Introduction
Eleanor Roosevelt once said, “The purpose of life, after all, is to live it, to taste experience to the utmost, to reach out eagerly and without fear for newer and richer experience.” Living life to the fullest is what occupational therapy practitioners (OTPs) aim for their clients to achieve, as advocated by the American Occupational Therapy Association. The practice of occupational therapy (OT) is directed toward enabling clients with or without disability to participate in functional tasks that are of significant meaning to them and intrinsically related to their “health, self-esteem, social competence, happiness, and satisfaction with life.”
Traditionally, an OT client receives in-person individualized initial evaluation, shared goal setting (with family and OTP), customized interventions, and regular reevaluations to ensure that the desired outcomes are being met. In line with evidence-based practice, the OTP provides a holistic approach to patient care by also evaluating and modifying the client’s environment, whether at home, school, workplace, or leisure.
Unfortunately, barriers to accessing in-person OT services exist in various health care settings around the world. Some of these barriers are related to urbanization of health care services, shortage of OTPs, lack of nearby OT facilities, transportation issues, time conflicts, social stigma, socioeconomic and language challenges, geographical limitations, travel and weather restrictions, functional mobility impairments, and immunocompromised clients. Recently, social distancing and health risks related to the COVID-19 pandemic have also become an additional significant barrier to rehabilitation access worldwide. With the increasing evidence that the aforementioned barriers can be addressed by telerehabilitation, various OT stakeholders (i.e., OTPs, clients, carers, families, remote health care providers, OT students, society) have been given the opportunity to virtually reach out to each other and achieve common goals.
Telerehabilitation in Occupational Therapy
Telerehabilitation in OT may be referred to by various other terms such as telehealth, telemedicine, teletherapy, teleoccupational therapy, telecare, telepractice, and digital or virtual care, among others. Telerehabilitation refers to the use of any form of information and communications technology (ICT) to “deliver clinical services at a distance by linking clinician to client, caregiver, or any person(s) involved in client care” (e.g., remote therapist or local health care provider) for “evaluation, intervention, monitoring, supervision, and consultation,” consistent with the full scope of OT practice (e.g., health promotion, habilitation, rehabilitation, etc.). In 2014 the World Federation of Occupational Therapists (WFOT) recognized telerehabilitation as a viable method to deliver client-centered OT services when accessing in-person care is “not possible, practical or optimal,” and/or when telerehabilitation is “mutually acceptable to the client and provider.” For instance telerehabilitation may be appropriate to (1) bridge the gap between specialists and clients; (2) enable access to rehabilitation especially in geographically isolated and disadvantaged areas; (3) reduce travel or waiting times; (4) minimize direct and indirect expenses; (5) personalize care; (6) promote clients’ active engagement in their natural environment; and/or (7) protect people from COVID-19.
Similar to other rehabilitation disciplines adopting telerehabilitation as a service delivery model, OT that is conducted from a distance should observe all applicable jurisdictional, institutional, and professional regulations and policies. Ideally, OTPs should be trained and culturally competent to deliver services remotely to clients with the same standards of care as traditional or in-person encounters within the natural limitations of telerehabilitation. Telerehabilitation should not be viewed as a new OT intervention, but rather a new way of delivering usual care.
Current Evidence
OT services may be delivered via telerehabilitation to clients across all ages and in any phase of the care spectrum. Telerehabilitation has been widely used for various conditions or purposes, such as “wheelchair prescription, neurological assessment, adaptive equipment, prescription and home modification, ergonomic assessment, school-based practice, early intervention services, health and wellness programming, and rehabilitation for individuals who have experienced stroke, breast cancer, traumatic brain injury, polytrauma, Parkinson’s disease, and other neurological and orthopedic impairments.”
