Delivering Physical Therapy via - PowerPoint Presentation

Delivering Physical Therapy via Telerehabilitation Donald Hayes, PT Central Iowa VA Health Care System Des Moines, IA

Goal of TelehealthIncrease access for patients to therapy services

Population StatisticsAccording 2010 Census 19.3% population in rural areas in US 2010 Census for Missouri 37% (equates to approximately 2.22 million) Population density US cities comprise 62.7% population but comprise 3.5% land area-2013 Census Bureau

Telehealth DefinitionDefinition: “Telehealth is the delivery of health-related services and information via telecommunications technologies. Telehealth could be as simple as two health professionals discussing a case over the telephone or as sophisticated as doing robotic surgery between facilities at different ends of the globe.” 1

Definitions continuedTelerehabilitation : “within the larger realm of telehealth is the application of communication technology for supporting rehabilitation services” 2 AOTA position paper

History3 Teleconsultations and telehomecare were common by 1940’s 1960’s telemedicine or telehealth transmit vital signs with NASA for astronauts 1970’s progressed into real medical applications 1980’s military started using store and forward and videoconferencing-increase access to specialists 1990’s Federal agencies started telemedicine programs

History cont. 1997 Telerehabilitation created by National Institute on Disability and Rehabilitation Research (US Department Education). 4 “priorities” Develop and evaluate telecommunication techniques for delivering training, education, and counseling rehabilitation services at a distance Develop and evaluate technologies for assessment and monitoring of progress and outcome of rehab at a distance Develop/evaluate technologies for therapeutic intervention at a distance Conduct research on application of VR technologies to rehab

Ways to use Telerehabilitation Videoconferencing Peripherals that can be used Stethoscope Blood Pressure monitor Pulse ox Goniometer Tape measure Store and forward Can be still pictures or video Study in Japan 4

Ways to use Telerehabilitation Evaluation to discharge Challenging Mental health dx such as agoraphobia, anxiety Mix of in person and telehealth visits Most common Home safety/wheelchair evaluation Supervisory visits for assistants

Supervisory Visits5 Large contract company in Washington state with many facilities Shortage of PTs Telehealth for supervisory visits with PTA with patient

Wheelchair positioning2009 Study from Canada 6 As likely to meet patient goals with telerehab versus face to face Able to see patients sooner Limitation of study Small sample size- 30 total subjects between 3 groups Could have further research using pressure mapping for SNF, rural outpatient , hospitals

AdvantagesAble to see patient’s sooner-Consumer centered approach Able to see patient in home environment Quicker screening process-faster referrals Facilitates more active patient role Therapist able to see more patients Improve access to patients in rural/densely populated areas Have to be innovative with approaches

Advantages examplePatient with BPPV Typically use Epley for treatment Requires second operator to assist with position changes or can be self-applied but may be confusing during episode Half somersault could be used for home program instead 7 Patient performs on own (Active patient role) Different way to address BPPV (Innovative) Decrease patient travel to clinic

BarriersReimbursement 48 states and DC have some form Medicaid payment for telemedicine 32 states and DC have private insurance policy for payment with telemedicine Therapists resistant-getting comfortable with being uncomfortable Connectivity/Technical Issues Not every patient is appropriate (i.e. vision deficits, hearing deficits, decreased cognition)

Reimbursement8

Considerations Patient Selection Cognitive deficits Visual deficits Hard of hearing Mental health Patient Safety Balance/fall risks Transfers Gait Building rapport with patient

Laws Regarding PT and Telehealth “Majority of state PT and OT regulatory boards are silent on telehealth-related issues” 9 “Occupational therapy may be provided via technology or telecommunication methods, also known as telehealth, however the standard of care shall be the same whether a patient is seen in person, through telehealth, or other method of electronically enabled health care” (Illinois Occupational Therapy Practice Act, 2013)

Ethical IssuesPrivacy Apps with encryption for protected health information Using private office on provider end Identify all persons in room, if not private office Standard of care does not change, only the method to achieve outcome is different

Evidence Based Practice

Clinical Expertise

Evidence Based Practice Clinical Expertise Education for therapists with telerehab Networking-American Telemedicine Association- Special Interest group

Patient Preference and Values

Evidence Based Practice Patient Preference Studies have shown majority of patients like telemedicine 10 Patient Perspective 11 Study for patients post TKA found 6 main themes Improving access/reduce need transportation Developing strong therapeutic relationship while having personal space Complementing with in-person Tailored HEP Perceived ease of use of equipment Feeling sense of support Higher adherence for home programs (?)

