Introduction
Physical therapy, also known as physiotherapy, is a health care profession that uses evidence-based kinesiology, exercise prescription, health education, mobilization, electrical and physical agents to treat acute or chronic pain, movement and physical impairments resulting from injury, trauma, or illness typically of musculoskeletal, cardiovascular, respiratory, neurological, and endocrinological origins. Physical therapy is concerned with human function and movement and maximizing physical potential to identify and promote health-related quality of life and movement potential.
Physical therapy is used to improve a patient’s physical functions through physical examination, diagnosis, prognosis, patient education, physical intervention, rehabilitation, disease prevention, and health promotion. Physical therapy is practiced by physical therapists (or physiotherapists). Physical therapists can help people at any stage of life when movement and function are threatened by aging, injury, diseases, disorders, conditions, or environmental factors. Maximizing movement is an important benefit of physical therapy as pain-free movement is crucial to quality of life, ability to earn a living, and independence. Personalized care is emphasized through treatment plans for each person’s individual needs, challenges, and goals regardless of whether the individual is dealing with a chronic condition or recovering from injury, or wants to prevent future injury and chronic disease. Physical therapists provide customized care in hospitals, private practices, outpatient clinics, homes, schools, sports and fitness facilities, work settings, and nursing homes. They promote recovery by empowering people to be active participants in their care by working collaboratively with other health care professionals.
Physical therapists are also key members of the health care team in other important areas. Physical therapy is an important part of international efforts to avoid overuse of opioids. In some situations, dosed appropriately, prescription opioids are an appropriate part of medical treatment. However, the Centers for Disease Control and Prevention urges health care providers to reduce the use of opioids in favor of safe alternatives like physical therapy for most long-term pain. Opioid risks include depression and mood disorders, overdose, and addiction, plus withdrawal symptoms when stopping use. Physical therapy can also help people avoid and/or delay surgery. For some conditions, including meniscal tears and knee osteoarthritis, rotator cuff tears, spinal stenosis, and degenerative disc disease, treatment by a physical therapist is as effective as surgery. Moreover, in conjunction with medical management or nonoperative orthopedic care provided by a physical medicine and rehabilitation physician, orthopedist, or even primary care specialist, many patients can avoid the need for surgery altogether.
Telerehabilitation and Telerehabilitation in Physical Therapy
Telerehabilitation has been defined as “the delivery of rehabilitation services via information and communication technologies” and encompasses services that include assessment, prevention, treatment, education, and counseling. Telerehabilitation in physical therapy (TelePT) is a subcomponent of telerehabilitation, defined as delivering physical therapy services to patients at a distance using information and communication technologies (ICTs).
In the late 1990s telePT was used for one-on-one physical therapy and for monitoring the progress of people with stroke during rehabilitation. Over the last decade, telePT has been widely used for consultations, assessment, and treatment in a range of conditions. It has also been used to deliver education-based interventions and promote physical fitness and well-being. On the one hand, technology may contribute to sedentary behavior (e.g., playing computer games or working in front of a computer for prolonged periods in a seated position) across different age groups and socioeconomic levels. On the other hand, using technology, such as smartphone applications and wearable devices, can provide innovative solutions to increase physical activity and reduce sedentary behavior.
Currently, more than 6.8 billion people use mobile phones worldwide. An analysis conducted in 2013 revealed that over 40,000 health and fitness applications are currently available to the public, and over half of smartphone users report having downloaded such applications. More specifically, in physical therapy, Machado et al. conducted a systematic review of mobile applications targeted at people with low back pain. They included 61 apps in their analyses out of over 700 available apps in iTunes and Google Play between 2015 and 2017.
