Introduction
Telerehabilitation, supported by the worldwide use of smartphones, broadband internet, and computers, is a useful method in the intricate setup of the holistic treatment and rehabilitation of individuals with spinal cord injuries, traumatic brain injuries, strokes, and other causes of motor function impairment. Telerehabilitation provides additional diagnostic and therapeutic support to a wide range of patient populations with motor dysfunctions: from previous simple telephone calls for follow-up of patients in remote areas after discharge from the hospital to video-assisted examinations and therapies reaching other continents.
Telerehabilitation concepts are not new. In 1993 Delaplain and coworkers upgraded the rehabilitation process and established the use of videoconferencing for physiotherapy consultations and rehabilitation instructions from the Tripler Army Medical Center in Hawaii (Oahu) halfway across the Pacific Ocean to the Kwajalein Atoll (army base). Telerehabilitation studies addressing postcardiac surgery rehabilitation are relatively abundant, while studies in the field of surgical rehabilitation of patients with major motor dysfunctions are sparse. There are studies in hand surgery that show equivalent results as in physical follow-ups, a high degree of patient satisfaction, and no increased frequency of complications. However, the patient selection in those studies consisted of more standardized procedures that usually required only postoperative training instructions or immobilization. Moreover, none of the studies included rare diseases or telerehabilitation across national borders. Our structured international telerehabilitation approach integrated in our regular upper-limb reconstructive surgery service is new. The location of the Swiss Paraplegic Centre in the middle of Europe, and the fact that most of our team members are fluent in speaking and writing in English, French, German, and Italian, both facilitate communication.
Our outreach services, Nottwil Tetrahand and the International FES Centre at the Swiss Paraplegic Centre, have evolved rapidly over the last few years, in a large part due to the use of telerehabilitation and the increased demand for international services. Nottwil Tetrahand has tried to assure that treatment quality of telerehabilitation is safe, effective, patient-centered, timely, efficient, and equitable. We believe that the traditional medical setting needs to be adapted to the new technological possibilities as much as possible.
A medical examination and the planning and execution of a rehabilitation program demand for a physical contact with hands-on practice at a certain time. This means that a physical examination by a physician and/or therapist is vital before a defined rehabilitation protocol can be initiated. Furthermore, a thorough patient evaluation is essential for the best possible rehabilitation outcomes and therefore requires high-quality input from the local health care team. In addition, and with our focus on surgical rehabilitation, a number of physical prerequisites need to be fulfilled before any preparatory measures for surgery are taken (see later).
The combination of telerehabilitation patient guidance and local health care professionals can guarantee continuous rehabilitation support and communication in all directions ( Fig. 25.1 ). This is particularly important in surgical services to avoid/detect a potentially unfavorable evolution of a postoperative state, allowing for early countermeasures to commence. Furthermore, with the aid of the local health care professionals, follow-up checks including physical examination, as well as evaluations, are performed more efficiently and with more focus on medical details.
Accessibility and Data Security
We provide patient care with the belief that accessibility to our specialized services is important. Our homepage informs patients and colleagues about our services and how to connect with us. A shared email inbox is checked frequently to ensure patients and external colleagues a quick response to simple questions. For more complicated/technical questions or a specific patient request for a telerehabilitation session, planning is necessary. Patient data sent to us by a referring physician or other health professional need patient’s approval. Data are then stored in personalized, limited-access special folders in a separate archive according to the Swiss Paraplegic Centre security regulations as described in the internal document “medical data storage.”
Cross-border health care provides all European Union (EU)/European Economic Area (EEA) citizens with the opportunity to receive treatment in other EU/EEA countries. Switzerland is not part of the EU but has a bilateral agreement with the EU and the European Free Trade Association countries, which enables patients to receive treatment in Switzerland paid for by their insurance. This means that an EU citizen can request medical treatment abroad according to the social insurance rules. All treatments abroad must, however, be approved in advance by the national health insurance in the patient’s home country. Upon approval, a so-called S2 form is sent abroad for processing. National health services or health insurers generally grant authorization for treatment of rare diseases that are not available in home country or that are of documented better quality abroad. This applies provided that the treatment in question is also delivered for patients living in the country referred to. For non-European citizens, a deposit of the entire cost of care is required before the patient can undergo surgery and subsequent postoperative rehabilitation. In addition, two postoperative telerehabilitation consultations are charged (2 × 250 CHF = 500 CHF [≈560 USD]).