Evidence Part of EBP

Types of Patients SeenMusculoskeletal Neurological i.e. Parkinson’s disease, CVA, ALS, MS Amputee Spinal cord injuries Cardiopulmonary TBI Chronic Pain Pediatrics through Geriatrics

Musculoskeletal EvidenceMusculoskeletal Conditions (Cottrell et al 2016) 12 Systematic review (13 studies were included) Telerehabilitation appeared to be superior when compared to standard practice for improving physical function Viable option for the clinical management of musculoskeletal conditions Comparable but not inferior to standard face to face physiotherapy treatment following total knee arthroplasty

Musculoskeletal Evidence Continued Musculoskeletal Disorders (Mani et al 2016) 13 Systematic review with 11 studies included Good validity for pain, edema, ROM, strength, balance, gait and functional outcomes Low validity for lumbar spine posture Moderate validity for special orthopedic tests, neurodynamic test and scar assessment

Musculoskeletal Evidence Continued Evaluation of knee (Richardson et al. 2017) 14 Face to Face versus telerehab self-palpation, self-applied modified special tests, AROM, functional tasks High level of agreement Areas to improve for telerehab were more through questions about mechanism injury and palpation Small sample size= 18

Cardiopulmonary Evidence Cardiopulmonary Disease (Hwang et al 2015) 15 A systemic review (11 studies) Results: telerehabilitation was no different than other delivery models Appears to have higher adherence rates Compelling evidence still limited COPD study 16 Low drop out rate and higher compliance with pulmonary rehab Mirrored centere -based programs Small sample size-36

Cardiopulmonary continued Assessing exercise capacity with chronic heart failure (Hwang et al 2017) 17 17 patients (small study) seen same day in-person and via telerehab Assessed TUG, 6 minute walk, grip strength Found to be valid and reliable

Neurological Evidence Post-stroke ( Bernocchi et al 2016) 18 23 patients sub-acute to chronic Mixed method approach with 1-2 home visits, 1-2 phone calls, and 2-8 videoconference sessions Improved in global functional capacity-especially static and dynamic postural balance, UE dexterity paretic side, and physical performance Decreased depression and caregiver strain

Neurological continued Scoping review outcomes measures post CVA ( Veras et al 2016) 19 28 studies included 58 different outcome measures used with telerehabilitation /virtual reality Study for access and willingness to use post CVA ( Sakakibara et al 2016) 20 Technologies used were TV, landline phone, computers Most patients interested to receive assessments (58.4%) Education/HEP (64%) 71% believed quality of care would be less than in-person

Neurological continuedAssessment patients with Parkinson (Russell et al 2013) 21 12 subjects examined face to face and telerehab simultaneously Timed stance test, TUG, step test, steps in 360 turn, Berg, and lateral/functional reach Used eHAB system Found to be accurate and reliable

Function/Quality of Life Evidence PT delivered via telerehabilitation (Levy et al 2014) 22 Completed on 26 veterans Really mixed-method approach with 25% visits face to face Improvement in the following: Physical Functions (2 minute walk test) Cognitive Functions ( MoCA ) Functional Independence (FIM) Health Related Quality of Life

Physical ActivitySystematic review ( Hakala et al 2017) 23 8 studies Found TR as effective as similar promotions without technology Potential for increased motivation counselling Facilitating communication between healthcare professionals and patients Need to determine cost-effectiveness

Pain Evidence Hip or knee OA ( Rini et al 2015) 24 Pain COACH App for Pain education 109 participants completed study Showed clinical promise to strengthen the effects and adherence was very high 23% of potential participants declined due to not wanting to use a computer but in the end preference for completing on a computer increased from 50% to 62% among participants Patient Perceptions TR ( Lawford 2016) 25 330 people with hip/knee OA completed survey Mostly positive perceptions except concern about lack of physical contact with therapist-recommended education and mixed approach

Pain Evidence Systematic review for technology-supported exercise 26 25 studies Concluded when telerehab alone was not better Paired with standard treatment in a complementary manner resulted in significantly greater improvements RTC for chronic neck pain 27 100 patients after outpatient PT (50 control/50 treatment) Phone calls fortnightly (every 2 weeks) for 6 months Treatment group lower pain and disability scores, higher adherence to HEP

