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'''Telerehabilitation'''
Introduction
Telerehabilitation (TR) is defined as the use of telecommunication devices and technologies to deliver rehabilitation services to people who are in need of rehabilitation services 1. The types of services may include monitoring, intervention, supervision, education, assessment, consultation, counseling, preventions and enhancing the continuum of care. The point of service for telerehabilitation has a broad range, including outpatient clinics, schools, residential homes, and other community-based sites2. TRcan be considered as a subset of telemedicine and a relatively new yet growing niche as the first published paper in this field merely dates back to 19982. The most common clinical use for TR is in neuropsychology and counseling since physical contact is typically not required for treatment. However, recently the field of speech-language-pathology (SLP) has gained increasing clinical usage from TR as the assessment quality has improved3. Application of TR is known to be beneficial to patients in reducing their travel time and its associated costs: it allows clinicians or healthcare practitioners to remotely engage and deliver patient care without physically being present in the same proximity to patients4.
Stakeholders and Types of Technology Used
The stakeholders who are involved in the clinical use of TR include, but are not limited to rehabilitation physicians, nurses, researchers, physical therapist, occupational therapist, speech-language pathologist, audiologist, assistive technologists, teachers, psychologists, and dieticians. Other paraprofessionals may include family members, caregivers, and technical support personnel within the healthcare organization or third party entity 5,6.
There are variations of technology used within the field of TR. The most commonly used technology for TR during last 10 years is a combination of audio and video type of technology, although virtual reality and sensor-based technology is rapidly gaining interests especially as e-health gains popularity. 2 Recent systematic reviews by Kairy et al. and Rogante et al., reported a wide range of technologies used in TR: videoconferencing, webcams, telephone lines, videophones, web applications through Internet and virtual reality.
1) Audio/Video communication Technology: Also referred to as videotelephone, which is composed of real-time audio-video transmission between users at two or more different locations2,7,8. It may include telephone, webcam, and videoconferencing systems.
2) Message Texting Technology: Using primary text messaging through Instant Messaging Platform or Short Message Service (SMS)2
3) Sensor-Based Technology: Using sensor equipment on patients to monitor and assess their performance real-time or store-forward processing2. One example of more recent technological advancement in sensor-based technology is the wearable accelerometry-based technology (ABT), which allows remote assessment of patient’s functional mobility9.
4) Interactive software: Often using Internet browser to access home exercise programs that are specifically catered to patient’s impairments. For example, Cranen et al. used web-based telerehabilitation services to engage and assess chronic pain population10.
5) Virtual Reality –This is a mixture of both sensor-based technology with software modules allowing patients to participate in simulated environment through real-time audio, visual and haptic interface2. The unique feature of virtual reality is the effects of three-dimensional reconstruction technology which facilitates more accurate representation of patient’s movements and therefore performance and evaluation11. Virtual reality systems can also be based on computer programs designed to simulate real-life objects, events and functional activities2.
Effectiveness of Telerehabilitation
Generally, most of the studies reviewed by systematic reviews reported positive patient satisfaction and clinically significant outcome from the use of TR in their studies2,4,12.One systematic review gathered 61 studies and reported that over 51% TR applications were clinically significant with home cardiac and neurological rehabilitation being the most frequent types of studies found12. However, it was noted that only 50% of the studies were considered high or good quality based study design, such as large randomized controlled studies (RTC) to non-comparative studies, and study quality based on specific intervention, patient selection and outcome reporting12.
Examples of clinical applicationsof TR in Physical Therapy and Speech-Language-Pathology settings:
1) 48 postoperative total knee replacement (TKE) community-living adults who participated in RTC study for physical therapy using videoconferencing CODECs technology for 8 weeks8.
2) 22 postoperative total shoulder arthoplasty (TSA) patients in RTC study for physical therapy using similar videoconferencing technology for 8 weeks13.
3) 100 dysphagic patients for clinical swallow examination from speech-language-pathologist using custom video conferencing software audio and video compression technology for real time communication. Patient also used lapel microphone14.
Cost effectiveness of Telerehabilitation
There is limited data and lack of uniformity in the reported accounting of associated costs of implementation, its usage and maintenance of TR. According to one systematic review, only five studies out of 28 reported some level of cost analysis of TR intervention6. Within these studies there were variations of theoretical and actual cost savings. One study estimated that the application of TR would save about 17% or cost of $100 per patient during 12 sessions of physical therapy at home in comparison to theoretical home care15. Another study, which focused on TR in home-cardiac rehabilitation program, reported a significant savings of 58% of the cost for a 3-month duration of treatments compared to 3-week hospital rehabilitation services16. In similar studies, cost perspectives were taken from the organization’s side compared to the patient’s perspective. For example, a study by Sicotte et al. reported that a patient would incur a maximum of $20 per session based on personal cost from work time loss17. However, this was published in 2003 and if you consider inflation, current cost would be equivalentto $25.68 according to the inflation formula. While most of these studies that reported cost analysis showed savings in both practical and theoretical models, the expected amount of savings remains inconclusive due to variations in cost factors.
Barriers to Telerehabilitation
1) Reimbursements: Reimbursement for TR services vary across the United States. While 44 of 51 states have known to reimburse some level of telehealth treatments, only 9 states are reimbursed for various TR services through Medicaid plans. These states include Alabama, Kentucky, Minnesota, New Mexico, Nevada, Ohio, South Carolina, Virginia, and Wyoming18. However, the scope of practice also varies as some states follows Medicare’s restrictions by denying some of the key rehabilitation practitioners as eligible telehealth providers (i.e SLP, PT, OT) 19.