People of all ages with a variety of symptoms and medical conditions may be candidates for telePT, for example, people with balance disorders, people seeking pre- and postoperative care, management of chronic pain, amputation care, people with neurological conditions (like stroke, spinal cord injury [SCI], traumatic brain injury [TBI]) receiving home-based rehabilitation, and so on ( Table 19.1 ). TelePT has been proven valuable in improving postoperative outcomes and functional recovery in surgical patients, where patients considered telePT as a positive experience and suitable for those with long traveling distances or mobility issues, flexible exercise hours, and the ability to integrate exercises into daily life directly. Also, telePT has been valuable in overcoming the discontinuities that may arise in communication between the hospital and another health care provider and primary care facilities for treating complex surgical cases in the community.
| Technology | Population | Potential Use |
|---|---|---|
| mHealth | Chronic disease management in elderly | Reminding people to undergo scheduled exercise |
| mHealth | Various disabilities | Allow patients to record and share their health measures and send them electronically to physicians and/or specialists |
| Online technology/mHealth | Various disabilities in aging population |
|
| mHealth | Various acute and chronic conditions | Function as self-assessment, screening and testing tools and symptom checkers, goal setters, and treatment/exercise logs and prescribers |
| Interactive websites | Musculoskeletal conditions in all age groups | Tailored and progressive home exercise programs (HEPs) and monitoring compliance |
There is also growing evidence showing positive effects of telePT on clinical outcomes in patients with certain types of cancer, neurological disorders, sports injuries, cardiac disease and rehabilitation, musculoskeletal disorders, chronic pain, chronic obstructive pulmonary disease (COPD), and pelvic floor disorders. TelePT has been delivered in various formats: smartphone applications, web-based use of activity trackers (pedometers), videoconference, and text messages to monitor conditions, deliver exercise, and educational strategies.
Role of TelePT in Initial Consultation and Assessment
Some of the common assessment items of a conventional physical therapy session are easily collected via telePT. Therefore an initial telePT consultation can include subjective assessment, observational analysis of function, posture and gait, quality of movement, observation of active range of motion, pain tolerance, and irritability. In an initial consultation, if telePT is being delivered in addition to face-to-face sessions, the therapist should identify the need for investigation before attending face-to-face appointments. Education is another important component of treatment in chronic pain and disease management, exercise interventions, review, and program updates. TelePT can successfully deliver interventions targeting education.
Some assessment components such as manual tests for strength and mobility, neurological examination of reflexes and sensation, motor control assessments, and special tests for diagnostic purposes can be challenging to conduct via telePT. Therapists can seek alternative ways of obtaining these data by questioning the patient, acquiring it from their physician, and considering the need for a complimentary face-to-face appointment. There are challenges in delivering interventions that involve manual guidance or specialized equipment such as joint manipulation or body-weight support treadmill training. In those cases, the therapist should seek alternative interventions. Although carers may assist in delivering some simple interventions such as supporting a limb during an active-assisted exercise, it is the therapist’s responsibility to ensure the patient’s safety during the session.
The use of telePT has been proven effective for an initial consultation in musculoskeletal conditions, neurological conditions, and delivering rehabilitation consultations using a low-bandwidth internet-based telePT for remote areas. TelePT has been now widely used in assessing range of motion and muscle strength and in diagnosing conditions like low back pain, shoulder disorders, knee conditions, and other nonarticular lower-limb conditions.
Role of TelePT in Advocating Education and Treatment
The role of the physical therapist in the management of chronic conditions has changed in the past decades. Self-management interventions, including education and strategies to increase physical activity, have superior results to hands-on physical therapy interventions. Self-management is the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a chronic condition. Patient education, empowerment, and monitoring are key components for the success of self-management strategies.
Self-management strategies consisting of educational modules delivered via email or websites have been successful in increasing physical activity participation in people with acquired brain injuries, reducing pain and disability in chronic low back pain, and improving quality of life for people with COPD. To increase adherence and motivation, online educational modules can be supplemented with weekly phone calls or videoconferencing for monitoring, which can significantly reduce face-to-face time with therapists and, in turn, reduce costs related to long-standing disease management.
TelePT has been widely used for delivering education and treatment for various disorders, such as stroke, SCI, brain injury, cardiovascular disease, and amputation. A meta-analysis of 12 studies involving stroke survivors suggested that telerehabilitation can be a suitable alternative to usual rehabilitation care, especially in remote or underserved areas. The outcomes included in this meta-analysis were activities of daily living, balance scale, and motor functions. Another review in adults with TBI found that structured telephone interventions were effective for improving some outcomes (but not physical function outcomes) following TBI. The review included 10 randomized controlled trials looking at the feasibility and/or effectiveness of telephone-based and internet-based interventions. TelePT has also been widely used in people with spinal cord disease. A systematic review of telerehabilitation and mobile health (mHealth) interventions suggested the potential to improve health-related outcomes in people with SCI in home and community settings. This review included nine studies delivering a telerehabilitation intervention via phone or video call facility (such as Skype, Scopia, Tandberg conferencing equipment, and CareCall system). Also, some of these studies used adjunct technologies to deliver the intervention and capture real-time outcomes, such as the eTDS bundle, ReJoyce workstation, a powered toothbrush, adapted flosser, and/or oral irrigator. In the last few years, telerehabilitation has been gaining popularity for prevention, such as cardiovascular diseases. A meta-analysis, including 13 studies, suggested insufficient evidence in reducing overall cardiovascular risk.
