To investigate the efficacy of telehealth-based and in-person social communication skills training (TBIconneCT) for people with moderate to severe traumatic brain injury (TBI) based on outcomes reported by the survivor and a close communication partner.
Australia. Two telehealth dyads were located outside Australia.
Adults (n = 51) at least 6 months after moderate-severe TBI with social communication skills deficits, and their usual communication partners (family members, friends, or paid carers).
Partially randomized controlled trial, with a telehealth intervention group, in-person intervention group, and a historical control group.
La Trobe Communication Questionnaire (LCQ) (total score, and number of items with perceived positive change). Both self- and other-reports.
Trained participants had significantly more items with perceived positive change than did historical controls. A medium effect size in the sample was observed for improvements in total score reported by trained communication partners after treatment. Comparisons between telehealth and in-person groups found medium to large effect sizes in the sample, favoring the telehealth group on some LCQ variables.
Whether delivered via telehealth or in-person, social communication skills training led to perceived positive change in communication skills. It was unexpected that outcomes for the telehealth group were better than for the in-person group on some variables.
TRAINING COMMUNICATION PARTNERS is best practice in providing intervention for cognitive communication impairments after traumatic brain injury (TBI).1 Providing communication partners with skills to enable effective conversations creates a more positive daily communication environment for people with a TBI. Training focuses on addressing negative patterns that communication partners may use in conversations with people with TBI, such as failing to follow up on the person’s contributions, not giving enough information to support the person’s comprehension, using questions designed to test the person’s memory rather than asking for meaningful information, and querying the person’s accuracy.2 The aim of training is to facilitate collaborative interactions between people with TBI and communication partners.3 The TBI communication partner training program with the highest level of evidence is TBI Express.4 This program has been shown to improve the quality of conversations5,6 and self-reported communication outcomes.7
TBI Express is an intensive program, involving 35 hours of intervention consisting of a combination of group sessions and dyad sessions (attended by both the person with TBI and their communication partner). This makes it difficult to implement TBI Express in full, given limitations on clinician time.8 Availability of families is a further barrier to accessing training, given factors of distance from rehabilitation services9 and competing time demands.10 The TBIconneCT program is a reduced-intensity version of TBI Express involving 15 hours of intervention over 10 sessions with the option for in-person or telehealth delivery. Each session involves the person with TBI and their communication partner attending together. TBIconneCT has shown positive outcomes using telehealth delivery with 2 participants in a single case experimental design study.11 To further investigate the effectiveness of TBIconneCT, a clinical trial was conducted. This trial had 3 arms: in-person TBIconneCT training, telehealth TBIconneCT training, and a historical control group.
The current study reports on a secondary outcome measure from this previously reported trial of TBIconneCT.12 The previous report addressed the primary outcome measure of conversational quality using the Adapted Measure of Support in Conversation (Reveal Competence scale)13 based on ratings from a blinded assessor. The secondary outcome measure reported in the current study evaluated the impact of the training on communication problems from the perspectives of the most important stakeholders: people with TBI and their usual communication partners.14 The La Trobe Communication Questionnaire (LCQ)15 is the secondary measure analyzed in the current article. Although level of insight will affect participants’ reporting, the LCQ has been shown to be a valuable tool that is sensitive to change, and it has been recommended as a supplemental outcome measure in TBI research.16
The research questions for the current study were:
(1) Is TBIconneCT training more efficacious than no training in improving LCQ outcomes as rated by people with TBI and their usual communication partners?
For the purposes of this question, the group of trained participants (formed by combining in-person and telehealth participants into a single group) was compared with the group of historical control participants.
(2) What is the magnitude of any difference in LCQ outcomes between telehealth and in-person training?
The sample size of this trial was not large enough for a noninferiority design. This question is therefore exploratory in nature.[…]
A physical therapist guides a patient through an exercise directed at treating pain symptoms in the leg.
By Taylor C. Kucera, PT, DPT, MBA, SCS, CSCS, and Chris Chalko, PT, DPT, COMT, OCS
Telehealth may be a new term to some, but it has been around since the early 2000’s. The American Physical Therapy Association (APTA) defines telehealth as the use of electronic information and telecommunication technologies to remotely provide health care information and services.1 Telehealth was originally designed to provide physical therapy services to underserved populations in rural areas and those with limited access to treatment. Most recently, telehealth has added “global pandemic” as one of its reasons for current widespread implementation. The threat of COVID-19 has patients living in uncertainty, with many self-isolating in their homes, and is disrupting daily life. To help curtail those fears, companies have recently begun using telehealth as an option to treat patients in an attempt to help add some sense of normalcy to society.
AN EFFECTIVE MEANS FOR DELIVERING THERAPY
Telehealth for physical therapy gives patients access to a healthcare professional in their own homes. A physical therapist (PT) can provide patients with personalized treatments through a variety of services. Some services include live “face-to-face” interaction with real-time audio and video, while other forms involve “store and forward” technology that allows for prerecorded information to be viewed at a later date. The option of virtual physical therapy sessions allows the patient to maintain maximum continuity in their care. Levy et al performed a retrospective, pre-post study using clinical data from the Rural Veterans TeleRehabilitation Initiative and concluded that telehealth provides a significant and meaningful improvement in patients’ physical and cognitive functioning as well as health-related quality of life.2
MEDICARE AND MANUAL THERAPY?
