Telehealth: the evidence, the challenges, the benefits and the opportunities.
It is coming close to a full month since physiotherapy practices and gyms across Ireland closed their doors and went fully operational online using digital technologies. From discussing this amongst my peers and fellow Physiotherapists, there have been varying levels of success since moving online. Factors include technology and demographics but ultimately it boils down to the patient/clients willingness to take their rehabilitation/training online.
I felt it was important to look at some of the current evidence surrounding Video Call Consultations (also known as Telerehabilitation/Telehealth) and detail some of the opportunities and challenges that can present to both practitioner and patient.
Source: Evidently Cochrane
Below are some studies/reviews that look at the evidence base regarding Telehealth -
1 | Richardson et al. 2017
Richardson et al. 2017 studied the assessment and diagnosis of musculoskeletal disorders of the knee. The aim of this study was to evaluate the accuracy and reliability of an online musculoskeletal physiotherapy assessment of the knee complex using Telerehabilitation compared to traditional face-to-face assessment. The results showed that primary diagnoses were in exact agreement in 67% of cases and were similar in 89% of cases. The system of pathology was found to be in agreement in 17 out of 18 cases (94%). They concluded that Telerehabilitation assessment of the knee complex appeared to be feasible and reliable.
2 |Cottrell et al 2017
Cottrell et al 2017 carried out a systematic review in which the objective was to evaluate the effectiveness of treatment delivered via real-time Telerehabilitation for the management of musculoskeletal conditions, and to determine if real-time Telerehabilitation is comparable to conventional methods of delivery within this population. Results suggest that Telerehabilitation is effective in the improvement of physical function whilst being slightly more favourable than the control cohort following intervention. Sub-group analysis reveals that Telerehabilitation in addition to usual care is more favourable than usual care alone, whilst treatment delivered solely via Telerehabilitation is equivalent to face-to-face intervention for the improvement of physical function. The improvement of pain was also seen to be comparable between cohorts following intervention.
3 | Richardson et al. 2017
The same group of researchers from the first study, based out of Queensland, Australia, found that telemedicine is a feasible solution to the issue of rural health service access; however, it also highlighted that there was little existing evidence for clinical efficacy or cost-effectiveness. The aim of the study was to establish the criterion validity and reliability of remote physical assessment and diagnosis of lower limb musculoskeletal conditions that are nonarticular in origin via Telerehabilitation. An example of nonarticular condition would be a soft tissue muscle strain. It hypothesised that Telerehabilitation is a valid and reliable medium for physical assessment and diagnosis of nonarticular lower limb musculoskeletal conditions.
4 | Mani et al 2015
Finally, Mani et al 2015 carried out a systematic review which analysed 11 articles in the effort to look at the validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders. The physiotherapy assessments such as pain, swelling, range of motion, muscle strength, balance, gait and functional assessment demonstrated good concurrent validity. However, the reported concurrent validity of lumbar spine posture, special orthopaedic tests, neurodynamic tests and scar assessments ranged from low to moderate. They concluded by saying Telerehabilitation physiotherapy assessment was technically feasible with overall good concurrent validity and excellent reliability, except for lumbar spine posture, orthopaedic special tests, neurodynamic tests and scar assessment.
Potential Challenges for both Practitioner and Clients
Issues surrounding poor audio and video quality due to low bandwidth connections act as a potential barrier. Rural populations and locations may not have the capabilities to maintain a clear and effective video session compared to an area with high-speed broadband.
2) The Need for Manual Therapy
Overcoming this roadblock will require plenty of education. Clients need reassurance that their conditions can be effectively managed with Telehealth and that passive techniques like massage, dry needling or ultrasound are not a prerequisite for them improving their condition.
3) Ineffective Cueing & Communication
As the assessment and overall experience will have altered from a standard face-to-face consultation, so should the skill set of the Practitioner. Practitioners must recognise this in order to develop different techniques and strategies to effectively assess their clients. This will help them to provide the correct information, in a clear and coherent manner.
4) Insufficient Follow Up
While it should always be standard practice to follow up with every client with advice, exercises etc, no more than ever has it been so vital. Not providing clear instructions that the client will be able to follow on their own can only lead to poor outcomes and a disconnect between both Practitioner and client.
5) Cost / Insurance Coverage
Given the financial implications associated with COVID-19, it undoubtedly is causing most people to review their spending. At the time of writing and according to the ISCP, VHI and Laya are both covering video call consultations, with Irish Life yet to respond.
Benefits to Patients & Practitioners
Benefits to the Client/Patient
• It expands the ability to connect with their Practitioner / Coach regardless of distance or remote locations. This continuity of care can only help both Practitioner and client achieve their goals.
• It decreases barriers such as negotiating parking and waiting rooms or travel time. There is a decrease in cost associated with travel and the reduced travel positively impacts on the environment.
• It increases safety by eliminating the need to travel for those with mobility impairments or ill health.
• It develops the client’s independence and control in managing their own health problems thanks to easy access to online self-monitoring and self-management resources.
Benefits to the Practitioner
• It Allows the Practitioner / Coach to continue to work with their client base without the need for face-to-face interaction.
• Rehabilitation protocols and timelines to be maintained and followed.
• Provides the Practitioner opportunities to think and work more creatively by leveraging the advantages afforded by ever-evolving technology options.
• Creates equity of health care provision that is independent of geography.
A Final Note
The overall emerging evidence appears to indicate that digital technologies are providing new opportunities for Physiotherapists to deliver high-quality and acceptable care to users of their service in ways that can have benefits for all. Whilst results do support the utilisation of telerehabilitation, further rigorous clinical trials, with respects to both specific musculoskeletal conditions and the treatment interventions provided, are warranted prior to formally concluding its efficacy.
On a personal note, I have found the benefits far outweigh the potential barriers and challenges, and I look forward to continuing in helping my current and new client base to the best of my abilities, in an online presence.
1) Richardson BR, Truter P, Blumke R, Russell TG. Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation. Journal of Telemedicine and Telecare 2017, Vol. 23(1) 88–95.
2) Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clinical Rehabilitation 2017, Vol. 31(5) 625–638.
3) Russell TG, Truter P, Blumke R, Russell TG. The Diagnostic Accuracy of Telerehabilitation for Nonarticular Lower-Limb Musculoskeletal Disorders. Telemedicine and e-HEALTH, Vol. 16 No. 5 June 2010.
4) Mani S, Sharma S, Baharudin O, Paungmali, Joseph L. Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review. Journal of Telemedicine and Telecare 2017, Vol. 23(3) 379–391.
Find out more
Eric Cullinane and Kathryn Dane are Chartered Physiotherapists working with FFS Physiotherapy, a practice based on Leeson St Lower. Chartered Physiotherapists have specialist knowledge in the field of work-related injury management.
If you need advice, a online physiotherapy assessment, or feel your team/business could learn more about working-from-home ergonomics, contact Eric or Kathryn at firstname.lastname@example.org or visit https://www.ffs.ie/train-ffs/physiotherapy/
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