The corovavirus-2019 (COVID-19) pandemic has caused clinicians to modify how rehabilitation services are delivered. Telerehabilitation (TR) has been one of the primary means to continue to treat patients during this time. A scoping review found TR could be used for consultation with caregivers of older adults but was underutilized.1 Systematic reviews (SRs) of TR have found clinical outcomes similar/better compared with face-to-face (FTF) and compliance with home programs high.2,3 One SR looked at allied health care including PT and found telehealth as effective as FTF.4 Older patients and those living in rural areas have even greater benefit with TR.5 TR supports numerous clinical conditions including age-related comorbidities.6 TR improves patient access to care, prevents unnecessary delays in care, facilitates coordination of care, promotes collaboration within the health care team, and provides greater access to specialists.7,8 An SR found TR facilitated communication between patients and health care professionals to improve physical activity.9 The Rehabilitation Enhancing Aging through Connect Health (REACH) project demonstrated TR with some in-person visits reduced emergency department visits, improved gait speed, and raised Short Physical Performance Battery scores for older adults.10
Despite these advantages, older patients are less likely to choose TR.11 TR may be viewed as a cultural change by older patients not comfortable with technology.12 Therapist perceptions about TR also influence a patient's belief in its value. Studies have found clinicians have several concerns about the use of TR including patient safety, tech support, lack of physical contact, and developing rapport with the patient.13–15
Educating therapists that TR is an adjunct to, not a replacement of, FTF may ease some concerns.16 An example of a mixed or hybrid approach involved patients with subacute or chronic stroke utilizing 1 to 2 telephone calls, 1 to 2 home visits, and 2 to 8 TR visits and resulted in improved function, decreased depression, and decreased caregiver strain.17 Quality of life (QOL) and functional improvements for veterans were found with a hybrid approach of 75% TR and 25% FTF visits.18 Additionally, few academic programs include TR in the curriculum.19 A survey of PT/OT/NP students found mainly positive attitudes about telehealth but thought it clinically less useful and perceived interpersonal barriers.20
However, most patients have a positive view of telemedicine after using it.21 Use of patient-centered communication developed the same level of rapport as with FTF visits, and patients favored telehealth due to convenience.22 A study involving patients with hip or knee osteoarthritis (OA) found that preference for TR increased from 50% initially to 62% in the end.23 Patients after total knee arthroplasty found TR improved access to care and were able to develop a strong therapeutic relationship while having personal space.24 TR also lessens caregiver burden by reducing the need to transport a patient to appointments, thus reducing societal costs.25
TR has been found valid and reliable for many aspects of the clinical examination, but does have some limitations.26 Agreement in several assessment areas was found between FTF and TR of the neck, shoulders, low back, elbow, and hand conditions.27–31 TR has proven diagnostically comparable to FTF for lower limb musculoskeletal conditions.32 There was a high level of agreement between TR and FTF evaluation of a knee.33 A TR ankle examination consisting of functional movements, task, and self-applied orthopedic/neuro test was comparable to an FTF examination.34 Questionnaires like the Neck Disability Index, Oswestry, and Lower Extremity Functional Scale can be administered with TR and provide information on pain and function. Some software platforms have built-in goniometers and tape measures to assess range of motion and edema.