SCI Evidence23 participants for high dose scapular stabilizer and rotator cuff strengthening using telerehabilitation (Van Straaten et al 2014) 28 Improvements in Wheelchair User’s Shoulder Pain Index, DASH, and Shoulder Rating Questionnaire Improved strength with serratus anterior and scapular retractors

Pediatric EvidencePilot program to deliver school-based OT via telerehabilitation ( Criss 2013) 29 Students aged 6-11 completed virtual eval and 6 30-minute sessions for handwriting High satisfaction and improvements with handwriting and IEP

Advancing Telerehab Quick search Pubmed Telemedicine and physiotherapy-287 articles Physiotherapy and shoulder-4627 articles Use of apps for all aspects of eval and treatment eHab app used in Australia Use of peripherals for data Body worn motion sensors 30 Portable kits for gait training 31

Advancing Telerehab Wearable haptic band 32 8 vibrator motors along wearable band Replace therapist’s hands for guiding movement Compared for both arbitrary motion patterns and typical therapy exercises Able to demonstrate efficacy

Strategies for success33 Recognize changing patient and provider expectations Untether telehealth from traditional reimbursement expectations Deconstruct the traditional physical therapy encounter Be open to discovery Be mindful of the importance of human and ethical factors Redesign care with focus on value Be bold and visionary

References Telehealth. ( n.d. ) In Wikipedia. Retrieved Oct 24, 2016, from https://en.wikipedia.org/wiki/Telehealth. Wakeford L, Wittman PP, White MW, Schmeler MR. Telerehabilitation Position Paper. AOTA 2005 Nov/Dec 59(6):656-660. http://eng.mu.edu/wintersj/rehab/rehab167/mod3/history.htm. Accessed Oct 17, 2016. Iwatsuki H, Fujita, C, Maeno R, Matsuya, A. Developing of a telerehabilitation system for training physiotherapists in rural areas. J Telemed Telecare . 2004; 10( suppl 1): S1:51-52. Lee ACW, Billings M. Telehealth implementation in a skilled nursing facility: case report for physical therapist practice in Washington. Phys Ther . 2016;96:252–259. Barlow IG, Liu L, Sekulic A. Wheelchair Seating Assessment and Intervention: A Comparison Between Telerehabilitation and Face- toFace Service. Internnational Journal Telerehabilitation . 2009;1(1):17-27.

References Foster CA, Ponnapan A, Zaccaro K, Strong D. Acomparison of Two Home Exercises for Benign Positional Vertigo: Half Somersault versus Epley Maneuver. Audiol Neurotol Extra. 2012;2:16-23. http://www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx . Accessed Dec 19,2016. Calouro , C, Kwong , MW, Gutierrez, M. An Analysis of State Telehealth Laws and Regulations for Occupational Therapy and Physical Therapy. International Journal of Telerehabilitation . 2014 Spring; 6(1). Susan S. Gustke , David C. Balch, Vivian L. West, and Lance O. Rogers. Patient Satisfaction with Telemedicine. Telemedicine Journal . July 2004, 6(1): 5-13. doi:10.1089/107830200311806 . Kairy D, Tousignant M, Leclerc N, Cote AM, Levasseur M. The patient’s perspetive of in-home telerehabilitation physiotherapy services following total knee arthroplasty. Int J Environ Res Public Health. 2013, 10:3998-4011. doi:10.3390/ijerph10093998. 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- anaylsis . Clin Rehabil 0269215516645148, first published on May 2, 2016 as doi:10.1177/0269215516645148.

References Mani S, Sharma S, Omar B, Paungmali A, Joseph L. Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: A systematic review. J Telemed Telecare. 2016 Mar 31. pii : 1357633X16642369. Richardson BR, Truter P, Blumke R, Russell TG. Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation . J Telemed Telecare. 2017 23(1):88-95. Hwang R, Bruning J, Morris N, Mandrusiak A, Russell T. A Systematic Review of the Effects of Telerehabilitation in Patients With Cardiopulmonary Disease. J Cardiopulm Rehabil Prev . 2015 Nov-Dec;35(6):380-9. doi : 10.1097/HCR.0000000000000121. Tsai LLY, McNamara RJ, Moddel C, Alison JA, McKenzie DK, McKeough ZJ. Home-based telerehabilitation via real-time videoconferencing improves endurance exercise capacity in patients with COPD: the randomized controlled TeleR study. Respirology . 2016 Dec 19. 1-9. doi : 10.1111/resp.12966. Hwang R, Mandrusiak A, Morris NR, Peters R, Russel T. Assessing functional exercise capacity using telehealth: is it valid and reliable in patients with chronic heart failure? J Telemed Telecare. 2017 23(2):225-232. Bernocchi P, Vanoglio F, Baratti D, Morini R, Rocchi S, Luisa A, Scalvini S. Home-based telesurveillance and rehabilitation after stroke: a real-life study. Top Stroke Rehabil . 2016 Apr;23(2):106-15. doi : 10.1080/10749357.2015.1120453. Epub 2016 Jan 9.