Another area where telerehabilitation has been widely used is people with lower-limb amputation, ulcer, and weight management. Telerehabilitation can promote better/faster healing of wounds and better adherence to self-care regimens, both of which may reduce health care costs for individuals with long-distance travel time.
Role of TelePT in Promoting Physical Activities
Physical inactivity has been identified as a global epidemic by the World Health Organization (WHO). It is the fourth leading risk factor for global mortality, contributing to approximately 3.2 million deaths annually worldwide. The Americas region has the highest prevalence of inactivity, followed by the Eastern Mediterranean region. The cost related to physical inactivity on health care systems is overwhelming. In the United Kingdom, the annual cost is $11.2 billion; in Canada, the cost is approximately $6.8 billion per year. The United States spends more than 75% of the $2 trillion annual health care budget on physical inactivity–related hospitalizations. To combat this growing epidemic globally, the WHO and many countries like Canada, the UK, and the United States have developed Physical Activity Guidelines.
Technologies for self-tracking have become increasingly popular within the general population. At the same time, health care professionals embrace the opportunities they perceive through using what has been dubbed “mHealth” to promote the public’s health. This electronic monitoring of human health behavior is fast becoming an area of increasing research focusing on “sensor fusion” using single systems or devices.
Many studies have provided evidence on the effectiveness of fitness technology to engage people in various types of exercise programs. A systematic review suggested positive results such as weight loss and changes in health risk behavior in individuals with inactive lifestyle in studies that used mixed technology-based physical activity interventions (web-based technology, mobile phones, and accelerometers). Some of the commonly used devices that measure and track physical activity are as follows.
Pedometers
They count and monitor the number of steps taken while walking, jogging, and running. They can also provide distance covered and caloric expenditure. Studies have shown that some pedometers provide a valid and reliable measure of step counts during walking, and pedometer-based walking increases physical activity. Bravata and colleagues studied efficacy of pedometers and reported that setting a step goal for a day on a pedometer was a key predictor for increasing physical activity by 27% over the baseline value. Programs such as pedometer-based walking were also associated with significant decreases in body mass index (BMI), body weight, and systolic blood pressure.
Accelerometers
They record body acceleration from minute to minute, providing detailed information about the frequency, duration, intensity, and movement patterns. They are more expensive than pedometers and used more widely in research.
Heart Rate Monitors
They are used primarily to assess exercise intensity for individuals with cardiac conditions and highly trained competitive athletes. These devices can also estimate exercise energy expenditure. The use of heart rate monitor data in conjunction with an accelerometer can improve energy expenditure by 20% during physical activity. Some devices monitor heart rate and body motion at the same time to provide valid and reliable physical activity measures.
Interactive Video Games
They promote physical activities, improve aerobic capacity, and promote fitness level, for example, Dance-Dance Revolution, Wii Sports, and Sony Play Station. Exergaming is the term given to interactive digital games in which the player actively moves. Bailey and McInnis evaluated the enjoyment and 10-minute energy demand of six different exergaming systems and treadmill walking for children of normal and above-normal BMIs. The associated metabolic equivalent (MET) levels were in the moderate- to vigorous-intensity ranges.
Fitness Smart Trackers
Fitness trackers can monitor daily steps, heart rate, physical and sports activities, and sleep, such as smartwatches and wrist bands.
Smartphone Applications
They allow users to track physical activities such as jogging/biking routes, workout data, and comprehensive workout history. Some smartphone applications provide professional virtual reality coaching to promote physical activity.