There is substantial evidence for treatment of musculoskeletal conditions with TR, especially as an adjunct to FTF. Examples of TR as an adjunct include booster sessions and a partial replacement of FTF for patients with chronic low back pain.35,36 An SR concluded TR combined with standard treatment may produce superior results compared with standard treatment alone.37 Some exercise programs have been created for TR, such as a high-dose shoulder program and knee OA.38,39 Many other exercise programs are easily adapted for TR. In addition to therapeutic exercise, treatment options include chair yoga, self-acupressure, and nerve mobilizations.40–43 Self-applied joint mobilizations have beneficial for several joints.44–47 Additionally, extended care for patients after hip fracture improved functional outcomes and is another advantage with TR.2,48
More studies demonstrating the benefits of TR involve post-joint replacement surgery. Systematic reviews have found TR at least as effective as FTF after total hip or knee arthroplasty.49–51 Compared against routine care, TR showed greater improvement in the Timed Up and Go (TUG) test.52 TR as an adjunct to FTF after hip surgery had greater improvements in gait speed, TUG, 2-minute walk test, 5 times sit to stand, and the 10-m walk test.53 Accuracy of exercise performance after total hip replacement was high.54 Telephone consultations reduced emergency department visits with patients after joint replacements.55 TR has also been found to reduce health care costs after total knee arthroplasty.56
GAIT AND BALANCE
TR lends itself well to the assessment and treatment of gait and balance disturbances. Longer fall programs have greater success than shorter ones, and TR provides these longer episodes of care.18 An SR found programs of less than 6 months reduced fall rate by 21% beyond 12 months and no difference in risk of falling between control and intervention groups while programs 6 to 12 months in length reduced fall rate 33% and the risk for falls decreased 36% beyond 12 months.57 Each component of a fall program (strength, endurance, balance, and acceptability to older adults) can be delivered with TR.58 Many clinical tests for these components translate easily to TR. An SR found 5 times sit to stand, TUG, functional reach, stepping activity, single-limb stance, and double-limb stance tests valid and reliable with TR.59 In some instances, a different test for the same system may be selected. Due to space limitations the 2-minute step test and the 4-m walk test are substitutions for the 6-minute and 10-meter walk tests, respectively.60 Strength and balance tests such as the 30-second chair rise, 30 1-arm curl, 8-ft TUG, and feet together/semi-tandem/tandem standing are able to be performed with TR as with FTF.60 There are several characteristics outlined for a clinical gait examination.61 Except for perturbation tests, other than when a technician assists, all other aspects are observable or measurable with TR. Low-cost motion analysis platforms have proven valid measurements for gait speed, stride length, gait cycle, sagittal plane range of motion at hip/knee/ankle, and upper extremity shoulder patterns.62 TR has also been used for gait device height assessment.63 A comparison between TR and in-person gait assessments found no differences in recommendations.64 Clinical tests such as the Berg Balance Scale (BBS) and the Performance-Oriented Mobility Assessment-Gait (POMA-G) are valid and reliable with TR.63,65 Studies have shown a licensed practical nurse used as a technician could be educated to assist in performance of tests such as the POMA, proprioception of the great toe, dynamic visual acuity, and could help to identify whether additional services were needed.66,67 The technician also provided safety guarding for the performance of some exercises.67
A TR balance program improved balance and strength and decreased depression.68 The Otago exercise program (OEP) has been shown to improve physical function in older adults.69 TR has been demonstrated effective in the delivery of the OEP.70 Tai chi delivered with TR improved balance and reduced fear of falling.71 The Balance Intensity Scale and verbal markers provide valid measurements for intensity of balance exercise with older adults and may be used with TR.72,73 Home safety assessments can be completed with TR before a patient leaves the hospital or skilled nursing facility.74 A home safety assessment that looked at patient self-care, mobility, household, and leisure activity was found feasible with TR.75 A high level of agreement was found between FTF and TR when measuring the height of items in a house.76
Many older adult patients have searched for smartphone applications (app) to improve their function. One study examined an app for the Functional Gait Assessment and found the app eliminated subjective errors and promoted self-care.77 Therapists should review patient-selected apps to determine accuracy of the information provided. Standardized reviews of smartphone balance apps found that many did not have scientific support or were not developed by a therapist.78,79
Vestibular dysfunctions such as hypofunction and benign paroxysmal positional vertigo (BPPV) are treatable with TR. Questionnaires may be used as screening tools for vestibular disorders and BPPV.80,81 Smartphone-recorded eye movement with the Dix-Hallpike maneuver had high sensitivity and specificity.82 When treating BPPV with TR, patient safety must be considered. A sensation of being thrown to the ground after canalithiasis repositioning maneuvers has occurred in some patients.83 Treatment of chronic vestibular syndrome showed TR alone and a hybrid approach had greater improvements in symptoms compared with usual care with the hybrid approach having the greatest reduction in stress, anxiety, and depression.84 Use of an iPod provided objective information about head turn frequency.85
