Introduction
Mother Teresa once said, “I alone cannot change the world, but I can cast a stone across the waters to create many ripples.” Rehabilitation professionals are agents of change, capable of transforming disability into “this ability.” In line with the 2030 Agenda for Sustainable Development, the 17 internationally agreed goals led by the United Nations to transform the world include “good health and well-being,” with particular emphasis on the inclusion and development of persons with disabilities (PWD). Current and up-and-coming physiatrists and allied health professionals can work together to promote rehabilitation as a vital means of achieving the Sustainable Development Goals, while ensuring that PWD and health care settings with limited resources are not left behind.
The Global Burden of Disease Study 2019 estimates that 2.41 billion people are living with disabilities and require rehabilitation. Despite the absence of specific data on disability in developing countries, the World Health Survey shows that disability prevalence estimates are highest in low- and middle-income countries (LMIC). Unfortunately, as the global need for rehabilitation continues to rise, many challenges to face-to-face delivery of or access to physical medicine and rehabilitation (PM&R) services remain unaddressed, especially in resource-limited countries.
Recognizing the vastly unmet need for rehabilitation, the World Health Organization’s Rehabilitation 2030 Call for Action cites the lack of rehabilitation workforce (i.e., PM&R doctors, physiotherapists, occupational therapists, speech and language therapists, prosthetists and orthotists, nurses) as a pressing challenge. In many low- and lower-middle-income countries, the density of skilled rehabilitation professionals is below 10 per 1 million population. Meanwhile, challenges to face-to-face rehabilitation in developed and developing countries alike may include geographical landscape, lack of nearby rehabilitation facilities, traffic, transportation and logistical concerns, disability-related limitations, direct and indirect costs of services, long waiting times, lack of awareness, poor compliance, caregiver fatigue, and loss of productivity, among others.
Telerehabilitation—which is the use of information and communication technologies (ICTs) to provide remote rehabilitation services across a continuum of care—has the potential to address the aforementioned challenges. Although internet connectivity and costs are commonly reported as challenges to synchronous telerehabilitation, asynchronous techniques—such as short messaging system (SMS) using certain low-cost mobile phone models—are feasible and practical, despite their inherent limitations (e.g., data privacy, patient safety, medicolegal liabilities). In any health care setting, especially when catering to patients with limited resources and in geographically isolated and disadvantaged areas, telerehabilitation in the form of internet-independent, low-cost, and locally available technologies should also be accessible.
Telerehabilitation in Low-Resource Settings
In developing countries, there is a general scarcity of publications on telehealth, more so on telerehabilitation. The majority of available reports leverage the technology to link health care providers, usually in geographically isolated and disadvantaged areas with urban-based specialists. Despite the worldwide growing evidence for telerehabilitation, adoption of this emerging technology in developing countries has been slow because of various interrelated factors, such as: a lack of acceptance among patients and rehabilitation providers; inadequate digital knowledge, skills, and resources; the noninclusion of telehealth in the educational curriculum of current and future health care professionals; a lack of adequate telehealth training and experience; the long-standing history and culture of in-person clinical encounter; a lack of clear national guidelines; legal and ethical considerations; and a shortage of studies documenting safety and cost-effectiveness. Nonetheless, the value of telerehabilitation cannot be overemphasized in times like the COVID-19 pandemic or certain disasters, which have moved previous nonadopters to reconsider alternative means to connect with patients or health care providers when physical encounters are not possible.
As of 2020, there are no systematic reviews summarizing the extent of telerehabilitation experiences in different developing countries. This may be due to a lack of interest by senior practitioners, limited acceptance of new technologies, and reservations about allocating budget for procedures that have not been widely studied. In the Philippines, the telerehabilitation literature is limited to feasibility studies and case reports, and telerehabilitation is done mostly in academic institutions or university hospitals that provide free educational and clinical support to rural communities in either doctor-to-doctor or doctor-to-community health worker format as an alternative to community-based rehabilitation. Community-based rehabilitation, an “ongoing evolutionary process,” adapts to the changing times by taking advantage of locally available technology (i.e., telerehabilitation through mobile phones) to cater to the needs of PWD. Over 5 billion people worldwide own either a smartphone (>50%) or any mobile phone. As the text capital of the world, the Philippines has more than 110 million mobile subscriptions, possibly implying that low-cost digital tools can be leveraged to provide universal access to health care. Text messaging or SMS generally remains the most common method of remote referral, monitoring, and support service in the Philippines, similar to other LMIC. However, the limited capacity to accurately and comprehensively conduct remote examination using SMS should be carefully considered.
