Tel e m e d i c i n e i n

Rehabilitation
Marinella DeFre Galea, MD

KEYWORDS
 Telerehabilitation  Telehealth  Telemedicine

KEY POINTS
 Telemedicine offers the opportunity to deliver rehabilitative services in the patients’ home,
closing geographic, physical, and motivational gaps.
 The exponential growth of telerehabilitation has yielded the proliferation of studies with
varying methodologies.
 Several methods of telerehabilitation delivery alone and in conjunction with traditional
rehabilitation methodology have been explored based on available technology, patient lit-
eracy and level of function, and caregiver availability.

INTRODUCTION

In the past decade, the use of technology for remote assessment and intervention in
rehabilitation has grown exponentially, paving the way for the development of
telerehabilitation. The services provided under this term are wide in scope and can
include evaluation, assessment, monitoring, prevention, intervention, supervision, ed-
ucation, consultation, and coaching. There is no formal structure for the delivery of tel-
ehealth, and the exchange of data may occur in numerous forms. Telephone,
messaging and e-mail, or multimodal systems, such as videoconferencing, virtual
therapists, and interactive Web-based platforms are some examples. In the field of
rehabilitation, the patient-centered team approach has guided the identification of
ad hoc solutions to overcome geographic, temporal, social, and financial barriers.1
Telerehabilitation has been shown to strengthen the patient-provider connection by
(1) enhancing the knowledge of the patients and their contextual factors, (2) providing
information exchange and facilitating education, and (3) establishing shared goal
setting and action planning.2 In the inpatient setting, telerehabilitation has been
used to shorten hospital stay, facilitate discharge home, and provide patient and care-
giver education and support.3–5 In the outpatient setting, telemedicine supplements or

The author has nothing to disclose.

Department of Spinal Cord Injury and Disorder, Amyotrophic Lateral Sclerosis Program, Mul-
tiple Sclerosis Regional Center, The James J Peters VAMC, SCI/D Unit, 130 West Kingsbridge
Road, Bronx, NY 10468, USA
E-mail address: [email protected]

Phys Med Rehabil Clin N Am 30 (2019) 473–483

https://doi.org/10.1016/j.pmr.2018.12.002 pmr.theclinics.com
1047-9651/19/Published by Elsevier Inc.
474 Galea

substitutes face-to-face encounters in acute and chronic neurologic, cardiac, and

musculoskeletal conditions commonly treated by physiatrists.
As the application of telehealth proliferates, a central concern is how to protect data
to preserve patient privacy. The Office of the National Coordination for Health Informa-
tion Technology reported that health information is at a high risk for breaches, with
more than 113 million individuals affected in 2015.6 Although health care providers
routinely receive mandatory training about how to safeguard the privacy and security
of health care information during face-to-face encounters, the same is not true for vir-
tual visits. In fact, very few studies have reported on the privacy and security of health
care information in the context of telehealth. A systematic review by Peterson and
colleague7 shows that health care providers do not have a clear idea of how to protect
health information when using telehealth. The investigators conclude that existing best
practices are inconsistent across telehealth services and tools to assist health care
providers are needed. To address this gap, the American Telemedicine Association
(ATA) has recently developed a document to inform and assist practitioners in
providing effective and secure telerehabilitation services, laying the foundation for
developing discipline-specific standards, guidelines, and practice requirements.8
The development of a user-friendly, cost-effective, integrated telerehabilitation sys-
tem aligned with existing policies will necessitate a business model that ensures effec-
tive, sustainable, and value-based services.9 A forecast by Goldman Sachs estimates
the comprehensive value of the US telerehabilitation market at $32.4 billion, of which
45% derives from remote patient monitoring; 37% from telehealth; and 18% from
behavioral modifications.10 Data from the QYR Pharma & Healthcare Research Center
confirm the growth trend of the telerehabilitation market in the United States.11 Cost-
effectiveness has been shown in the application of tele-stroke,12 cardiac rehabilita-
tion,13,14 traumatic brain injury,15 and hip replacement rehabilitation.4 Although
insurance coverage for telerehabilitation services varies, the cost of technology is
decreasing, making telerehabilitation modalities more affordable.9 The 2017 ATA
State Telemedicine Gap analysis16 shows that, of the 37 states analyzed, 13 states
do not cover telerehabilitation services for their Medicaid recipients. Although state
policies vary in scope and application, 24 states reimburse for telerehabilitative ser-
vices in their Medicaid plans. Only 12 states reimburse for telerehabilitative services
within home health benefits.
This article presents recent applications of this burgeoning field of telerehabilitation
by various medical subspecialties. These case studies demonstrate the evidence
base for telerehabilitation, highlight potential areas of improvement, and propose po-
tential future directions and applications.