A response from the Centers for Medicare and Medicaid Services (CMS) during the COVID-19 outbreak made it easier for health practitioners to provide remote care for patients during periods of quarantine and statewide shelter-in-place orders. Under the Section 1135 waiver authority, CMS has allowed doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers to be reimbursed for telehealth sessions.3 Reimbursement and legality differ from state to state as well as between Medicare and commercial insurances. It would be wise to research one’s specific state rules and regulations to stay compliant with individual state standards.
The number one criticism of telehealth is the omission of manual therapy from the plan of care. As physical therapists, we all understand that skilled manual therapy is a service that sets us apart from other health care providers. Increasing amounts of research have outlined the importance and positive effects of human touch on a patient’s emotional investment in therapy, pain reduction, and overall satisfaction. Though a telehealth session may lack information a therapist gathers from the nonverbal body language and physical interactions that would normally be gained from an in-clinic visit, there are other factors that a therapist can rely on to still achieve the patient’s goals. In order to still maintain the human element, the therapist will need to use his/her knowledge, expertise, and ability to concisely articulate educational instructions to create a personal and interactive experience to reinforce positive habits in order to successfully complete a personalized plan of care that provides lasting relief.
EQUIPPING THE HOME-BASED THERAPY PATIENT
Another one of the biggest perceived challenges to successful telehealth is patients’ access to exercise equipment, which may be limited since they are at home rather than in a clinic. In truth, there are a multitude of exercises that can be done with minimal equipment while still yielding great results. However, patients who do invest in additional equipment can greatly expand their repertoire of exercises and increase results. Recommended equipment for patients to purchase should be both versatile and affordable to provide them with maximum value. Equipment that can meet these demands has a better chance to become an integral part of a patient’s exercise plan after treatment to maintain their health. ATI Physical Therapy, which has been offering telehealth services since March 2020, advises therapists to recommend to their patients an investment in the following equipment to make the most of remote therapy:
• Resistance bands: An easy and inexpensive option for patients to perform a variety of resistance-based exercises at home. CanDo exercise bands by Fabrication Enterprises, White Plains, NY, is one of the brands utilized in ATI’s clinics, and whose brands are latex free and separated by color to denote their elasticity and difficulty. Resistance bands are especially useful because they are stocked in almost every physical therapy clinic and can be distributed to a patient at their initial evaluation or even mailed to them prior to their telehealth sessions. • Sport cords: A more “deluxe” version of resistance bands and some versions of this product include handles for upper extremity activities, loops for knee or hip exercises, or cuffs for resisted multiplanar joint movements. One of ATI’s preferred brands for this type of product is SPRI Products Inc, Libertyville, Ill, whose cords are utilized in clinics daily. They provide greater resistance and tend to be more durable than resistance bands and are more appropriate for higher-level patients who are progressing toward the end of their plan of care. Because of their variable resistances, sport cords are a better cost- and space-saving option for patients when compared to purchasing multiple pairs of dumbbells. • Stretching Tool: Another excellent product for telehealth is the Stretch Out Strap by Orthopedic Physical Therapy Products (OPTP), headquartered in Minneapolis. This strap can be a good alternative for when therapists are not able to manually stretch their patients. It has multiple loops sewn along a long strap, allowing it to accommodate all levels of flexibility. The strap assists in providing overpressure, creating different angles of pull, and extending the lever arm to help stretch multiple body parts at sub noxious levels. It is also relatively inexpensive, making it an affordable option for patients to purchase.
There are also other pieces of equipment that a patient might have in their home that could be useful at key points in the session. Three commonly found home exercise equipment pieces might be a treadmill, a stationary bike, or a rower. While not required, an effective way for anyone to warm up before any type of activity could be a brisk walk on a treadmill, a 500-meter row on a rowing machine, or a 10-minute warm-up on a stationary bike. Therapists should advise each patient if this type of activity would be useful prior to the session beginning. Some of the more popular home brands of this type of equipment include NordicTrack T-series treadmills based in Logan, Utah; Life Fitness C3 Go Upright Lifecycle, based in Rosemont, Ill; and Sunny Magnetic Rowing Machine Rower, based in City of Industry, Calif. It is important to be properly fitted for any home exercise equipment and follow the instruction manual before use to avoid injury.
Product Resources:The following companies offer products that can be used for fitness and exercise programs of all types:
One of the more challenging exercises to properly teach patients through a telehealth session doesn’t even actually require any equipment. The exercise is called abdominal bracing and is performed by the patient correctly initiating a contraction of the transverse abdominis muscle. The transverse abdominis is the deepest abdominal muscle and wraps around the trunk, providing protection and stability. It is an important exercise to master because it is used in conjunction with a multitude of other upright, loaded functional tasks.4 Being the deepest abdominal muscle, most often it is necessary for the therapist to provide tactile cues and feedback by placing his/her hand over the area to confirm contraction of the correct muscle.