Unlike telemedicine, telerehabilitation does not provide remote consultations only. Winters’ four conceptual models of telerehabilitation service delivery, aside from teleconsultation, included telehomecare (i.e., remote support), telemonitoring (i.e., remote assessment), and teletherapy (i.e., remote coaching of exercises). While these services have evolved and expanded over the past 18 years to safely and adequately deliver care—particularly teleconsultations and teletherapy—synchronous videoconferencing requiring a reliable internet bandwidth is advantageous. Nonetheless, as the internet has continued to improve in LMIC compared to earlier years, real-time interactive telerehabilitation has become more feasible.
In 2019, more than half of the world’s population was using the internet. In developed or high-resource countries, 87% and 81% of people had internet access in urban and rural areas, respectively. In contrast, 65% and 28% of people in developing or low-resource countries had internet access in urban and rural areas, respectively. Internet access remains unevenly distributed, particularly in geographically isolated and disadvantaged areas in developing countries, where setting up internet infrastructures may not be profitable. Nevertheless, with the sustained efforts of government and private sectors to improve internet availability, the internet-of-things (IOT), including telehealth, continues to diffuse to developing countries at a faster rate than before. As a corollary, incorporation of telerehabilitation in clinical practice, teaching, and research has the potential to become widespread.
Even though internet speed lags in many developing countries, there is a huge potential for telehealth. While it is true that the extent of using digital technology is largely dependent on internet speed, the minimum bandwidth speed of 4 megabits per second (Mbps) recommended for a single physician telerehabilitation practice may be achievable in several LMIC. This recommended speed enables high-quality video consultation between a physician and a patient, noncontinuous remote monitoring, access to electronic health or medical records, email, and web browsing, but does not allow real-time image downloads. Higher bandwidth speeds are required to support larger telerehabilitation practice settings (e.g., rural health clinic and nursing homes: up to 10 Mbps, hospital: 100 Mbps, academic medical center: 1000 Mbps). Even though the Philippines and India are reported to have the lowest average internet speeds among surveyed countries in the Asia-Pacific region, at 5.5 and 6.5 Mbps respectively (which are below the global average of 7.2 Mbps), they continue to develop and improve telehealth programs.
Aside from the internet, however, there are several health issues and needs unique to LMIC that may affect their uptake of telerehabilitation or telehealth in general. Examples of this include poverty, civil unrest, workforce shortage, inability to “build the capacity to build capacity,” substandard health care, limited health information systems, expensive telecommunication costs, low average educational and technological literacy, inadequate political support, or poor electrical supply. To help address these, the second global survey on eHealth presented four strategies that could enable telehealth implementation, namely (1) governance, (2) policy, (3) scientific development, and (4) evaluation.
Governing bodies formed through multisectoral collaborations have the paramount role of developing legal, regulatory, and capacity-building requirements that can guide telehealth initiatives. Administrative and monetary support from the government, health care institutions, and professional organizations is crucial in the success of telehealth in any country. Substantial planning is required to facilitate telehealth, particularly telerehabilitation, at the national level.
Clear and comprehensive telerehabilitation policies are required to direct rehabilitation professionals in designing, implementing, and evaluating telerehabilitation solutions appropriate for their respective health care settings. The choice of telerehabilitation method should fit the health care setting’s purpose, clientele, technical resources and support, workforce eHealth skills, and financial capacity, among others. Policies founded on a combination of local best practices and lessons learned from other countries should start with the need for telerehabilitation, operational definitions, and scope of services, followed by administrative, clinical, technical, and ethical principles. When the need for telerehabilitation is accurately assessed, documented and communicated with various stakeholders (i.e., patients, families, health care providers, policymakers), relevance and sustainability of related programs can be ensured. Telerehabilitation policies should be “designed and established organically within the context and setting in which they will be applied.” Carefully contextualized policies may help improve the adoption and implementation of telerehabilitation.
Colleges of rehabilitation sciences, medical schools, and teaching hospitals are potential drivers of the scientific advancements of telerehabilitation in any country, including LMIC. Through the expertise of clinicians and academicians, along with institutional resources dedicated to research and development, telerehabilitation can be systematically applied and evaluated. Furthermore, telehealth experts can be involved in the education and training of current and future generations of doctors and allied health professionals. For instance, since 2017, Philippine General Hospital (PGH), the country’s national university hospital, has incorporated telerehabilitation in its teaching-learning activities for third- to fifth-year medical students prior to and during their rural community immersion. In unprecedented times, such as during the COVID-19 pandemic, knowledge and skills on telehealth—or telerehabilitation in particular—of both educators and students prove to be practical and socially relevant.