References Veras M, Kairy D, Rogante M, Giacomozzi C, Saraiva S. Scoping review of outcome measures used in telerehabilitation and virtual reality for post-stroke rehabilitation. J Telemed Telecare. 2016 0(0) 1-21. doi : 10.1177/1357633X16656235. Sakakibara B, Eng JJ, Edgar MC, Monsees S, Rhebergen J, Waring J, Van der Star J. Feasibility of telerehabilitation in stroke recovery: A survey on access and willingness to use low-cost consumer technologies. Arch Phys Med Rehabil . 2016 Dec; 97(12):e10-e11. Russel TG, Hoffman TC, Nelson M, Thompson L, Vincent A. Internet-based physical assessemnt of people with Parkinson disease is accurate and reliable: a pilot study. J Rehabil Res Dev. 2013;50(5):643-50. Levy CE, Silverman E, Jia H, Geiss M, Omura D. Effects of physical therapy delivery via home video telerehabilitation on functional and health-related quality of life outcomes. J Rehabil Res Dev . 2015;52(3):361-70. doi : 10.1682/JRRD.2014.10.0239. Hakala S, Rintala A, Immonen J, Karvanen J, Heinonen A, Sjogren T. Effectiveness of technology-based distance interventions promoting physical activity: systematic review, meta-analysis and meta-regression. J Rehabil Med. 2017; 49:97-105. Rini C, Porter LS, Somers TJ, McKee DC, DeVellis RF, Smith M, Winkel G, Ahern DK, Goldman R, Stiller JL, Mariani C, Patterson C, Jordan JM, Caldwell DS, Keefe FJ. Automated Internet-based pain coping skills training to manage osteoarthritis pain: a randomized controlled trial. Pain . 2015 May;156(5):837-48. doi : 10.1097/j.pain.0000000000000121.

References Lawford BJ, Bennell KL, Hinman RS. Consumer perceptions of, and willingness to use, remotely-delivered service models for exercise management of knee and hip osteoarthritis: a cross-sectional survey. Arthritis Care and Research (Accepted Article). 2016 doi : 10.1002/acr.23122. Matheve T, Brumagne S, Timmermans A. The effectiness of technology-supported exercise therapy for low back pain. Am J Phys Med Rehabil . (ahead of print) 2016 doi:10.1097/PHM.0000000000000615. Gialanella B, Ettori T, Faustini S, Baratti D, Bernocchi P, Comini L, Scalvini S. Home-based telemedicine in patients with chronic neck pain. Am J Phys Med Rehabil . (ahead of print) 2016 doi:10.1097/PHM.0000000000000610. Van Straaten MG, Cloud BA, Morrow MM, Ludewig PM, Zhao KD. Effectiveness of home exercise on pain, function, and strength of manual wheelchair users with spinal cord injury: a high-dose shoulder program with telerehabilitation . Arch Phys Med Rehabil . 2014 Oct;95(10):1810-1817 Criss MJ. School-Based Telerehabilitation in Occupational Therapy: Using Telerehabilitation Technologies to Promote Improvements in Student Performance. International Journal of Telerehabilitation . 2013Spring ;5(1):39-46. Horak F, King L, Mancini M. Role of Body-Worn Movement Monitor Technology for Balance and Gait Rehabilitation. Phys Ther . 2015;95(3):461-470

References Giansanti D, Morelli S, Maccioni G, Grigioni M. Portable kit for the assessment of gait parameters in daily telerehabilitation . Telemed J E Health . 2013 Mar;19(3): 224-232 Delgado A, Alzate J, Beekhuizen s, Delgado H, Donaldson P, Hall A, Lago C, Vidal K, Fox EJ. Assessment of haptic interaction for home-based physical therapy using wearable devices and depth sensors. Studies in Health Technology and Informatics. 2017;220:33-38. Billings M, Russell T. Federation of State Boards of Physical Therapy. Winter Forum 2015.