However, telehealth physical therapists do not have the luxury of using tactile cues and therefore need to rely on other means of coaching. Therapists must get creative and adapt their instructional cueing. A few ways to elicit the appropriate patient responses are through visual cues such as diagrams displaying the target muscle and videos or personal demonstrations to mirror precise technique. In this situation, sight becomes the therapist’s main tool and, therefore, places a greater reliance on appropriate lighting and camera positioning.
ATI Physical Therapy utilizes a telehealth platform that is extremely user-friendly. Virtual sessions can be initiated by simply clicking a link, which makes connecting with a therapist clear and straightforward even for less tech-savvy individuals. Through a library of pre-recorded videos, the platform provides both visual and verbal demonstrations of exercises that can be easily shown to patients. Additional features include time length estimations of how long virtual sessions last, the patient’s option to toggle on/off the therapist’s camera, and technology using body landmarks to collect measurements during initial evaluations, progress notes, and discharges. ATI has gradually deployed its telehealth services nationwide, with plans to expand to additional clinics in each state over the course of this year.
HERE TO STAY
Telehealth is a relatively novel, but ever-expanding, portion of physical therapy that has gained recent attention because of the effects of the COVID-19 pandemic. The pandemic has caused many healthcare providers to re-evaluate current models of distributing services, which opens the door for telehealth to play a more vital role in patient care. It is imperative that physical therapists be flexible and innovative in providing the patient with resources and the necessary equipment to make remote telehealth sessions a success. PTP
Taylor C. Kucera, PT, DPT, MBA, SCS, CSCS, is a physical therapist at ATI Physical Therapy in Las Vegas, where he is the clinic director specializing in sports rehabilitation. Kucera graduated from the Nova Southeastern University Physical Therapy Program in 2015 and the MBA Program from the University of Nevada, Las Vegas in 2019.
Chris Chalko PT, DPT, COMT, OCS, has been an outpatient orthopedic and sports physical therapist for ATI Physical Therapy for more than 10 years. He has taught clinical skills courses, mentored students and clinicians, and consults and screens for high school athletes in his community. Chris graduated from Elon University and has been practicing since 2009. For more information, contact PTPEditor@medqor.com.
Levy C, Silverman E, Jia H, Geiss M, Omura D. Effects of physical therapy delivery via home video telerehabilitation on functional and health-related quality of life outcomes. JRRD. 2015;52(3):361-370.
Centers for Medicare and Medicaid Services. Telehealth Services MLN Booklet. Medicare Learning Network.
Mcpherson SL, Watson T. Training of ransversus abdominis activation in the supine position with ultrasound biofeedback translated to increased transversus abdominis activation during upright loaded functional tasks. PM&R: The Journal of Injury, Function, and Rehabilitation. 2013. Available at: https://doi.org/10.1016/j.pmrj.2013.11.014.
This editorial introduces another of Journal of Physiotherapy‘s article collections.1,2 The studies in this article collection relate to telephysiotherapy. Telephysiotherapy can take many forms such as telemonitoring, telecoaching and telerehabilitation.
Telemonitoring is an automated process of data transmission about a patient’s physiological status (such as oxygen saturation and blood pressure) and clinical symptoms (such as dyspnoea and pain) from the home to the healthcare provider.3 In a Cochrane review, telemonitoring and structured telephone support have been shown to reduce the risk of all-cause mortality and heart failure-related hospitalisations, as well as improve health-related quality of life and self-care behaviours.3 The study by Rathleff et al4 progresses our understanding of monitoring exercise adherence in adolescents with patellofemoral pain. The innovative monitoring system they describe (consisting of an in-built sensor attached to an elastic resistance band and connected to a tablet) provided physiotherapists and patients with information on exercise dosage (such as time under tension and number of repetitions and sets) and pain intensity before and after each exercise during the unsupervised training. Interestingly, study participants only achieved 15% of the prescribed exercise dosage, confirming that self-reported diaries overestimated adherence.4 The authors suggested that this monitoring system could promote exercise adherence and assist physiotherapists to adjust the exercise dosage.4
Another study in this collection is on telecoaching, which can be used to provide in-home support or advice via motivational text messaging and phone coaching to help patients take greater responsibilities for the achievement and maintenance of treatment goals. Iles et al5 present a randomised controlled trial on the effects of phone coaching in patients with non-chronic, non-specific, low back pain. The coaching sessions encompassed identification of the patient’s readiness to change, motivational interviewing and goal setting. These authors reported that five coaching sessions added to usual physiotherapy improved both activity levels and recovery expectations at 12 weeks.5
Several studies in this article collection relate to telerehabilitation, which is the delivery of rehabilitation services at a distance via telecommunication technology such as phone, videoconferencing and the internet.6 In addition to telemonitoring, this approach enables clinical assessment and implementation of treatment. There has been a recent proliferation of literature investigating the effects of telerehabilitation in the management of health conditions such as stroke,6 musculoskeletal conditions7 and chronic diseases. Chien et al8 extended the evidence for phone-based telerehabilitation in patients with heart failure. In this study, participants in the intervention group were encouraged to undertake home-based strengthening exercises combined with walking for at least 30 minutes per session, three sessions per week, over 8 weeks. Participants received phone follow-up every 1 to 2 weeks to monitor progress, provide feedback and solve problems. These authors demonstrated improved quality of life and functional exercise capacity in the experimental group compared with a control group who maintained usual activities.8 Similarly, a 12-week exercise-based rehabilitation program delivered by videoconferencing has also been shown to be non-inferior to a traditional centre-based program in terms of functional exercise capacity but had higher attendance rates in patients with heart failure.9 These results indicate that videoconferencing has the benefit of providing direct supervision of a group-based exercise program and enabling real-time audiovisual feedback. Importantly, outcomes from both of these studies were achieved using readily available off-the-shelf equipment (such as telephone, laptop computer, videoconferencing software, automatic sphygmomanometer and pulse oximeter), which boosts their translation into the clinical settings.