Conducting systematic and regular program evaluations is an indispensable step in ensuring telerehabilitation success. Results of these evaluations—including satisfaction of various stakeholders, safety, and cost-effectiveness—must be communicated within and among professional organizations, and translated to policy changes whenever possible. Given the scarce empirical evidence of telerehabilitation especially in LMIC, studies of any research design are encouraged to be submitted for peer review and publication to make their data accessible to other local and international rehabilitation professionals and policymakers.
Educating Health Care Professionals About Telerehabilitation
Following the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF) framework, telerehabilitation and its related contextual factors are appropriate to incorporate in the holistic evaluation of patients. Identifying these factors can help a health care professional to plan a telerehabilitation approach suitable to the patient’s needs, considering relevant medical, clinical, functional, environmental, and personal backgrounds. Using the WHO-ICF as a guide can facilitate individualized patient care, stimulate multidisciplinary research, and ultimately update health policies. Table 27.1 lists the factors to consider prior to engaging in telerehabilitation with a patient.
| Domains of WHO-ICF | Factors Influencing Telerehabilitation |
|---|---|
| Health condition |
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| Body functions and structures |
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| Activities |
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| Participation |
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| Environmental factors |
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| Personal factors |
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Telerehabilitation stays true to the purpose of PM&R, which is essentially “the prevention, medical diagnosis, treatment, and rehabilitation management of persons of all ages with disabling health conditions and their comorbidities, specifically addressing their impairments and activity limitations in order to facilitate their physical and cognitive functioning (including behavior), participation (including quality of life), and modifying personal and environmental factors,” albeit performed virtually within the apparent limitations of telehealth. Similar to in-person setups, telerehabilitation can be provided by a patient-centered multidisciplinary team of rehabilitation professionals, namely, physiatrists or medical doctors who specialized in PM&R, physiotherapists, occupational therapists, speech and language therapists, psychologists, prosthetic and orthotic technicians, rehabilitation nurses, social workers, and dieticians, among others. Ideally, any of these rehabilitation professionals can be called to provide distant support to PWD within the scope of their professional practice and jurisdiction. Currently, however, few active rehabilitation professionals, especially those in LMIC, have been trained to perform remote “assessment, monitoring, prevention, intervention, supervision, education, consultation, and counseling,” which are the services of telerehabilitation. Telerehabilitation and even telehealth, in general, are not part of the curriculum in many medical and allied health schools in the Philippines, India, and other developing and developed countries.
Fast internet speeds, virtual reality, wearable devices, remote physiological sensors, haptics, or other high-cost technologies being researched for telerehabilitation in advanced health care settings are not common in LMIC and other areas in developed countries. Nonetheless, telerehabilitation can still be conducted using locally available technologies. Many PM&R interventions, such as therapeutic exercises, functional training, occupational and vocational activities, cognitive and sensorimotor training, speech-language treatments, seating and wheelchair prescriptions, and environmental modifications can benefit PWD through telerehabilitation, despite the lack of highly advanced technologies. However, open-mindedness, creativity, resourcefulness, careful planning, and proper implementation are necessary. According to limited published data on telerehabilitation from LMIC, the doctor-to-doctor setup and preference for former over new patients have always been the common practice in teleconsultations to address various concerns, such as patient safety due to the lack of an initial face-to-face physical examination. However, during the COVID-19 pandemic when in-person delivery of nonessential services including rehabilitation was not feasible, many patients, health care practitioners, and institutions had to find ways to adapt and reconsider means to provide optimal care for PWD, while observing adequate risk mitigation. This included seeing patients for both initial and follow-up evaluations through telehealth, and expanding various forms of rehabilitative treatments based on clinical judgment as opposed to research.
Within the context of the patient, telerehabilitation goals and treatment planning can be directed toward addressing the functional consequences of the health condition ( Table 27.1 ). Telerehabilitation can be useful for a wide spectrum of medical and/or surgical conditions in different phases of care, from wellness and prevention to acute, subacute, chronic, and perioperative rehabilitation. It is commonly accessed by outpatients from the comfort of their homes, but it may also be available to inpatients, such as those isolated due to COVID-19, in some hospitals even in LMIC, wherein the scarcity of personal protective equipment, medical resources, and health workforce contributes to the temporary suspension of face-to-face rehabilitation services for patients with confirmed or suspected COVID-19.
