Introduction
Rehabilitation of the hand and upper extremity requires a clinician to be knowledgeable as well as creative due to the complex, intricate, and functional design of this most valuable human tool. Having an in-depth understanding of the anatomical, physiological, neurological, and psychosocial functions of the upper limb is crucial for the clinician when evaluating a client, setting goals, and developing a treatment program. When using telerehabilitation to conduct this same process, the clinician must rely on both past experience and intuitive guidance to provide valuable service to clients in need of individualized care.
The unique nature of upper extremity rehabilitation embraces the strengths of both occupational and physical therapy professions. The philosophical tenets of physical therapy include evaluation and treatment of the musculoskeletal and neurological systems using clinical measurements, physical agent modalities, manual therapy techniques, and therapeutic exercises. Occupational therapy tenets include evaluation and treatment of these same systems, while focusing more often on functional assessments, behavioral and environmental modifications, orthotic fabrication, and psychosocial approaches. Through the use of meaningful activities, occupational therapists are able to promote subconscious functional movements of the upper extremity embedded in occupation. Occupational therapists commonly utilize both biomechanical and occupation-centered interventions in upper extremity rehabilitation. Therefore they must continue using evidence-based yet practical approaches to reflect the unique benefits of the two treatment principles.
On a worldwide basis, upper extremity conditions are both prevalent and costly, particularly in the areas of work-related musculoskeletal disorders (WMSDs) and neurological conditions such as cerebral vascular accidents (CVAs). In developing countries, muscular pain in the neck and upper limbs accounts for up to 42% of work-related injuries, impacting not only employees’ health, quality of life, and occupational performance but also the overall public health system of the countries in which they reside. Although the prevalence of CVAs resulting in upper extremity dysfunction has decreased in developed countries over the last 40 years, developing countries have experienced just the opposite scenario. The increased prevalence of CVA in developing countries places undue stress on already fragile systems that are unable to meet the growing demand by people in need of health care and social services.
According to the US Department of Labor Statistics in 2018, there were 286,810 upper extremity injuries, which accounted for almost 32% of all nonfatal occupational injuries and illnesses resulting in days away from work. From January to December of 2009, over 92,000 patients were diagnosed with an upper extremity injury, resulting in approximately 3,468,996 people with upper extremity injuries visiting emergency departments in the United States. The incidence of upper extremity injuries is 1130 cases per 100,000 people per year, implying that an individual has a 1-in-88 chance of incurring an upper extremity injury needing emergency medical care in any given year. According to the Centers for Disease Control and Prevention (CDC), upper extremity disorders most frequently occur among people who engage in work requiring frequent repetitive and resistive tasks. These conditions affect the nerves, tendons, and muscles of the neck, shoulder, elbow, wrist, and hand, for which organizations pay more than USD 2.1 billion in direct and indirect workers’ compensation costs. These medical costs have created a negative impact on the financial status of the American health care system.
Telerehabilitation and Neurological Conditions
The COVID-19 pandemic has catalyzed the unprecedented shift to alternative delivery methods of hand rehabilitation in various health care settings throughout the world in order to prevent or address the devastating functional consequences of hand conditions left untreated. Telerehabilitation is a viable option that existed even pre-pandemic, albeit not as popular then as now. Nonetheless, it is found to be feasible, logical, and practical specifically for hand rehabilitation for several reasons: (1) potential ability to maximize neuroplasticity or neuromuscular recovery; (2) adaptation in the client’s home or work environment; and (3) promotion of client’s active engagement in the rehabilitation process.
Upper extremity telerehabilitation, particularly for neurological conditions including strokes and spinal cord injuries, may involve technological home or workplace-based solutions which can increase the number of repetitions and duration of training required to promote neuroplasticity. A potential for spontaneous recovery and neuroplastic adaptation may be achieved using an intensive telerehabilitation program in which the client can engage for a longer period in the home environment, as compared with the same intensity of in-clinic rehabilitation program. The client typically performs this in-clinic program for fewer hours with no reassurance of functional carry-over at home or in the workplace. The usual frequency of in-clinic stroke rehabilitation sessions may provide substantially less activities to maximize neuroplasticity, for which 300 repetitions of task-specific upper extremity activity are recommended. Aside from frequency, continuous progression of exercise intensity is needed to improve motor skill that can likewise be facilitated remotely by a trained clinician. In addition, functional gains may be more sustained and contextualized through telerehabilitation as the client actively performs exercises using actual household items relevant to day-to-day living. It is important for the clinician to evaluate the client’s natural environment and provide appropriate recommendations for adaptation or modification. As long as the client consents, telerehabilitation may provide clinicians with the opportunity to observe and analyze the client’s environmental context with higher accuracy as compared with in-clinic evaluations, wherein verbal reports from the client or caregiver may not be as accurate and informative.