CONTENT
Neurologic Telerehabilitation
The use of telemedicine in acute stroke has validated the proof-of-concept that
specialized services can be delivered virtually when they cannot be easily provided
face-to-face.17 Several teleneurology applications have been proposed to manage
patients with chronic neurologic diseases where impaired mobility hinders access.18
Stroke
Research has shown that more time spent on exercise therapy in the first weeks to
months after stroke leads to better functioning.19 Under the present health care sys-
tem, transitional care programs are insufficient to address the barriers preventing
community stroke survivors from achieving their highest potential, leading to hospital
readmission, poorer outcome, and permanent disability.20 Several randomized
 Telemedicine in Rehabilitation 475

controlled trials have used alternative solutions to provide and/or supplement care in
the patient’s home after discharge.
Caregiver-delivered rehabilitation services have been evaluated to augment inten-
sity of practice. A Cochrane review21 showed that caregiver-mediated exercises
(CME) administered alone or in combination with standard therapy have no significant
effect on basic activities of daily living. However, CME significantly improved patients’
standing balance and quality of life with no significant effects on caregiver strain. A
more recent review showed that telerehabilitation interventions were associated
with significant improvements in recovery from motor deficits, higher cortical dysfunc-
tion, and depression in the intervention groups in all studies assessed. Modalities used
included tele-supervision, virtual reality, game-based virtual reality, and interactive
mobile phone applications.12
Ongoing studies promise to provide more definitive evidence on CME and to
assess the utility of televisits by the interdisciplinary team using more rigorous
methodology.22,23
Approximately one-third of all people with stroke suffer from depressive symp-
toms,24 using more health care services and increasing costs. In addition, the pres-
ence of depression is associated with poor functional outcomes after stroke.24
Telerehabilitation has been successfully applied to address motor and nonmotor do-
mains measured by the Stroke Impact Scale in a study comparing the effects of home-
based robot-assisted rehabilitation coupled with a home exercise program versus
home-based exercise alone.25 The investigators were not able to determine why the
quality-of-life and depression outcomes improved. They hypothesized that the posi-
tive trend could be attributed to the intervention per se, the resulting modest motor
improvement, or the weekly interaction between the participants and the therapists.

Spinal cord injury

Individuals with spinal cord injury (SCI) experience substantial physical, psychological,
and social challenges, requiring frequent, specialized, and interdisciplinary care.
Several telerehabilitation modalities have been proposed to deliver specialized care
and provide education and training. As described in a recent literature review,26 to
date there are a limited number of randomized controlled studies with different patient
selection, outcomes, and modalities. The investigators conclude that there is not
enough evidence about optimal methods of utilization, policy, and efficacy of telereha-
bilitation in SCI. Of note is that the reviewed studies showed high patient satisfaction
and engagement.
Within the SCI system of care, the Veterans Health Administration (VHA) has devel-
oped a robust telehealth structure to address the postacute and chronic conse-
quences of SCI. The Disease Management Protocol consist of semicustomized
questions delivered to the patients’ home via data messaging devices to evaluate
changes in comorbidity severity and health-related quality of life.27 The system has
been shown to be most beneficial to newly injured patients recently discharged
from acute rehabilitation that live far from specialty SCI care facilities. In recent years,
the VHA has supported the use of Clinical Video Telehealth, a real-time videoconfer-
encing system, to provide health care services. Qualitative analysis has shown that the
system is complex and requires coordination and communication among stake-
holders.27,28 Video connect is a new secure provider to patient solution that is used
to supplement face-to-face visits; data regarding its efficacy in delivering care and
comparability with face-to-face encounters are not yet available. Notably, the VHA
has invested in extensive health care provider education and training, constructed a
safe and secure telemedicine structure, and marketed to its consumers.
476 Galea