Participation in a telerehabilitation program requires the patients to access and use technological devices such as smartphones, computers and tablets with a good internet connection. However, it is unclear if patients, especially those in cardiopulmonary rehabilitation programs, are technology engagers. Seidman et al10 presented an Australian survey that significantly advances understanding of the acceptability of telerehabilitation. Of 254 patients attending metropolitan pulmonary rehabilitation, 92% were classified as technology engagers (personal access to and use of at least one technological device in their home), and participants cited enhanced therapy and convenience as motivators to participate in telerehabilitation.10 The reported ability of pulmonary rehabilitation attendees to engage with technology was later confirmed in the study by Bonnevie et al.11 In this study of 105 adults with chronic respiratory disease who were referred to pulmonary rehabilitation, all could quickly learn to operate a Bluetooth pulse oximeter during home exercise.11 Almost all of the study participants also considered this monitoring equipment to be acceptable and the oximetry data were transmitted with a minimal artefact or invalid data.11 This is particularly welcome evidence, as the uptake of telerehabilitation requires patients to engage with the technology and associated monitoring equipment.
The remaining articles in this collection relate to general considerations for implementing telephysiotherapy. A key consideration for patients receiving telephysiotherapy is outcome assessment, including functional exercise capacity. Given the space constraints within the home environment, physiotherapists may be tempted to undertake a 6-minute walk test on a shorter track than the recommended guidelines. However, in a study by Beekman et al,12 shorter distances were achieved with a 10-metre track compared with the standard 30-metre track in patients with chronic obstructive pulmonary disease. These authors warned that the results obtained with a shorter track should be interpreted with caution, as studies on prognosis and normative values were generated through tests on longer tracks.12
The growing number of technologies also pose important considerations for physiotherapists. For instance, do mobile applications, virtual reality programs and wearable devices used in telephysiotherapy constitute medical devices and, if so, are they subject to regulatory approval? Physiotherapists have responsibilities in developing and recommending mobile applications or console games as a medium for therapy. To illustrate these responsibilities, Professor Trevor Russell and Anne Jones expertly discussed several scenarios in Tables 1 and 2 of their editorial.13
On a positive note, there are emergent opportunities to deliver physiotherapy services into the home via telehealth, in light of the technology advances and ubiquitous nature of the internet. Telephysiotherapy has the potential to overcome transport barriers reported in traditional centre-based rehabilitation programs. For instance, in an extensive literature review, Cox et al14 summarised a range of barriers to pulmonary rehabilitation, with the most frequently represented domain being ‘environment’ which included travel, transport and healthcare system resources. These findings reinforce the growing need for alternative models such as telephysiotherapy.
Furthermore, telephysiotherapy has the potential to distribute physiotherapists’ expertise to more patients across a wider geographical area. This provides an opportunity to augment existing services and expand services to meet the needs of new patients. This is vital for rural and remote regions that have difficulties in accessing traditional physiotherapy services but will also benefit metropolitan areas by alleviating transport barriers and fostering a more flexible delivery model. Telephysiotherapy also offers patients an opportunity to receive physiotherapy services in the comfort of their own homes, while supporting physiotherapists to monitor and progress the intervention. Fortunately for readers of Journal of Physiotherapy, Professor Anne Holland’s editorial provides some wise insights into telephysiotherapy.15
The extraordinary situation of the coronavirus disease 2019 (COVID-19) pandemic is leading to the rapid adoption of telephysiotherapy, as this delivery model may improve access and minimise cross-infection risk to patients. In addition to the papers in this article collection, some useful resources to guide telephysiotherapy have been compiled on the PEDro website.
This extraordinary situation is providing an unprecedented ‘natural experiment’ in our healthcare services by relaxing some system barriers. This provides an ideal opportunity to explore the feasibility and acceptability of integrating telephysiotherapy into routine service delivery. The experimental experience may inform future planning such as investment opportunities when resuming usual practices.
In summary, this article collection includes a range of important developments in telephysiotherapy. The studies in this article collection present evidence on telemonitoring, telecoaching, telerehabilitation and some general considerations for implementing telephysiotherapy. The limited research in long-term outcomes and cost-effectiveness warrants further research in the area. It may also be necessary to identify which subgroup of patients will most likely benefit from telephysiotherapy. Importantly, each clinical trial paper has clear implications for physiotherapists, which are highlighted in the paper’s ‘What this study adds’ summary box.
