The science and practice of telehealth have undergone rapid growth in recent years. A search of the Web of Science for the term ‘telehealth’ would have returned only two papers in 1995, compared with 104 papers in 2000, and 5069 papers in June 2017. This exponential growth is also evident in the number of randomised, controlled trials and systematic reviews indexed in the Physiotherapy Evidence Database with ‘telehealth’ in the title, rising from 10 records in 2008 to 70 records in 2017. These papers span the breadth of physiotherapy practice, with particularly strong representation from musculoskeletal and cardiorespiratory physiotherapy (Figure 1). High-quality randomised, controlled trials that support the benefits of telehealth interventions in many physiotherapy subdisciplines have been published over recent years. These have included telephysiotherapy interventions for chronic knee pain,1 non-specific low back pain,2 chronic obstructive pulmonary disease (COPD),3 heart disease,4 breast cancer,5 joint arthroplasty,6 and urinary incontinence.7Many of these studies have demonstrated significantly better clinical outcomes than usual care that did not include physiotherapy, including improved exercise capacity, better physical function, reduced symptoms and enhanced health-related quality of life.
Telephysiotherapy can take many different forms, with the components driven by the goals of treatment. Videoconferencing provides direct contact between patients and physiotherapists, either one-to-one1 or in a virtual group setting.3 For some telephysiotherapy programs (eg, pulmonary rehabilitation, stroke rehabilitation) it may be necessary to perform a limited number of home visits, in order to perform assessments or provide instruction in the use of equipment.3, 8 However, some telephysiotherapy programs are delivered entirely from a distance, without ever meeting the patient in person, including notable examples of successful treatment of stress urinary incontinence using email support7 and a mobile app.9 Telephysiotherapy programs may include remote monitoring of physiological signals, such as pulse rate, oxygen saturation, electrocardiograms (ECG), and joint range of movement, in specific populations such as cardiorespiratory or orthopaedic disease.4, 10, 11Whilst some telephysiotherapy models require specially designed equipment,6, 11 others have achieved similarly successful outcomes with off-the-shelf consumer devices and software.1, 3 The ubiquitous nature of the smartphone provides new opportunities for telephysiotherapy, including: physical activity monitoring; sound and light cues to set exercise intensity and duration; real-time feedback on exercise performance; and text messaging to provide exercise advice or progression.10, 12 Simple web-based diaries can be used to record exercise and provide feedback.12 Didactic or interactive education programs can also be provided.1 In some populations it may be possible to automate aspects of a telephysiotherapy program to provide efficient and effective care to large patient populations, for instance using internet platforms that provide automated goal setting and feedback in conjunction with a pedometer for patients with non-specific low back pain.2
The increase in our capacity to deliver physiotherapy at a distance using telehealth has occurred at the same time that ‘hands-on’ physiotherapy techniques have become less important for some health conditions. For example, electrotherapy is no longer recommended for routine treatment of low back pain,13 whereas exercise therapy is an important component of care.14 Interventions designed to increase physical activity and physical fitness now have an important role in physiotherapy management for numerous clinical groups and across the lifespan, recognising the critical impact of these factors on long-term health outcomes.15 Many of these interventions, which typically involve goal setting, exercise prescription and self-management training, do not require hands-on therapy and are highly amenable to telephysiotherapy.
Despite the potential for telehealth to increase the capacity of the health system and deliver better health outcomes, there has been relatively slow uptake in practice. Enthusiasm has been tempered by the lack of clinically relevant benefits seen in some large-scale randomised trials involving people with chronic diseases such as heart failure and COPD;16, 17, 18 however, these trials relied heavily on telemonitoring of physiology and symptoms, rather than on delivery of therapy. Remote monitoring has not delivered consistent benefits over usual care, perhaps because it is difficult to maintain long-term adherence with monitoring, or the difficulty in identifying meaningful changes in monitored variables. Trials in telephysiotherapy, which typically involve delivering a treatment from a remote location, have generally been more successful, producing similar results to interventions that are delivered face to face. For instance, in 205 patients who had undergone knee arthroplasty, in-home rehabilitation delivered by videoconference demonstrated equivalent outcomes for pain, stiffness and function when compared with face-to-face rehabilitation.6 Similarly, in 152 people with heart failure, cardiac rehabilitation with exercise prompts and ECG monitoring transmitted via a mobile phone produced similar benefits to a traditional outpatient cardiac rehabilitation program.10 A key feature of these successful telephysiotherapy interventions is that they delivered treatments of known effectiveness in a different way, using technology to reach patients who are located away from healthcare facilities. […]