In order to increase the amount of rehabilitation received by the clients and minimize costs, involvement of reliable co-located family members or caregivers during and after the telerehabilitation sessions may seem logical. In a randomized, noninferiority clinical trial that compared stroke home-based telerehabilitation with in-clinic therapy, there was noted improvement in motor status and patient knowledge about stroke with either approach. A meta-analysis showed moderate, albeit limited, evidence that stroke telerehabilitation of varied approaches (i.e., videogame-driven, virtual reality) is comparable with in-clinic rehabilitation in terms of functional improvement and motor gain. Nonetheless, a Cochrane review argued that telerehabilitation is still emerging and understandably more studies are required for more definitive conclusions.
Although telerehabilitation has the potential to promote and sustain functional improvements, it should be emphasized that no “one telerehabilitation program fits all.” For instance, impairments in tone and sensation of the hand, attention, cognition, and consciousness are some factors that may limit manipulation of household or makeshift items used for telerehabilitation. The effectiveness of various telerehabilitation approaches depends on the type and severity of the disease, along with accompanying impairments and comorbid conditions. Hence, a creative and individualized telerehabilitation program must be carefully prepared. Clients with lifelong conditions, such as degenerative joint disease and neurological diseases such as stroke, polyneuropathies, and spinal cord injuries, for whom long-term in-clinic rehabilitation may be costly, monotonous, and burdensome, may be transitioned to pure telerehabilitation or hybrid telerehabilitation (i.e., mixed in-clinic and home-based virtual rehabilitation).
Telerehabilitation and Musculoskeletal Conditions
Acute and postsurgical conditions initially require a hands-on approach to treatment, which can later be transitioned to telerehabilitation to ensure proper and sustained supervision by a clinician. Generally, in-clinic approach is advised for initial comprehensive evaluation of acute and postsurgical hand conditions and for instituting appropriate meticulous interventions, such as wound care, edema management, and orthotic fabrication. Following this initial phase of treatment, which may involve as few as two or three in-clinic visits, telerehabilitation sessions may then follow for further promotion of healing and function incorporating client/caregiver education and home exercise programs. The decision to transition to telerehabilitation should be based on the sound clinical judgment of the clinician and informed consent and cooperation of the client. The clinician must consider the various biopsychosocial factors affecting the client’s participation with telerehabilitation, such as cognitive, visual or hearing impairments, lack of caregiver support, loss of fine motor skills, incoordination, and technical resources and capacity.
Chronic and nonsurgical conditions, such as tendinopathies, fractures with immobilization protocols, and cumulative trauma disorders, may be treated with either a pure or hybrid telerehabilitation approach. During evaluation, clinicians must gather adequate subjective and objective information to establish an effective and practical home exercise program with the client. After establishing rapport with the client, the clinician can develop an occupational profile and encourage the client to incorporate objects and activities from the natural environment. In this way, the clinician can observe the client’s occupational performance and make recommendations as needed. For instance, if a client with lateral epicondylosis reports pain and difficulty with specific tasks, the clinician can educate the client regarding behavior modification as it impacts occupations of self-care, work, or leisure.
Because telerehabilitation is different from an in-clinic therapy experience, establishment of rapport between clinician and client is imperative. This rapport will be the foundation upon which the clinician may initiate client education, promote understanding and acceptance of “skilled education” and the advantages of remotely supervised home-based interventions, and assure clients that their needs and goals will be met through the therapeutic process in spite of the distance. In reality, the process does not occur in a sequenced, step-by-step fashion. Rather, it is fluid and dynamic, allowing clinicians and clients to exchange ideas on what will work best, while maintaining their focus on preidentified clinical outcomes. As with in-clinic sessions, reassessments are needed to continually reflect on the current treatment plan and make appropriate adjustments as needed.