By using ICT that ranges from simple low-cost telephone interviews to advanced internet-enabled gamified virtual rehabilitation with robot telepresence, telerehabilitation can be performed by OTPs according to the “individuals, groups, or cultures they serve, contextualized to the occupations and interests of clients.” With a client-centered approach, the choice of appropriate technology is determined by each client’s needs, resources, digital capacity, and preferences, and is guided by the OTP to ensure that real-world trade-offs are recognized and balanced (i.e., benefits outweigh the risks inherent to telerehabilitation). In clinical practice, the chosen technology is usually the simplest and least expensive that can meet the client’s OT goals. For instance, in resource-limited countries with an unstable internet connection (if any), the following store and forward techniques may be used: text messaging; sending private messages on social media; emailing short video clips of a client performing common activities of daily living (ADLs); sending ancillary or imaging results; and forwarding links to exercise videos or useful online health-related resources.
For a structured presentation of the growing body of evidence supporting the use of telerehabilitation as an OT service delivery model, two conceptual frameworks are presented as follows:
- 1.
Person-Environment-Occupation-Performance (PEOP) Model
The PEOP model emphasizes the client’s functional performance within his/her natural, often least restrictive, environment. Using this model, telerehabilitation can facilitate skills development, environmental modification, and/or healthy behavior adoption or reinforcement.
- 2.
Coaching Model (CM)
Following the principles of early intervention (EI), the CM used in telerehabilitation is founded on the active and huge role of the clients and their primary carers, who are empowered and guided by the remote OTP to develop, implement, and sustain therapeutic interventions.
In addition, research on telerehabilitation-delivered OT services can also be presented according to its primary focus or objective, such as teleevaluation (e.g., conducting remote assessments, establishing reliability of remote assessments), teleintervention (e.g., employing preventative, habilitative, or rehabilitative strategies), teleconsultation (e.g., providing health-related advices), and/or telemonitoring (e.g., obtaining health-related information and following through of clients with chronic conditions). Essentially all practice areas within the scope of OT can potentially utilize telerehabilitation for at least some components of care. Table 20.1 presents a shortlist of these practice areas based primarily on recent systematic reviews.
| General Practice Areas a | Specific Areas or Conditions |
|---|---|
| Academic education | Teaching OT students on interprofessional education |
| Children and youth |
|
| Developmental disabilities |
|
| Health and wellness |
|
| Home and community health |
|
| Mental health |
|
| Productive aging |
|
| Rehabilitation and disability |
|
| Work and industry |
|
a Adapted from the special interest sections of the American Occupational Therapy Association (American Occupational Therapy Association [n.d.]; Cason [2012] ).
Teleevaluation and teleconsultation present both opportunities and limitations. Physical examination, functional assessment, and other OT-specific measures may be challenging to administer accurately and safely at a distance. In order to acquire these particular competencies, clinicians in general can attend formal and/or informal education and training opportunities on practical and creative techniques to circumvent the absence of hands-on evaluations. A significant amount of knowledge can also be gained from the growing body of literature that describes teleevaluation for various conditions or services (see Table 20.2 ). The reliability and validity of common assessment tools administered via telerehabilitation have been established in previous studies, but further research is warranted for other useful tools and conditions as well. It is crucial that clients are properly and adequately evaluated during the teleconsultation before appropriate OT assessment, diagnosis, and plan-of-care can be formulated.