Limited tele-exercise studies have been successfully executed in small cohorts of

individuals with SCI.
One pilot study29 used a platform consisting of a home monitoring system to record
physiologic parameters, a hand ergometer to perform a customized home exercise
program (HEP), and a tablet to conduct video training. The therapy sessions were
led by a telecoach. Results showed 100% adherence to the HEP, that all participants
experienced a modest improvement in aerobic capacity (24%), and physical activity
and increased satisfaction with life scores. Subjects valued the motivation and
disability-related expertise provided by the telecoach, consistent with the theory of
Supportive Accountability,30 which accounts for the complex interaction of a health
care professional and consumer when communicating through electronic health
technology.
Van Straaten and colleagues31 studied the effectiveness of a HEP on pain and func-
tion. Results showed that after a 12-week intervention consisting of a high-dose
scapular stabilizer and rotator cuff strengthening program using telerehabilitation for
supervision, shoulder pain was reduced even in individuals with longstanding symp-
toms. The study was limited by sample size, lack of a control group, and low to mod-
erate levels of pain at baseline.
Video visits have been used in SCI to provide nonurgent specialized consultation in
lieu of, or in addition to, face-to-face visits. A recent pilot study32 using iPads in the SCI
population confirmed previous findings33,34 that videoconferencing is a clinically
viable and effective tool. The type of interactions between clinicians and participants
varied from generalized hospital follow-up and SCI–primary care to specific questions
on medications and coordination with subspecialty clinics. This modality has been
well-accepted by patients and caregivers and has reduced rate of hospitalization
and overall length of stay.

Multiple sclerosis
Individuals with multiple sclerosis (MS) are at risk for developing long-term disability.
Rehabilitation provides treatments and therapies to lessen the impact of disability and
improve function; however, access to those services is complicated by limited
mobility, fatigue, and related issues. It has been shown that individuals with MS are
willing to receive rehabilitative services through telemedicine. However, patients
with moderate-to-severe disability may experience technical difficulties due to cogni-
tive and physical impairment.35
Charvet and colleagues36 have used an adaptive online cognitive improvement pro-
gram to train individuals with MS at home. The patients were randomly assigned to
either a conventional adaptive cognitive remediation program or an active control of
ordinary computer games. This telerehabilitation modality provided modest improve-
ment in cognitive performance as measured by changes in a composite of neuropsy-
chological tests.
Khan and colleagues37 conducted a systematic review of the use of telerehabilita-
tion to provide or supplement therapy to individuals with MS. The studies evaluated
included multiple delivery modalities, some complex, with more than one rehabilitation
component and included physical activity, educational, behavioral, and symptom
management programs. With such heterogeneous methodology, it was concluded
that there is limited evidence on the efficacy of telerehabilitation in improving func-
tional activities, fatigue, and quality of life in adults with MS. The review also found
that evidence supporting telerehabilitation in the longer term for improved function,
impairment, quality of life, and psychological outcomes is poor. A very recent random-
ized trial38 provides higher-quality evidence that telerehabilitation is technically
 Telemedicine in Rehabilitation 477