Our telerehabilitation platform is MS Teams. After giving consent to participate, we invite patients to join the platform and inform the patient that no recording whatsoever takes place; however, question and answer notes are taken and added to the patient’s chart.
Telerehabilitation in Upper-Extremity Surgery
Our telerehabilitation program involves the remote assessments of preselected patients suitable for surgical reconstruction of arm and hand function. Additionally, it includes follow-ups at fixed times after reconstructive surgery, as well as per request communications with patients and therapists during the course of postsurgery rehabilitation. It does not, however, provide rehabilitation services through telecommunication technology directly to patients at home without the physical presence of a therapist.
Rehabilitative, reconstructive surgery for persons with disabilities includes several challenges. It is obvious that teaching, for example, contracture prevention in a patient with spinal cord injury or traumatic brain injury requires close contact with the patient. Also, it is evident that surgical reconstruction of the upper extremity in these or other patient groups necessitates both thorough expert physical examination and additional tests (electromyography [EMG], magnetic resonance imaging [MRI], joint range of motion, motor point mapping, spasticity, and pain analyses). However, initial contact via telerehabilitation can successfully address key issues about feasibility before intervention ( Table 25.1 ). For the upper extremities, examinations and tests are almost exclusively undertaken with the patient sitting in an electric or manual wheelchair. This facilitates targeted physical revaluation of upper-extremity functions and allows for primary assessment of whether surgical reconstruction is a treatment option. Telerehabilitation is also a patient-oriented, cost-efficient tool to improve and assure posthospital discharge rehabilitation on site after the return to home/local rehabilitation. Our telerehabilitation postsurgery starts with multiple weeks of inpatient care including therapy–three to four times daily for motor relearning and training of transferred or reinnervating muscle functions. Subsequently, at the time of discharge, detailed written instructions with didactic illustrations about what, how, and when to train new and previous motor functions together with general instructions about training of trunk stability, shoulder mobility, and other key functions to optimize arm and hand functions are provided. The gradual transition of muscle functions into patient performance and ability in daily life is also clearly outlined in these instructions. At our follow-up telerehabilitation contacts, all these functions and abilities are tested in a patient-specific manner, depending on the surgeries performed.
| Topic # a | Questions | Answers | Considerations | Decision |
|---|---|---|---|---|
| 1 | Medical, physical, mental, social factors satisfactory? | Yes/No | Timing, motivation, rehabilitation status OK? |
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| 2 | Patient’s goal? | COPM b | Goals realistic? |
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| 3 | Spasticity? Where? | Yes/No | Affecting decision-making? |
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| 4 | Pain? Yes/No, Where? | Yes/No |
|
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| 5 | Comorbidities? | Yes/No | Affecting decision-making? |
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| 6 | Medication? What? | Yes/No | Affecting decision-making? |
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a Note: Topics 1 and 2 require “YES” under “Considerations” to qualify for next step in preparation for surgery. If “NO” surgery is contraindicated.
International Telerehabilitation Services
By working with and through other rehabilitation centers outside Switzerland, we have gradually built mutual understanding and trust to offer patients telerehabilitation consultations across several national borders. Typically, the cooperative rehabilitation unit or our unit requests a date and time for consultation. To obtain a time-efficient consultation and to meet the patient’s expectations, we have structured the consultations into three levels depending on the expected complexity of the case to be presented ( Table 25.2 ). The consultations include follow-ups at 6 and 12 months postsurgery, as well as new patients. One to two follow-ups (15 minutes each) and one new patient for primary assessment (30 minutes) usually can be performed in a 1-hour clinic. Often, a complication-free patient can be followed up at Level 2 or 3 ( Table 25.2 ). The follow-up patients report their perceived outcomes including scoring how well they have reached their prioritized goals (performance and satisfaction) according to the Canadian Occupational Performance Measures (COPM). Patients’ scores are then compared with the corresponding scores for the identical activities reported preoperatively. Since this is our primary outcome measurement, it is crucial for both the referring rehabilitation provider and our own unit to verify that the patient has reached or has clearly improved their skills so they can reach their preoperatively defined goals.
| Level of Consultation | At Patient’s End | At Expert Team’s End |
|---|---|---|
| Level 1 | Patient a + rehabilitation team | Physician + therapist b and assistant |
| Level 2 | Patient + physician or therapist | Physician + therapist |
| Level 3 | Patient + personal assistant or relative | Physician + therapist or assistant |
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