| Teleevaluation Services | References |
|---|---|
| Adaptive equipment prescription and home modification | Sanford et al. (2009) |
| Cognitive screening | Abdolahi et al. (2014); Stillerova et al. (2016) |
| Ergonomic assessment | Baker & Jacobs (2012) |
| Home assessment | Hoffman & Russell (2008); Nix & Comans (2017) |
| Lymphedema assessment | Galiano-Castillo et al. (2013) |
| Neurological examination | Boes et al. (2020) |
| Orthopedic (hand) assessment | Worboys et al. (2017) |
| Pain assessment of orthopedic or neurological conditions | Wahezi et al. (2020) |
| Special tests for orthopedic or neurological examination | Verduzco-Gutierrez et al. (2020) |
| Wheelchair prescription | Schein et al. (2010); Schein et al. (2011) |
| Reliable Teleevaluation Tools | References |
| Canadian Occupational Performance Measure | Dreyer et al. (2001) |
| Ergonomic Assessment Tool for Arthritis | Backman et al. (2008) |
| European Stroke Scale | Palsbo et al. (2007) |
| Functional Independence Measure | Hoffmann et al. (2008) |
| Functional Reach Test | Palsbo et al. (2007) |
| Jamar Dynamometer | Hoffmann et al. (2008) |
| Kohlman Evaluation of Living Skills | Dreyer et al. (2001) |
| Mini-Mental State Examination | Ciemins et al. (2009); McEachern et al. (2014) |
| Montreal Cognitive Assessment | Abdolahi et al. (2014); Stillerova et al. (2016) |
| Nine-Hole Peg Test | Hoffmann et al. (2008) |
| Preston Pinch Gauge | Hoffmann et al. (2008) |
| Timed Up and Go Test | Hwang et al. (2016) |
| Unified Parkinson’s Disease Rating Scale | Hoffmann et al. (2008) |
a Largely based on the telehealth position paper of the American Occupational Therapy Association (American Occupational Therapy Association [AOTA] ).
In 2019 Hung and Fong published a systematic review of the current evidence on telerehabilitation in OT practice, wherein they analyzed 15 articles with the following study designs and corresponding levels of evidence: three randomized controlled trials (RCTs) (level II), eight quasiexperimental studies (level III), one single-group postintervention trial (class III), and three single-case studies (class IV). Their search was limited to articles published from 2008 to 2017. The patients included in the reviewed articles were aged 2 to 70 years and had different medical conditions ( Table 20.1 ). All accessed telerehabilitation services at home, except for one program where services were accessed in a community center. The majority of patients were accompanied by a significant other (i.e., parent or carer) for technical support and in-person assistance in assessment, treatment, or monitoring. Telerehabilitation was conducted using different hardware (e.g., telephone, smartphone, personal computer, iPad, digital camera, external web camera, robot, sensor glove) and software (e.g., videoconferencing platforms, customized mobile applications, web-based applications, instant messaging system, videogames, screen avatar) in either synchronous, asynchronous, or hybrid (mixed) formats.
An example of a telerehabilitation study in which the PEOP model is applicable with focus on teleintervention is one RCT that recruited 99 adult patients with subacute stroke assigned to either treatment group (i.e., hand robot-assisted device coupled with home exercise program) or control group (i.e., traditional home exercise program only). All patients exercised for 3 hours for 5 days a week for 8 consecutive weeks. Pretest-posttest comparisons showed statistically significant changes in most domains on the Stroke Impact Scale and the Center for Epidemiologic Studies Depression Scale for both groups. In a similar earlier report, a 54-year-old patient with right medullary pyramidal infarct that completed 38 hours of robotic-assisted training plus 47 hours of home exercises demonstrated clinically important improvements on the Action Research Arm Test, Functional Ability Scale, Fugl-Meyer Assessment, and a portion of the Wolf Motor Function Test. Telerehabilitation in these studies might have applied the PEOP model of care to facilitate motor and functional recovery.
In another RCT, the CM was applied with focus on telemonitoring. Twenty-four children with spastic hemiplegic cerebral palsy and mild-to-moderate functional impairment were recruited. The children’s primary carers received in-person training in performing standardized assessments and function-based treatments at home. Those assigned to the treatment group received closer supervision or guidance by a remote OTP through hybrid telemonitoring using a web-based camera software. Equal improvement in satisfaction with occupational performance was observed in both groups, but greater improvements in dexterity and functional performance were seen in the treatment group. In another study, collaborative OT sessions with parents of children with autism spectrum disorder (ASD) were conducted initially in-clinic, followed by online sessions for 6 weeks. The CM seemed to have been employed through use of family schedules, sensory diets, and archived webcam sessions. Results showed improved carryover of home interventions by “providing opportunities for parents to ask questions, review sensory techniques, and understand the therapist’s clinical reasoning.” Ensuring active family participation in patient care through remote consistent coaching is indeed vital in telerehabilitation.