Once a plan of care is established, the clinician can assist the client in identifying actual household items as well as accessible make-shift exercise equipment that can be used during the telerehabilitation sessions. For instance, if dumbbells or exercise bands are unavailable for upper limb strengthening exercises, a client can use a handheld plastic stapler (weighing approximately half a pound), canned vegetables (1 pound), unopened bottle of water (450 mL), or empty wine bottle (750 mL; 1 pound), half gallon of milk (4–5 pounds), or full gallon of milk (8 pounds). Utilizing table-tops, kitchen counters, and doorways at home in performing self-assisted range of motion or active-assisted range of motion (aided by a reliable caregiver) can allow the client to engage in home exercise programs without purchasing additional equipment. Transitioning to active range of motion exercises in functional reaching patterns, shoulder flexion and external rotation, and elbow, wrist, and finger extension can be incorporated in everyday home activities. Tools needed for basic and instrumental activities of daily living (ADL) during telerehabilitation sessions can help improve impairments and improve specific skills. For instance, utilizing buttons, zippers, and fasteners can improve mobility and fine motor coordination, while allowing the client to regain independence and self-confidence in the area of dressing.
Therapeutic exercises can be an integral part of a telerehabilitation intervention when improving hand function. However, addressing impairments through exercise may be challenging without manual guidance from the clinician or use of specific equipment, such as resistance bands and putty, which are typically available during in-clinic rehabilitation. Clinicians are encouraged to utilize their clinical judgment and reasoning to overcome this challenge. For instance a toolkit of therapeutic items may be carefully curated together with the client or family to help address certain deficits in performance skills and achieve rehabilitation goals. If the client lives within a reasonable distance from the rehabilitation center, a family member or caregiver may be asked to pick up therapeutic tool kits from the clinician for use during their telerehabilitation appointments. The clinician may also choose to mail or deliver the toolkits to the client as another option.
Special Considerations
Clinicians treating clients with upper extremity conditions have traditionally utilized patient-rated outcome (PRO) assessments to promote a client-centered and occupation-centered treatment approach. PRO assessments typically address client engagement in occupation and elicit important subjective information relevant to function. Such data may be required to evaluate client function and justify the need for therapeutic services. Commonly used PRO assessments include the Disabilities of the Arm, Shoulder, and Hand (DASH) Inventory, Quick DASH (QDASH) Scale, and Patient-Rated Wrist Evaluation (PRWE). In a scoping review of outcome measures for stroke telerehabilitation, the most commonly used tools include the Fugl-Meyer Assessment of Stroke Recovery (FMA) and the Box and Block Test (BBT). These psychometrically sound assessments address function and provide clinicians a systematic method to adequately evaluate occupational performance within a telerehabilitation delivery system.
Telerehabilitation in this area of practice does limit clinicians’ ability to offer hands-on treatment techniques, such as orthotic fabrication, manual therapy, wound/scar management, and certain modalities for addressing pain and edema. Clinicians must ensure that communication and education of the clients and caregivers are clear, concise, and easily understood to ensure positive outcomes and avoid misconceptions or unmet expectations.
There is undoubtedly significant potential in the area of telerehabilitation in addressing upper extremity dysfunction, although many challenges remain within this upcoming field of practice. Fear of technology and operability by health care providers as well as clients may decrease willingness to utilize this mode of care. Learning new technology skills may be a source of apprehension particularly among clients, who may be significantly limited physically as well as cognitively. Inflexibility in transitioning from the “hands-on” in-clinic approach to a virtual medium of service delivery and concerns regarding effectiveness and ability to achieve rehabilitation goals have potential negative impact on the emergence of telerehabilitation, including hand telerehabilitation. A paradigm shift facilitated by clinicians’ open-mindedness and practical clinical reasoning, along with clients’ empowerment and active participation in the treatment process, may help pave the way to greater adoption of telerehabilitation for various conditions.
State licensure issues, which include professional portability, have the potential to limit telerehabilitation services. Within the United States, clinicians must be licensed within the state they are practicing as well as within the state the client is receiving the care. Clinicians must abide by state laws and regulations related to telehealth as well as state occupational therapy licensing board regulations and policies. Inconsistent laws, regulations, and policies among states (and even within states) necessitate the need to continually check state statutes and occupational therapy practice regulations and policies to ensure compliance when delivering services via telehealth. Licensure laws in conjunction with lack of reimbursement and payment systems currently impede a greater platform for delivery of telerehabilitation services. In addition, the need for research supporting telerehabilitation as a service delivery model and development of outcome measures specifically for the use of evaluating and measuring progress through telerehabilitation are imperative for its continued use in various health care settings.