Patients who have suffered strokes can benefit from TR to reach their maximum functional potential. An SR and meta-analysis found TR had similar outcomes/effect with activities of daily living, upper extremity/lower extremity function, balance, walking (or better), physical activity, and participation.86 Another SR and meta-analysis found no differences between TR and FTF with Barthel Index, BBS, Fugl-Meyer Upper Extremity, and Stroke Impact Scale.87 However, another SR found TR interventions have equal or better effects on motor, higher cortical, and mood disorders, BBS, Dynamic Gait Index, 10-m walk test, and Caregiver Strain Index.88 A scoping review found 58 different outcome measures used with TR/virtual reality after stroke.89 Equal effects to balance and functional mobility were found with TR as with FTF in a clinical setting.90
Parkinson disease is another neurological condition where TR benefits the patient. TR was found accurate and reliable for assessment of the timed stance test, TUG, step test, steps in 360 turn, BBS, and lateral/functional reach for patients with Parkinson disease.91 TR has been found to be valid and reliable with high-level agreement with FIM (except bowel management with modified independent and independent levels), UPDRS (except handwriting, action tremors, and speech volume), and Nine Hole Peg Test for patients with Parkinson disease.92 TR can be used to administer the Montreal Cognitive Assessment for patients with Parkinson disease.93 An SR found telehealth effective to improve motor impairment in subjects with Parkinson disease.94 TR used in combination with the Lee Silverman Voice Training Big program improved 6-minute walk distance and TUG time.95 Yoga and tai chi have moderate to high evidence and have been found effective with TR.40,71,96 Additionally, group-adapted tango dancing using TR has proven beneficial.97 A case study for a patient with cerebellar ataxia used TR for 59 of 60 visits with improvements in gait speed, TUG, and pegboard tests.98
TR has shown many positive outcomes for patients with cardiopulmonary conditions. TR used as a partial replacement for FTF visits for patients with pulmonary disease improved in dyspnea rating and 6-minute walk test (6MWT).36 An SR concluded TR was no different from traditional service delivery on the 6MWT, peak oxygen consumption, and QOL.99 The SR also concluded home program adherence seemed higher. The dropout rate and compliance with pulmonary rehab have been found higher with TR.100 A randomized controlled trial (RCT) found TR reduced risk of acute exacerbation and emergency visits for patients on maintenance pulmonary rehab.101 In Canada a nationwide initiative was developed to deliver pulmonary rehab with TR.102 Another RCT TR program for heart failure resulted in improved QOL and 6-minute walk distance with improvements sustained at 4 months.103 There is a framework for comprehensive pulmonary rehabilitation with TR.104
COMMON CONDITIONS FOR OLDER ADULTS
TR as a part of the treatment plan for common conditions found in the elderly such as diabetes, frailty, chronic pain, wounds, cancer, incontinence, and dementia has been beneficial. A diabetic telemedicine clinic improved glycemic control with enhanced access to clinical care.105 TR used for exercise and nutritional education improved balance, gait speed, and QOL in a frail elderly population.106 A prefrail older adult population used TR with a program based on the OEP and improved QOL.107 Elderly adults with sarcopenia utilized TR to increase muscle mass and sitting balance.108 Patients with chronic pain preferred TR for feedback and monitoring of their progression.109 A case study concluded TR could be used to deliver therapeutic neuroscience education remotely.110 Another case study for wound care found a similar result.111 Wound healing times were found shorter with telemedicine compared with traditional follow-up visits.112 TR used to treat various cancers has improved physical function, QOL, cognitive functioning, and decreased pain.113,114 Remote-guided exercise for patients with stable gliomas improved cardiorespiratory fitness.115 TR for stress incontinence improved symptoms and QOL.116,117 An SR found TR had comparable effects to FTF for cognitive rehabilitation in patients with mild cognitive impairment, Alzheimer disease, and frontotemporal dementia.118 TR reduced caregiver burden, stress, depression, and hours of care provided for patients with dementia.119
ADVANCEMENTS WITH TR
Technology advancements including wearable haptic bands to remotely replace a therapist's hands for guiding movement and clothing for monitoring vital signs with chronic patients.120,121 The UPDRS has poor to moderate correlation with different tasks and different times of day.122 Sensors worn by individuals with Parkinson disease all day can give insight into how a person performs in home throughout day and could give aggregate score.122 Sensors used for upper extremity movement could be used to identify typical from atypical movement across lifespan.123
TR has been a growing area for health care for decades and the COVID-19 pandemic has accelerated this growth. As the technology grows and more therapists become experienced with TR, its use will continue to grow. The Federation of State Boards of Physical Therapy provided recommendations for therapists using TR. These recommendations included recognizing changing patient and provider expectations, deconstruction of the traditional physical therapy encounter, being open to discovery, and being bold and visionary.124
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