Consistent with the PEOP model, each person’s home or environment (e.g., for work, study, or leisure) is as unique as the performance needs of the individual. With proper modifications, the surroundings of a person with disability can provide support for daily activities, instead of magnifying the functional loss arising from injury or illness. Typically, OTPs perform a predischarge environmental assessment for inpatients to ensure person-environment fit and safe transition to home. Telerehabilitation may be performed in lieu of in-person environmental assessment and intervention for various reasons, including, but not limited to, the following:
- ■
Factors on the side of the OTP: lack of manpower, time constraints, heavy workload including administrative tasks, travel costs, distance, nonpayment by insurance carriers, compensation, health risk (e.g., COVID-19); and
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Factors on the side of the client: willingness, privacy, time constraints, health risk (e.g., COVID-19).
The rehabilitation medicine physician and/or OTP can virtually examine the client’s actual living setup or workplace ergonomics and analyze ADL performance within a natural environment. Through telerehabilitation, preferably using synchronous means (e.g., video call) over asynchronous means (e.g., taking photos and identification of potential hazards), environmental assessments can be conducted to identify existing architectural barriers that may be overlooked by the client or family. Using a mobile-based application capable of measuring actual distances and inserting pieces of durable medical equipment into a virtually created floor plan may also be helpful and practical. Depending on the assessment, appropriate home or environmental interventions can be instituted in the form of architectural modifications (e.g., durable medical equipment, ramp to front door, grab bar, improved lighting, removal of clutter, motion sensor light switch, fall-preventive measures), adaptive equipment (e.g., long-handled reacher), personal assistance (e.g., family or caregiver education), durable medical equipment (e.g., bedside commode), identification of things misused (e.g., use of towel bar to help get off the toilet), mobility equipment (e.g., walker, wheelchair), prosthetics (e.g., hearing aid, magnifying glass), and even technological adaptations and solutions (e.g., adjusting the phone settings for users with visual impairment, using voiceover screen reader). Currently, however, it is difficult to make comparisons across studies and determine which forms of environmental intervention, either delivered face-to-face or through telerehabilitation, are most appropriate for a given client or case because of variations in methodologies in the literature. Future research on best practices in home modification, especially when delivered through telerehabilitation, is recommended.
Nonetheless, a subjective individualized approach should take precedence over a mere objective checklist in recommending environmental modifications, which ultimately depend on the client’s and family’s needs, goals, and resources. For instance frail elderly patients with prior fall episodes at home would most likely prefer to continue “aging in place” despite environmental barriers that can result in further disability, but this does not mean they are not amenable to home modifications or advice. Proper and practical patient education can help them understand that home modifications and assistive technologies can delay dependence in functional activities, enhance carer self-efficacy, decrease mortality, and minimize costs for assistance and health care. A longitudinal study has shown that home modifications can reduce long-term difficulty with ADLs (i.e., up to 6 months), and each month of waiting for a home modification to be instituted can worsen functional dependence. Hence, a timely environmental intervention should be implemented as soon as a problem is identified.
Appropriate environmental interventions are proven effective in preventing falls, according to the results of a systematic review and metaanalysis consistent with Cochrane findings. Three-fourths or 75% of the following criteria should be met for an environmental intervention to be considered high quality or intensity:
- 1.
A comprehensive evaluation process of hazard identification and priority setting taking into account both personal risk and environmental audit;
- 2.
The use of an assessment tool validated for the broad range of potential fall hazards;
- 3.
Inclusion of formal or observational evaluation of the functional capacity (physical capacity, behavior, functional vision, habits) of the person within the context of their environment; and
- 4.