Background: Stroke is the leading cause of serious long-term disability in the United States. Barriers to rehabilitation include cost, transportation, lack of trained personnel, and equipment. Telerehabilitation (TR) has emerged as a promising modality to reduce costs, improve accessibility, and retain patient independence. TR allows providers to remotely administer therapy, potentially increasing access to underserved regions.
Objectives: To describe types of stroke rehabilitation therapy delivered through TR and to evaluate whether TR is as effective as traditional in-person outpatient therapy in improving satisfaction and poststroke residual deficits such as motor function, speech, and disability.
Methods: A literature search of the term “telerehabilitation and stroke” was conducted across three databases. Full-text articles with results pertaining to TR interventions were reviewed. Articles were scored for methodological quality using the PEDro scale.
Results: Thirty-four articles with 1,025 patients were included. Types of TR included speech therapy, virtual reality (VR), robotic, community-based, goal setting, and motor training exercises. Frequently measured outcomes included motor function, speech, disability, and satisfaction. All 34 studies reported improvement from baseline after TR therapy. PEDro scores ranged from 2 to 8 with a mean of 4.59 ± 1.94 (on a scale of 0-10). Studies with control interventions, randomized allocation, and blinded assessment had significantly higher PEDro scores. All 15 studies that compared TR with traditional therapy showed equivalent or better functional outcomes. Home-based robotic therapy and VR were less costly than in-person therapy. Patient satisfaction with TR and in-person clinical therapy was similar.
Conclusions: TR is less costly and equally as effective as clinic-based rehabilitation at improving functional outcomes in stroke patients. TR produces similar patient satisfaction. TR can be combined with other therapies, including VR, speech, and robotic assistance, or used as an adjuvant to direct in-person care.
Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial.Cramer SC, Dodakian L, Le V, See J, Augsburger R, McKenzie A, Zhou RJ, Chiu NL, Heckhausen J, Cassidy JM, Scacchi W, Smith MT, Barrett AM, Knutson J, Edwards D, Putrino D, Agrawal K, Ngo K, Roth EJ, Tirschwell DL, Woodbury ML, Zafonte R, Zhao W, Spilker J, Wolf SL, Broderick JP, Janis S; National Institutes of Health StrokeNet Telerehab Investigators.JAMA Neurol. 2019 Jun 24;76(9):1079-87. doi: 10.1001/jamaneurol.2019.1604. Online ahead of print.PMID: 31233135 Free PMC article.
The resources on this page have been collected for use by stroke care and rehabilitation professionals to provide telehealth services due to COVID-19 isolation or social distancing.
This web page contains links to information and materials and other content that might assist health professionals work and consult remotely with people with stroke, and with people with stroke who may have been discharged prior to completing their full rehabilitation programs.
The linked information, materials and other content on this web page has not been created, produced or endorsed by the Stroke Foundation.
The linked information, materials and other content on this web page is not intended to replace a health professional’s own professional judgement and decision-making.
The Stroke Foundation shall not bear any liability for reliance by any user on the linked information, materials and other content on this web page.
Synapse Medical has a free blog that answers questions about COVID-19 numbers. FAQs are also available, and questions can be posted.
Communication tools for people with aphasia
Accessible healthcare communication materials and resources may be needed by people with aphasia and/or cognitive difficulties. The Centre for Research Excellence in Aphasia Rehabilitation and Recovery have put together a repository of materials, including in languages other than English, and they will continue to update it. Open either the PDF or the Excel document to find all the links. Key information includes:
General public health information about COVID-19
Pictographics relating to COVID-19, to support communication
Supported communication training for health professionals, to enhance their communication with people with aphasia
Wellbeing, peer support and social connection
Adapting aphasia assessments
Technology and telerehabilitation, with aphasia-friendly resources for using web-based platforms.
As healthcare professionals transition to telerehabilitation, it may seem too challenging to include people with aphasia. However, it is absolutely possible and should be promoted.
Telehealth for patients, carers and other providers, with Resources for patients (4 min. video with subtitles) about how to link to a telehealth provider (note this is specific to NSW Health); and Telehealth etiquette for patients and carers (2 min. read).
NeoRehab telerehabilitation platform eHAB, designed specifically for allied health telerehab services. It contains tools for measurement, data capture, interactive media capabilities, and can do multi-point calls – all of which are often necessary for rehabilitation services. The platform has the necessary security features that health services demand. Training in how to use eHAB is available. The designer of this system, Prof. Trevor Russell, is happy to support teams to get set up with the system. Contact firstname.lastname@example.org
Video consultation guide for GP practices, a blog post that includes tips for high quality consultations, but is mostly COVID-19 diagnosis related. There is also a PDF document you can scroll through without having to download, which gives references for telehealth effectiveness.
Australian Physiotherapy Association’s webinar series on telehealth is freely available, with a Q&A about how to make a rapid transition. Additionally, the Australian Physiotherapy Neurology Group has a Facebook group you can request to join, where lots of members are sharing ideas and resources. You do not need to be an APA member, but you do need to be a physio and it may take a day or two for the moderator to get you linked in.
