in-person group for overall symptoms and vestibular-sensory-related symptoms. This might be explained by the difference in the programs. First, the physical therapist was unable to provide manual cervical spine therapy and joint position sense training was removed from the telerehabilitation program (Figure 1). Many mTBI symptoms can be a function of cervical dysfunction.21 While telerehabilitation participants received instruction for self-manual therapy, they may have not received the same level of treatment that can be provided by an experienced clinician. Second, we were unable to provide supervised aerobic exercise for the telerehabilitation program, which is known to help decrease symptoms.27 Using a graded and proactive exercise prescription, like the BCTT, may decrease symptom severity in those with persistent mTBI symptoms.27 Other studies have used activity trackers, like Fitbits (Fitbit LLC; San Francisco, CA), to prescribe and track exercise intensity and frequency for reducing symptoms.16 Lastly, the decreased ability to practice dynamic balance in the telerehabilitation group may explain fewer improvements in symptoms. Evidence supports the use of static and dynamic balance exercises, as well as vestibular rehabilitation therapy, to reduce dizziness symptoms and balance deficits after mTBI.18,23,29 People in the telerehabilitation group only completed progressions of eyes open dynamic balance on a firm surface due to equipment and safety concerns, thereby missing more challenging balance exercises that could potentially stimulate recovery and adaptations.28,49

Limitations

One main limitation was the small sample size for the telerehabilitation group since we were limited to enrolling telerehabilitation subjects to the time our research facilities were closed for in-person research. Once we were able to resume in-person research, we discontinued enrolling participants into telerehabilitation, per our funder's request. However, this period provided the opportunity to pilot this virtual rehabilitation program. Also, the telerehabilitation group had significantly more males than females at enrollment and there are known sex differences in symptom presentation and recovery.50,51 This study was not randomized and did not have a control group. A larger randomized controlled trial would be helpful to determine the efficacy of telerehabilitation after mTBI. It could be considered a limitation that our intervention included a set plan of all 4 subcategories rather than individualized treatment, as one would see in clinical care. We chose this design to best standardize the intervention and to set up this randomized controlled trial to be able to understand the effects of timing of rehabilitation after mTBI (the larger goal of this randomized controlled trial).30 Therefore, our approach does not reflect clinical practice of using a personalized treatment plan. For example, the clinical practice guideline for physical therapists treating mTBI recommends that physical therapists design a personalized intervention plan for patients that aligns interventions with the patient's identified impairments, functional limitations, participation limitations, self-management capabilities, and levels of irritability.18 Our study, however, can provide information on how a physical therapist could implement treatment methods for mTBI on commonly impaired domains through teleconference or virtual methods. Another limitation was the lack of objective measures for quantifying balance and gait recovery in the telerehabilitation group due to equipment limitations, space constraints, and the lack of published data on performing balance and gait assessments virtually. This is a potential future direction for studies that determine telerehabilitation for mTBI efficacy.

CONCLUSIONS

This study demonstrated that a multimodal, rehabilitation program for subacute mTBI can be partially adapted and administered virtually. People using telerehabilitation can attend sessions regularly with no adverse events. Additionally, people were able to successfully use the technology and found it helped with recovery and reduced post-mTBI symptoms. However, telerehabilitation was limited in some aspects of treatment and did not include hands-on cervical treatments, monitored aerobic exercise, and highly challenging balance exercises. Telerehabilitation may still be an appropriate intervention for those with limited access to in-person care. Future studies could improve on the telerehabilitation program detailed in the current study to overcome equipment limitations and safety concerns to deliver a feasible and effective rehabilitation program for the recovery from mTBI.

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Keywords:

concussion; mild traumatic brain injury; physical therapy; telehealth; telerehabilitation

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