Special considerations must be contemplated when assessing which clients will successfully participate in telerehabilitation. Clients who are used to receiving skilled in-clinic therapy have the potential to demonstrate significant physical and cognitive deficits, which can impact their ability to independently participate in telerehabilitation. Clients with diagnoses affecting upper extremity function, such as stroke and traumatic brain injury, may also present with visual, visuo-perceptual, and cognitive deficits (i.e., impulsivity, decreased comprehension, inability to follow verbal/visual directions, distractibility). These individuals may be at a disadvantage and will require clinicians’ clinical judgment to evaluate the need for adaptive technology, equipment, or adaptive therapeutic materials in order to allow for increased accessibility to this population. Clinicians may recommend in-clinic sessions or a hybrid approach in addition to significant support by caregivers or personal care assistants during virtual appointments.
Technology continues to improve, grow, and expand as new sensory-based rehabilitation, virtual environments, and video image-based telerehabilitation are being introduced. Nevertheless, availability of technology to individuals across socioeconomic levels and practice settings (including remote and rural areas) and limitations related to internet accessibility impact the availability of telerehabilitation as well as fluidity of video sessions with “freezing,” lagging, or dropped/interrupted sessions. These technology-related limitations in conjunction with predetermined length of sessions (e.g., 45 minutes) can significantly impact the success and quality of care. Thus for each telerehabilitation session, there should be a backup plan for failings in technology, which may include phone call follow-ups to minimize the impact on the therapeutic sessions. The type of telerehabilitation delivered will also determine the type of technology equipment required to participate in the sessions. For example, a client who is being treated for a distal radius fracture may need to be seated throughout the session while completing range of motion exercises and would require the use of a desktop or laptop computer. Alternatively, a client who is in phase 3 of a recovery of rotator cuff repair, initiating active range of motion at the shoulder through functional reaching and moving around their home environment, may require the use of mobile device such as a smartphone, tablet, or laptop. These devices also allow the individual to easily move around the environment and provide multiple visual points of movement and function.
Telerehabilitation limits physical examination and hands-on techniques typically utilized by health care professionals. These techniques include manual manipulation, custom splinting, and use of kinesiotaping and other modalities in clinic or hospital settings. Furthermore, at this time it limits the use of typical outcome measures of upper limb function including dynamometers, goniometers, nine-hole peg tests, and the Jebsen test among others. More research on outcome measures for evaluating hand and upper extremity conditions through telerehabilitation is, therefore, recommended.
Areas for Future Research
Unquestionably, the COVID-19 pandemic caused a massive shift in delivering hand and upper extremity rehabilitation services and opened avenues for future research. Clinicians must now shift their client-centered approach from using a hands-on technique in the clinic to incorporating a hands-off approach in the virtual and natural environment of the client. Fortunately, this shift offers clinicians, educators, and researchers more opportunities to examine and explore the benefits of treating clients using both traditional and telerehabilitation approaches in a hybrid model of practice. For instance, researchers have identified the following areas for future studies: communication with clients, education, and self-management; functional outcomes and therapists’ adherence to treatment guidelines; clients’ perceptions of and satisfaction levels with services provided; efficacy of telerehabilitation in various phases of the healing process (acute vs. chronic); and the socioeconomic implications of this hybrid approach on clinicians, clients, and reimbursement systems on a global basis. Since the onset of the COVID-19 pandemic, researchers also found the most at-risk populations to be older adults with chronic health conditions. During long periods of quarantine, they often experience a decrease in overall strength and endurance, which may further complicate the symptoms of their upper extremity conditions. The overall lesson is that health care providers must remain flexible, thinking outside of traditional means of treatment and ready to use alternative, skilled, and client-centered clinical approaches that optimize client outcomes and prevent further decline in function, most especially in the area of upper extremity care. This client-centered and holistic approach to care is central to the philosophy of occupational therapy; therefore integration of telerehabilitation services should be a natural transition into practice for occupational therapists.