Register for free UTS telepractice webinars for rapid transition during COVID-19. SPROUTS Clinic (Speech Pathology Reaching Out at UTS) is not just reaching out to speech pathologists during COVID-19 – they’re reaching out to all disciplines, health professionals, schools and health services caught up in the disruption to allied health services. The webinar is held fortnightly through April/May 2020 depending on demand, to support services Australia-wide in their rapid transition to implementing telehealth-related telepractice. Clinicians in other countries are welcome to attend, but time zones are made to suit UTS staff living in Sydney and NSW, Australia. The examples provided relate to speech pathology but can be easily applied to learning across any health discipline. Webinars will not be recorded. The main benefit in attending is the active learning model enabling engagement and interaction between the participants and with the teachers.
Free webinar: The role of Telehealth in curbing the COVID-19 Epidemic. Five expert panellists will share practical strategies for health professionals, including lessons from their own journeys and insights to how COVID-19 might change the way we use technology to deliver healthcare in the long-term. Register now for the webinar on Thursday 23 April 2020, 12–1 pm AEST.
Virtual conference 24 April 2020 – From the Frontlines: A Covid-19 Special Event (CPD points apply). The Australian Institute of Digital Health has brought together local and international professionals to discuss the critical role of technology innovation, data innovation, telehealth and virtual care. Attend live on Friday 24 April, or register and get access to watch the conference later, as well as get a month’s access to Digital Health TV – a collection of hundreds of videos and presentations about telehealth and digital healthcare innovation.
Bridges Self Management team have collated some of their evidence-based resources for self management. As they say, “if there was ever a time for good self-management support, it is now.”
iWalkAssess app from the University of Toronto provides instructions and tools to facilitate measuring walking speed and a 6-minute walk test. It includes automatic comparison to normative data and functions for goal setting. It is not designed for use via telehealth, but could possibly be adapted and may be a useful tool for novice clinicians.
Telepractice Dysphagia Assessment Service is an e-learning program for establishing and conducting adult clinical swallowing evaluations via telepractice. it has separate packages for Speech Pathology Managers implementing telepractice services, and for training clinical speech pathologists and healthcare support workers. The model of care described in this program was developed, tested and validated through research conducted by the Centre for Research in Telerehabilitation at The University of Queensland, and the Speech Pathology & Audiology Department at The Royal Brisbane & Women’s Hospital.
To access the Telepractice Dysphagia Assessment Service as a non-QHealth clinican, you first need to register for the iLearn website following the instructions in iLearn user help for external (PDF). Once your registration is processed, log into iLearn, go to the Course Catalogue, and search for “Telepractice”. Click on the link for the course (AHPOQ-R) Telepractice Dysphagia Assessment Service.
In addition to other resources below, physiotherapyexercises.com has a range of exercises on file that can be prescribed using a mobile option – and it’s free. There is a link to a 9-min video “how to guide” for the mobile version – look for “New Mobile Functionality” on the home page. It is also available in several different languages.
REPS Recovery Exercises app consists of video-guided, post-stroke exercise programs, including TASK. The aim of TASK is to help people after stroke to exercise at home, on an ongoing basis. People can practice everyday tasks, such as sitting, standing, stepping and standing up. It was designed to improve and/or maintain strength and mobility, as well as encourage people after stroke to be more physically active. TASK is also available as a web-based program.
Clock Yourself app is for balance training. It contains five stages that introduce progressively complex activities to train balance – very good for high-level balance exercises and dual tasking. Cost $1.99
AMOUNT trial patient instructions (PDF). This trial used readily available technology (e.g. Wii Fit, Xbox Kinect) and rehab technology (e.g. fysiogaming, Stepping tiles). The 14-page patient instructions are clear and aphasia-friendly, with clear instructions on using iPads as well as the trial-specific apps and FitBits. The AMOUNT trial protocol (DOCX) includes instructions and clinical decision-making guides.
Recovery of upper limb function and Walking learning modules on InformMe were created and reviewed by stroke, occupational therapy and physiotherapy experts. They contain practical advice for therapists when assessing and planning treatment for upper limb recovery and walking after stroke.
HEALTH HUB LIVE is hosted daily at 12.30 pm on Facebook by the team at St Vincent’s Private Hospital Sydney. These sessions guide people through daily prehabilitation exercises that can be done at home, as well as important health and wellness information to support people through COVID-19.
ViaTherapy app is designed as a decision tree for prescribing evidence-based arm exercises for people after stroke. It could be particularly useful for novice clinicians, or those with less experience in stroke. Easy to use on a mobile or PC interface.
GRASP program, with therapist Instructor manuals, participant manuals, and exercise log sheet and the target board are all available to download for free once you have registered at the website. GRASP is graded in three levels, dependent on the level of arm movement the person has. The program is available in both hospital and at home versions.
PUSH arm exercise program was originally designed and implemented at Bankstown-Lidcombe Hospital, Stroke Unit. The program is based on evidence regarding arm training and dosage. There is currently no specific evidence validating the PUSH program. PUSH is suitable for stroke survivors with limited movement in their affected arm.