feasible, desirable, and effective in improving gait and other outcomes in patients with
MS.
An ongoing study is evaluating the delivery of complementary and alternative med-
icine sessions at home to rural and low-income individuals with MS versus the same
intervention delivered in the clinic by a therapist.39
Traumatic brain injury
It has been shown that many people with traumatic brain injury (TBI) are interested in
accessing telerehabilitative services to assist with problems in memory, attention,
problem-solving, and activities of daily living.40 In addition, as their caregivers assume
increased responsibility for providing support, they receive limited access to services
leading to increased risk of anxiety and depression.41
Rietdijk and colleagues42 conducted a systematic review searching for interventions
delivered at distance with the use of technology, involving caregivers of adults and
children with TBI. They concluded that telehealth can be used to increase access to
services for families in rural areas, to train family members in the skills required to facil-
itate recovery after TBI, to provide appropriate and timely intervention for problems
arising at home, or to create a forum for peer support. Significant outcomes included
improved cognitive functioning of the person with TBI as well as psychological well-
being, support skills, and burden of caregivers. Several studies demonstrated that
participants reported training to be beneficial over the long-term after program
completion, and that improvements in outcomes were maintained over time.
A more recent systematic review by Ownsworth and colleagues15 aimed to deter-
mine whether telerehabilitation interventions are effective for improving outcomes
relative to usual care, alternative interventions, and baseline functioning. Of the modal-
ities described, telephone interventions focused on managing self-identified concerns
through tailored interventions, providing education and strategies for enhancing
cognitive skills and physical exercise, and encouraging compliance with prescribed
therapy, were most used. Of interest, Web-based platforms were rarely used
compared with other neurologic conditions, possibly because of TBI-related impair-
ments and dependence on caregiver assistance. Telephone-based interventions
were found to improve global functioning, posttraumatic symptoms, sleep quality,
and depressive symptoms for individuals with mild and moderate-to-severe TBI rela-
tive to usual care; however, the durability of these effects was either not demonstrated
or not examined by these studies.
Cardiac Telerehabilitation
Coronary artery disease
Cardiac rehabilitation has beneficial effects on morbidity and mortality in patients with
coronary artery disease (CAD); however, it is underused and short-term improvements
are often not sustained. Several randomized controlled trials13,14 have shown that tele-
rehabilitation provided positive results when compared with conventional hospital
rehabilitation. Of interest, these studies use a combination of communication technol-
ogies (Internet, video-consultation), on-demand coaching to encourage compliance,
and individually tailored coaching on both training intensity and physical activity.43
Frederix and colleagues14 have shown that a prolonged (1 year), Internet-based
comprehensive telerehabilitation program in addition to conventional cardiac rehabil-
itation is cost-effective, and can reduce cardiovascular rehospitalization.
Congestive heart failure
In a recent study by Hwang and colleagues,44 patients with stable congestive heart
failure were randomized to 12 weeks of real-time exercise and education intervention
478 Galea

using online videoconferencing software versus a traditional hospital-outpatient pro-

gram. The group-based video telerehabilitation program was noninferior to an outpa-
tient rehabilitation program and promoted greater attendance yielding few adverse
effects. These findings confirm previous reports45,46 that telerehabilitation is a safe
care delivery modality. Similarly, Nouryan and colleagues47 conducted a randomized
controlled trial, studying Medicare outpatients with heart failure after discharge from
home care for 6 months. Patients were randomized to home telehealth or comprehen-
sive outpatient management. The telehealth intervention consisted of weekly televisits
and daily vital signs monitoring. The results showed that the telehealth intervention
group improved all causes of emergency department utilization, length of stay, and
quality of life. A trend toward cost savings was reported in the telehealth intervention
group; however, it did not reach statistical significance.

Musculoskeletal
Orthopedic care provides a fertile ground for the utilization of telerehabilitation in an
aging population prone to osteoarthritis. In fact, procedures involving the musculo-
skeletal system are among the most common in the United States.48 These interven-
tions are paired with a rehabilitation program aimed at maximizing functional outcome.
A recent systematic review49 identified several studies in which postsurgical telere-
habilitation programs were implemented after total knee arthroplasty,50 total hip
arthroplasty,4 and upper limb and hand surgeries.51 Methods of administration
included real-time videoconferencing, asynchronous programs, telephone follow-
up, and interactive virtual systems. The investigators found strong evidence in favor
of telerehabilitation in patients following total knee and hip arthroplasty and limited ev-
idence in the upper limb interventions. Another review by Cottrell and colleagues52
analyzed evidence exclusively for the use of real-time telerehabilitation for the treat-
ment of musculoskeletal conditions. The investigators concluded that there was
strong evidence that the management of musculoskeletal conditions via real-time tele-
rehabilitation is effective in improving physical function, disability, and pain. At least
one study has been proposed to study the delivery of a pre-habilitation program in sur-
gical candidates awaiting total hip or knee arthroplasty, to address the reported long
wait times before surgery.53 Results are pending.
Occupational therapists often assess a patient’s home for safety before discharge
as part of their role in acute care and rehabilitation teams.54 When the evaluation
cannot be completed in a timely manner, delays in discharge and increased length
of stay ensue, or the patient is discharged without the assessment, potentially leading
to an increased risk of early readmission. The World Federation of Occupational Ther-
apists has published a position statement on the use of telehealth to improve acces-
sibility to occupational therapy. Telehealth has been suggested as an effective and
reliable way to access home modification services.55 Nix and Comans5 described
an initiative to improve the timeliness of occupational therapy home visits for
discharge planning by implementing technology solutions while maintaining patient
safety. The project demonstrated that on-site home visits can be safely and efficiently
performed or augmented using technology. The study also highlighted the positive
impact of the project on the occupational therapy department productivity.