Several human (e.g., stakeholders’ apprehensions, health care providers’ unreadiness) and organizational (e.g., lack of national guidelines) challenges hindering the emergence of telerehabilitation in developing countries may be rooted in the widespread lack of education, training, and clinical opportunities on telehealth for health care professionals. Especially amid the COVID-19 pandemic, the urgent need to “build the capacity to build capacity” for telerehabilitation becomes evident. One way of building the capacity of LMIC is by collaborating with an international academic institution, as exemplified by the Botswana-University of Pennsylvania Partnership and many others that provide underserved communities with necessary telerehabilitation equipment and expert-level care.
The rehabilitation workforce is the major driver of telerehabilitation and must therefore acquire relevant knowledge, skills, and experience. The curricula for undergraduate (i.e., medical and allied health schools) and graduate medical education (i.e., residency training in PM&R) vary worldwide, and many of these, whether in high- or low-resource countries, have not included telehealth. Since telerehabilitation implies a shift from traditional in-person care to virtual evaluation and management, which is used either as an adjunct (i.e., follow-up care) or an alternative health care delivery (i.e., during pandemic or disasters, or if with constraints to face-to-face access), there should be appropriate education and training for current and future practitioners. Current practitioners can engage in continuing professional development (CPD) or continuing medical education (CME) on telehealth or telerehabilitation. For more comprehensive training, current and future practitioners may enroll in classroom-based or online telehealth courses or modules offered by certain academic centers, most of which are located in developed countries like the United States, United Kingdom, Australia, and France. Formal university courses, such as Health or Medical Informatics, are also available. Moreover, the School of Health and Rehabilitation Sciences at the University of Queensland in Australia offers workforce training programs on telerehabilitation. In general, however, a training curriculum specific to telerehabilitation is not currently available in the literature. Therefore telehealth core competencies and syllabi from developed countries can be adapted and contextualized with respect to the unique health care needs and resources in LMIC. Nonetheless, there is little publicly accessible information from undergraduate medical schools in developed countries that explains how to integrate telehealth in preclinical or clerkship curricula. Moreover, it is unknown if, and how, telehealth is officially incorporated in schools and universities in LMIC.
At the PGH the Department of Rehabilitation Medicine has developed a stepwise curriculum on telerehabilitation for medical students. The curriculum is incorporated in the students’ learning activities when they rotate into the Department, beginning in the third-year or preclinical level, wherein students are introduced to the “what, who, where, when, why, and how” of telerehabilitation during a 2-hour combined lecture and case-based small group discussion with a consultant practicing telerehabilitation ( Table 27.2 ). This basic orientation is then reinforced during the fourth year or clinical clerkship level, when students rotate again into the Department and engage in a more in-depth discussion of the socioeconomic, technical, ethical, and legal aspects of telerehabilitation. The students end their usual 2-week rotation in the Department with a telerehabilitation role-playing exercise, wherein the small group is divided into two teams: (1) telecommunity team pretending to be the telepresenters in the remote spoke, and (2) telerehabilitation team pretending to be in the hub. Each team is in a separate, private room and connected only by the internet or alternative form of telecommunication. The telepresenters, acting as health care providers in the community, are tasked to refer a co-located sample patient to the telespecialists. On the other hand, the telerehabilitation team, acting as Rehabilitation Medicine providers in PGH, is tasked to receive, evaluate, and manage the referral over the simulated physical distance. The telerehabilitation team is composed of the following: (1) rehabilitation medicine consultants, who remotely provide clinical support to the community, and (2) allied rehabilitation professionals who demonstrate specific home exercises and provide concrete tasks and environmental modifications appropriate for the case. Meanwhile, an actual rehabilitation medicine consultant is also present in PGH to observe the telerehabilitation simulation and highlight teaching points or clinical pearls to the students on physiatric principles and proper conduct of telerehabilitation. The curriculum culminates in the fifth year or clinical internship level, wherein students can apply their prior knowledge and skills on telerehabilitation when they rotate in the community. The students get the chance to telepresent actual patients in the outpatient clinic of the rural health unit to the telerehabilitation team in PGH. In this way, interns receive e-supervision in their evaluation and management of PWD in the community, while fostering interprofessional training and collaboration with other members of the rehabilitation team.