See the Accessible healthcare communication materials and resources from the CRE in Aphasia Rehabilitation and Recovery linked above. The full contents are described at the top of this page, but they include information on adapting aphasia assessments, and aphasia-friendly resources for using web-based platforms.
Speech Pathology Australia has a telepractice web page, which is accessible to their members only. The telepractice FAQ page has additional information which may help speech pathology clinicians to set up telepractice services (e.g., videos on practicalities of telepractice), and information on funding streams. These web pages will be updated regularly as new resources become available.
thiswayup.org.au has online courses available for chronic pain and a range of mental health conditions. All courses are free until 30 April 2020.
Vision and perception
Read-Right program for hemianopic alexia: This online program, developed by the team at UCL Queen Square Institute of Neurology, is a practice-based therapy that aims to improve reading speeds in people with hemianopic alexia, a reading disorder related to a visual impairment (hemianopia) usually caused by a stroke or brain injury. The main part of the therapy involves reading scrolling text. The program includes in-built tests of visual fields, reading speed and visual search. Program participants are able to select from a wide range of reading materials including classic novels, current newspapers and popular novels (such as Harry Potter). The program is free for the first 7 days then at a cost of 5 GBP per month (approx $10 AUD).
Eye Search program for visual scanning: Free online therapy for patients with visual search problems (hemianopia or visual neglect) caused by stroke or brain injury, developed by the team at UCL Queen Square Institute of Neurology. It is behavioural therapy designed to improve patients’ speed and accuracy when finding objects through an online game that focuses on visual scanning and the training of the parts of the brain that control eye movements. Each level of the game then becomes increasingly difficult.
PAVING the Path to Wellness™: Emergency Response Edition, a free, 6-week virtual program for patients who are recovering from brain injury and stroke and don’t have the funds to pay for this rehabilitation. The program includes a wellness toolkit for building a healthy mindset through lifestyle changes such as creating a wholesome diet and exercise plan, learning how to enjoy regular sleep patterns, identifying important goals, finding meaning and purpose, and forming powerful personal connections. With funding from brain injury charity SameYou, Spaulding Rehabilitation Hospital will accommodate 150 free places on their program, on a first come, first served basis. See eligibility requirements and registration guidelines in the link.
Hacks for exercising after stroke, a 13 min presentation by Dr Sarah Valkenborghs aimed at inspiring stroke survivors, but which includes useful tips for exercising for people with significant mobility issues.
Aerobic exercise after stroke (PDF), from the Canadian Partnership For Stroke Recovery. This guide for stroke survivors addresses the benefits of aerobic exercise, who should participate, why they should participate, how to get started and what’s involved. It also includes a sample program and tips on how to monitor exercise intensity. The accompanying Clinician’s guide (PDF) includes key messages, elements and considerations of an aerobic program, addressing barriers and outcome measures.
Clock Yourself app is a training tool for patients developed by physiotherapist Meg Lowry. It progressively increases tasks for people and works on improving balance and reaction times.
Free “Senior Strong” workouts from the Body Project. This is a commercial company, but the workouts are freely available on YouTube and via the links below. The workouts were designed in conjunction with a nursing professor from the UK. They include older adults demonstrating as well as the fitness instructor. Instructors are engaging, with lots of talking but clear visual demonstrations. Some use dumbbell weights, which can be substituted with cans of beans or other household items. All (apart from the standing balance one) demonstrate sitting and standing options.
With many physiotherapists moving to delivery of online services because of the Coronavirus Disease 2019 (COVID-19) pandemic, we thought it would be timely to put together some high-quality clinical research to guide telehealth interventions. Following are a list of systematic reviews published in the last 5 years that evaluate the effects of tele-physiotherapy. The Chartered Society of Physiotherapy have produced a guide for the rapid implementation of telehealth consultations that may also be useful.
Loss of arm function occurs in up to 85% of stroke survivors. Home-based telerehabilitation is a viable approach for upper limb training post-stroke when rehabilitation services are not available. Method: A costing analysis of a telerehabilitation program was conducted under several scenarios, alongside a single-blind two-arm randomized controlled trial with participants randomly allocated to control (N=25) or intervention group (N=26). Detailed analysis of the cost for two different scenarios for providing telerehabilitation were conducted. The fixed costs of the telerehabilitation are an important determinant of the total costs of the program. The detailed breakdown of the costs allows for costs of future proposed telerehabilitation programs to be easily estimated. The costs analysis found that a program supplying all required technology costs between CAD$475 per patient and CAD$482 per patient, while a program supplying only a camera would have total costs between CAD$242 per patient and $245 per patient. The findings of this study support the potential implementation of telerehabilitation for stroke survivors for improving accessibility to rehabilitation services. This cost-analysis study will facilitate the implementation and future research on cost-effectiveness of such interventions.