2) Policy Challenges: Currently there are no standardized language of practice model, regulations and definitions of TR services across the states. While both the American Speech-Language-Hearing (ASHA) and the Federation of State Boards of Physical Therapy (FSBPT) have established model practice act language for states to consider, it has not been enforced for adoption. Thus, there are inconsistent definitions of practice model and lack of uniformity of language pertaining to the use of TR. Therefore, one must always check state’s statues, regulations, and policies before considering TR practice.
3) Current licensure standardsacross state and national borders: Not every state has established laws, regulations or policies regarding the use of TR across the state outside of practitioner’s licensing jurisdiction. For example, if the client receiving the TR services resides outside of the provider’s licensed state, the provider must also hold a license to practice in client’s state. However, there are provisions to allow SLP and OTs to practice across states without a license but it has time restrictions (i.e. up to 30 days/per year) and requires equivalent licensure requirements from his/her native state.
4) Liability and accountability: Because of the lack of uniformity of licensure requirements and practice act for TR services between states, malpractice policies and its insurance coverage will need to be considered by TR practitioner within prospective states.
5) Usability of TR for both patients and clinicians: It is typically required that a TR setup with videoconferencing system will require some initial setup assistance and training by technical support staff. From the current researches that specifically utilized rehabilitation services for post-operative care had minimal challenges with the use of TR in patient’s native environment8,13,14,20. It may be that a high speed network with minimal disruption coupled with simple interface setup played a significant factor for achieving usability. For example, Kairy et al. used high imaging quality which included a single button that turn on/off the system with 20-inch liquid crystal display (LCD) screens, and point-and-click to zoom in the customized interface20.
References
1. Parmanto B, Saptono A. Telerehabilitation: State-of-the-art from an informatics perspective. International Journal of Telerehabiliation. 2009;1(1):73-83.
2. Rogante M, Grigioni M, Cordella D, Giacomozzi C. Ten years of telerehabilitation: A literature overview of technologies and clinical applications. NeuroRehabilitation. 2010;27(4):287-304.
3. Ward E, Burns CL, Theodoros DG, G. RT. Evaluation of a clinical service model for dysphagia assessment via telerehabilitation. International Journal of Telemedicine and Applications. 2013;2013(Article ID 918526):1-7.
4. Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disabil Rehabil. 2009;31(6):427-447.
5. Russell TG. Physical rehabilitation using telemedicine. J Telemed Telecare. 2007(13):217-220.
6. Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disabil Rehabil. 2009;31(6):427-447.
7. Eriksson L, Lindstrom B, Gard G, Lysholm J. Physiotherapy at a distance: A controlled study of rehabilitation at home after a shoulder joint operation. Journal of Telemed and Telecare. 2009;15(1):215-220.
8. Tousignant M, Boissy P, Moffet H, et al. Patients' satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists' satisfaction toward technology for post-knee arthroplasty: An embedded study in a randomized trial. Telemed J E Health. 2011;17(5):376-382.
9. Schein R, Schmeler M, Saptono A, Brienza D. Patient satisfaction with telerehabilitation assessments for wheeled mobility and seating. Assistive Technology. 2010;4(22):215-222.
10. Cranen K, Drossaert CHC, Brinkman ES, Braakman-Jansen ALM, IJzerman MJ, Vollenbroek-Hutten MMR. An exploration of chronic pain patients' perceptions of home telerehabilitation services. Health Expectations. 2011;4(15):339-350.
11. Schmeler, M., Schein, R., McCue, M., Betz,K. Telerehabilitation clinical and vocational applications for assistive technology: Research, opportunities, and challenges. International Journal of Telerehabilitation. 2009;1(1).
12. Hailey D, Roine R, Ohinmaa A, Dennett L. Evidence of benefit from telerehabilitation in routine care: A systematic review. J Telemed Telecare. 2011;17(6):281-287.
13. Eriksson L, Lindstrom B, Ekenberg L. Patients' experiences of telerehabilitation at home after shoulder joint replacement. J Telemed Telecare. 2011;17(1):25-30.
14. Ward EC, Burns CL, Theodoros DG, Russell TG. Evaluation of a clinical service model for dysphagia assessment via telerehabilitation. International Journal of Telemedicine and Applications. 2013;2013(Article ID 918526):1-7.
15. Tousignant M, Boissy P, Corriveau H, Moffet H. In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: A proof-of-concept study and costs estimation. Disabil Rehabil Assist Technol. 2006;1(4):209-216.
16. Kortke H, Stromeyer H, Zittermann A, et al. New east-westfalian postoperative therapy concept: A telemedicine guide for the study of ambulatory rehabilitation of patients after cardiac surgery. Telemed J E Health. 2006;12(4):475-483.
17. Sicotte C, Lehoux P, Fortier-Blanc J, Leblanc Y. Feasibility and outcome evaluation of a telemedicine application in speech-language pathology. J Telemed Telecare. 2003;9(5):253-258.
18. American Telemedicine Association. State medicaid best practice telerehabilitation. . 2014. http://www.americantelemed.org/docs/default-source/policy/state-medicaid-best-practice---telerehabilitation.pdf?sfvrsn=4.
19. Cason J, JA. Telehealth regulatory and legal considerations: Frequently asked questions. International Journal of Telerehabiliation. 2011;2(3):15-18.
20. Kairy D, Tousignant M, Leclerc N, Côté A, Levasseur M. The patient’s perspective of in-home telerehabilitation physiotherapy services following total knee arthroplasty. International Journal of Environmental Research and Public Health. 2013;9(10):3998-4011.