Chronic Pain
Chronic pain is a major public health problem, which is expected to increase as the
population ages. Physical training has been proven to decrease pain and improve
function56 and therefore plays an important role in current pain rehabilitation pro-
grams. Improvements in chronic low back pain seen in physical therapy do not appear
 Telemedicine in Rehabilitation 479

to be retained over the long term, providing an opportunity for telerehabilitation ser-
vices to provide continuity and ensure sustainability.57
Patients with chronic pain were favorable to an “intermediate” telerehabilitation pro-
gram offering feedback and monitoring technology with some face-to-face consulting
and exercise location.58 However, Adamse and colleagues59 conducted a systematic
review of exercise-based telemedicine in patients with chronic pain and found no dif-
ference compared with usual care on physical activity, activities of daily living, and
quality of life.
Telerehabilitation interventions have proven to be beneficial to retain improvement
in low back pain and increase attrition, respectively, via booster sessions delivered
through a mobile phone application57 and videoconferencing.60
For patients with chronic knee pain, an Internet-delivered, physiotherapist-pre-
scribed home exercise and pain-coping skills training provided clinically meaningful
and sustained improvements in pain and function.61
Virtual complementary and integrative health modalities, such as yoga and tai chi
sessions, to treat chronic pain are being investigated.

Rheumatology
A recent systematic review62 shows that telemedicine has been applied to the field of
rheumatology in the form of remote consultations, monitoring of treatment strategies,
and Web-based self-management programs. Some of the chronic conditions treated
include rheumatoid arthritis, systemic sclerosis, fibromyalgia, osteoarthritis, and juve-
nile idiopathic arthritis. Types of intervention have included remote disease activity
assessment, tele-monitoring of treatment strategies, and information communication
technology–delivered self-management programs.
In the application of tele-consultation, it was concluded that this modality resulted in
high patient satisfaction rates, albeit lacking in diagnostic accuracy. Internet-delivered
programs revealed high feasibility and satisfaction rates, although effectiveness data
lacked homogeneity. Remote monitoring programs were also well received by pa-
tients. Cost-effectiveness needs to be evaluated, as readmission rates were higher
in patients on tight control and treat-to-target approaches. Self-directed kinesiother-
apy sessions were effective in improving hand function after drug-induced remission.
In a recent study by Pani and colleagues,63 the patients reported increased motiva-
tion and greater engagement of the medical staff in their therapy when using an ad hoc
telerehabilitation platform. Although the investigators did not perform a formal cost
analysis, they concluded that the proposed solution appeared to be cost-effective
compared with face-to-face therapy sessions.

SUMMARY

Studies have provided evidence that telerehabilitation is well received by patients

whether applied alone or to supplement conventional therapy; it does not add burden
to the caregiver; it is advantageous for patients recovering from motor deficits, higher
cortical dysfunction, and depression after stroke; and to recover after hip and knee
arthroplasty.
Lack of methodological rigor and variability of approaches used in telerehabilitation
studies to date hinder the ability to conclude that telehealth services can and should
be deployed more broadly in the delivery of rehabilitation.
Larger, well-powered, longer-term studies are needed to provide definitive evidence
and establish the indications and limitations of telerehabilitation utilization in the treat-
ment of acute and chronic conditions.
480 Galea

There is a need for best practices that are consistent across all types of telehealth
services for all health care providers. In this rapidly evolving field, existing research
may not reflect the most recent developments in practice or technology and best prac-
tice may be moving ahead of the research reported in publications.
Strong, evidence-based telerehabilitation methodologies together with best prac-
tices will provide the matrix to create effective services that can be both delivered
by health care structures and reimbursed by health insurance providers.

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