Provision of adequate follow-up by the health professional and support for adaptations and modifications.
Lastly, when performing an environmental assessment and intervention, the rehabilitation medicine physician and/or OTP must keep in mind the following four dimensions of the home:
- 1.
Physical dimension: referring to home structure (e.g., width of doorframes, height of steps, height of toilet), materials and finishes, services and facilities, space, ambient conditions, and location;
- 2.
Temporal dimension: referring to current and future family health and setup (e.g., aging family members, growth of children, resale value of the house);
- 3.
Occupational dimension: referring to modifications for self-care and domestic activities; and
- 4.
Societal dimension: referring to economic and political conditions affecting resources and control of people over their homes, such as “government policies, national standards, individual service restrictions, guidelines, and costs.”
The unprecedented interruption of in-person access to OT services during the COVID-19 pandemic put new and old clients at a disadvantage, with the vast majority of OTPs and students in a potential dilemma. The usual barriers to telerehabilitation may also apply to OT in various health care settings worldwide (e.g., lack of acceptance, resources, digital capacity). Of special note, however, the lack of telerehabilitation education, training, and experience among a number of current OTPs and their students may be a huge concern especially among non- or slow adopters of the technology. Appropriate relevant awareness campaigns and educational opportunities for stakeholders should, therefore, be provided or enhanced.
Interprofessional Education Through Telerehabilitation
Students now are the future drivers and users of telerehabilitation in OT. In order to prepare them for the continued modernization of health care delivery in many parts of the world, restructuring of the current academic curriculum may be necessary. Integrating telerehabilitation and interprofessional education (IPE) in teaching-learning activities can help students recognize the value of alternative service delivery models in the midst of workforce shortage, unequal distribution of resources, COVID-19, and other challenges to in-person health care access. A team-based approach to patient care consists of interacting with and learning with and from all the members of the rehabilitation team, which consists of, but are not limited to, the physiatrist, physiotherapist, speech-language pathologist, psychologist, prosthetist-orthotist, dietician, social worker, and rehabilitation nurse, among others.
The core values of IPE (e.g., values, ethics, responsibilities, collaboration, teamwork, mutual respect amid professional practice differences) may be incorporated in various course materials and contents. For instance, in one setting, the College of Nursing collaborated with the Department of Rehabilitation Sciences in the College of Allied Health in the same university to provide opportunities for students to work harmoniously together despite the physical distance via videoconferencing. Creating a structured learning online environment such as role-playing or simulations prior to an actual telerehabilitation session with a real client under the remote supervision of a teacher-clinician can help develop “webside” manners, teleevaluation, teleconsultation, teleintervention, and telemonitoring competencies, among others. Theoretical knowledge and virtual clinical experiences can also help orient trainees on the complexities of health care, barriers to telerehabilitation, reimbursement policies, medicolegal implications, jurisdiction, and other practical issues they may face in practice.
Recommendations for Future Research
Despite the development of cutting-edge technologies, there remains to be a huge gap in evidence-based telerehabilitation practice in OT. It is difficult to generalize the results of existing relevant studies in the midst of absent universal or standard patient eligibility criteria for different pathologies, limited sample size, and varying telerehabilitation protocols, technologies, and outcomes measures. Studies on the long-term effects, cost-effectiveness, client and provider characteristics that best suit telerehabilitation, medicolegal risk management, effective strategies to ensure data privacy and security, and reliability of remote (clinician-administered) and in-person (carer-administered) OT assessments are recommended.
Summary
There is a growing trend of telerehabilitation adoption worldwide during a health crisis that caught stakeholders unprepared for the sudden interruption of health care access. Through telerehabilitation, OT practitioners and clients can remain connected and achieve meaningful rehabilitation goals together. Various technologies can be leveraged within the context of the objectives, resources, and competencies on both sides. Educational opportunities to equip current and future stakeholders are necessary to utilize telerehabilitation effectively, safely, and wisely.