Many organizations and institutions are now utilizing interactive games to promote physical activity in children, adolescents, and older adults. Warburton and colleagues reported that an interactive video cycling game significantly increased heart rate and energy expenditure as compared to traditional cycling at constant, submaximal workloads. Interactive games are not exclusively for children and also hold promise for promoting functional independence, improving balance, preventing falls, reducing premature disability, and maintaining health by increasing adults’ and seniors’ physical activity levels. The elderly population who completed a 3-month video dancing intervention (30 minutes per session, twice weekly) showed improved balance confidence, mental health, and time walking along a narrow path.
Fitness technology often utilizes behavior change techniques, such as goal setting, feedback, rewards, and social factors to increase the individual’s adherence to physical activity. Providing feedback such as reminders, text messages, and real-time alerts is essential for tracking goals and increasing activity levels. Some fitness trackers’ features are to vibrate, ping, or display a congratulatory message when a goal has been achieved. Users can easily share their progress with their friends on social media as a great motivational tool. Technology-based fitness tools provide a less costly alternative to one-on-one therapy, are simple to use, and provide meaningful outputs to users. Studies have found that fitness trackers, such as wrist-worn devices, have acceptable reliability and validity comparable to research-standard devices in the laboratory.
Many reviews looking at the effectiveness of different digital interventions for different conditions have been published in the last decade. A review published in 2017 involving 27 studies suggested that digital interventions that include health education, goal setting, self-monitoring, and parent involvement can significantly improve adolescents’ dietary and physical activity behaviors. This review also found that the studies delivering interventions using websites as a platform are more effective than interventions delivered using digital platforms such as apps, text messages, and social media. Another review suggested positive effects of ICTs in physical activity interventions for children and adolescents, especially when used with other delivery approaches, such as the face-to-face method. An overview of reviews published in 2011 identified 12 recommendations for practice associated with increased effectiveness in dietary and physical activity interventions.
Performance of Telephysical Therapy
TelePT aims to overcome barriers and provide equitable access to physical therapy. TelePT also can help overcome barriers to face-to-face consultations, such as clinic scheduling and logistics, difficulties with transportation because of distance or financial issues, adverse weather, disasters, pandemics, and secondary conditions. There are various ways of administering telePT. The first two described here are traditional methods, but the latter two have evolved with advancing technology.
Synchronous
Health information is delivered in real time. This can be done through interactive video with the client and health professional present at the same time, such as through videoconferencing. It can be used for an initial consultation and for diagnosing and treating clients. This requires high bandwidth, constant connectivity, and investment in related hardware.
Asynchronous or Store and Forward
Health information is collected at the client site and then transferred for assessment to a physical therapist located at another site. An example of this is a person tracking their own activity or steps on a particular day, and then this information is sent to the physical therapist to monitor. Another example is using newer technology such as virtual reality or “wearables” to store and forward data back to the therapist. This is generally used for assessing or monitoring progress with an exercise routine. This is less dependent on constant connectivity but more complicated to administer. There is a time delay between when a message is sent from one party and received by the second party.
Mobile Health or mHealth
This is a special form of digital health, including mobile phone applications available directly to consumers. They are inexpensive and have built-in software functionality for accessing health information in a timely way. mHealth is seen as a potential means for worldwide change because of its high reach and low-cost solutions. Smartphone applications represent a new and emerging way to deliver telePT that promotes active participation from both the physical therapist and the client throughout the course of treatment.
Hybrid Model
This is usually a combination of synchronous and asynchronous telePT.
TelePT in Clinical Practice
The rapid evolution of technology has allowed physical therapy to deliver health care in a new, remote fashion. For example, videoconferencing allows for the provision of consultations, diagnostic assessments, and delivery of treatment interventions and provides verbal and visual interaction between the therapist and the client. In clinical practice, the use of telePT has been proven effective for initial consultation purposes, disease management, and advocating different types of therapy, for example, groups versus one-on-one, strengthening versus conditioning, and maintenance versus ongoing active therapy. The following telePT model of care can be applied to disorders or conditions that physical therapy treats. There are specific challenges that come with technology when managing a disorder or condition using telePT. These challenges are manageable and are usually outweighed by the benefits that come with telePT, also explained earlier in this chapter. The following figure depicts an overarching theoretical model on how telePT can be used and implemented in many different ways, targeting a different population with different disorders ( Fig. 19.1 ).