Remote workers are particularly prone to mental health problems (Bowers et al., 2018). Unfortunately, it is often difficult for them to access the quality psychological help that they need. As a result, psychological treatment is increasingly being delivered to remote workers via telehealth (videoconferencing and telephone calls). However, the perceived remoteness of the therapist during such treatments can greatly hinder progress. This project examined the potential of virtual reality (VR) to deliver psychotherapy to workers located in remote locations (since it can make people separated by great distances feel that they are “present” in the same virtual space). The study compared the experiences of 30 ‘clients’ who participated in both VR and Skype-based mock counselling sessions (delivered by trained psychotherapists). Overall, VR was found to outperform Skype:
1) as a therapeutic tool,
2) in terms of the perceived realism of the session; and
3), in terms of the degree of presence it generated in the clients and the therapists.
Clients did not report feeling sick or stressed when using VR and found it as easy to use as Skype. These study findings (based on formal questionnaire data) were also confirmed by interviews with both the therapists and clients.
This project examined the potential of virtual reality to deliver psychotherapy to workers located in remote locations.
The study compares the experiences of 30 ‘clients’ who participated in both VR and Skype-based mock counselling.
VR was found to outperform Skype: as a therapeutic tool, perceived realism of the session; and the degree of presence.
Clients did not report feeling sick or stressed when using VR and found it as easy to use as Skype.
In-home rehabilitation, using a telehealth system and supervised by licensed occupational/physical therapists, is an effective means of improving arm motor status in stroke survivors, according to findings presented by University of California, Irvine neurologist Steven C. Cramer, MD, at the recent 2018 European Stroke Organisation Conference in Gothenburg, Sweden.
“Motor deficits are a major contributor to post-stroke disability, and we know that occupational and physical therapy improve patient outcomes in a supervised rehabilitation program,” said Cramer, a professor of neurology in the UCI School of Medicine. “Since many patients receive suboptimal therapy doses for reasons that include cost, availability, and difficulty with travel, we wanted to determine whether a comprehensive in-home telehealth therapy program could be as effective as in-clinic rehabilitation.”
In a study conducted at 11 U.S. sites, 124 stroke survivors underwent six weeks of intensive arm motor therapy, with half receiving traditional supervised in-clinic therapy and half undergoing an in-home rehabilitation program supervised via a videoconferenced telemedicine system.
Subjects were on average 61 years old, 4.5 months post-stroke, and had moderate arm motor deficits at study entry. When examined 30 days after the end of therapy, subjects in the in-clinic group improved by 8.4 points on the Fugl-Meyer scale, which measures arm motor status and ranges from 0 to 66, with higher numbers being better. Subjects in the telerehab group improved by 7.9 points, a difference that was not statistically significant.
“The current findings support the utility of a computer-based system in the home, used under the supervision of a licensed therapist, to provide clinically meaningful rehab therapy,” Cramer said. “Future applications might examine longer-term treatment, pair home-based telerehab with long-term dosing of a restorative drug, treat other neurological domains affected by stroke (such as language, memory, or gait), or expand the home treatment system to build out a smart home for stroke recovery.”
He said that the demand for rehabilitation services will likely increase, due to an aging population and increased stroke survival as a result of better access to advanced acute care. Telehealth, defined as the delivery of health-related services and information via telecommunication technologies, can potentially address this growing unmet need.
“We reasoned that telerehabilitation is ideally suited to efficiently provide a large dose of useful rehab therapy after stroke,” said Cramer, whose research team is part of the NIH StrokeNet consortium.
This research builds on the findings of a pilot study of 12 patients with late subacute stroke and arm-motor deficits who were provided 28 days of home-based telerehab program. The results, published in November 2017 in the journal Neurorehabilitation and Neural Repair, found that patient compliance was excellent (97.9%) and participants experienced significant arm-motor gains (Fugl-Meyer scale increase of 4.8 points). The study also found that patients did not need any additional computer skills training due to the design of the telerehab system.
“Getting patients to remain engaged and comply with therapy is a key measure of success of any rehabilitation program,” Cramer said. “Greater gains are associated with therapy that is challenging, motivating, accompanied by appropriate feedback, interesting and relevant. Telerehab achieves this because therapy is provided through games, provides user feedback, can be adjusted based on individual needs, is easy to use—and is fun.”
This study was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development as well as the National Institute of Neurological Disorders and Stroke (grant U01 NS091951), the NIH StrokeNet Clinical Trials Network, the 11 US enrollment sites, the research team at the primary study site at the University of California, Irvine, and the patients and families who participated.
Purpose: This abstract reports a qualitative study on a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education at the patient’s home. Therapists examine patients then establish regular videoconferences with them via the system to discuss their progress, provide feedback, and adjust treatment. The aims of this study were to investigate patients’ general impressions about the benefits of and barriers to using the telerehabilitation system at home.
Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 10 participants who had completed a 6-week intervention using the telerehabilitation system. Thematic analysis was conducted using the grounded theory approach.
Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions and provision of an outlet for mental tension and anxiety. They mainly valued the following four merits of the system: engaging game experience, flexibility in time and location in using the system, having the therapists accountable, and having less burden on caregivers. In particular, all participants rated highly their experience using the videoconference capability, which provided a channel for therapists to observe, correct, and provide feedback and encouragement to patients. Most patients expressed that they established a personal connection with the therapist through use of the telerehabilitation system. By doing so, they felt less isolated and more positive and connected. Finally, communicating with therapists three times a week also held patients accountable for completing the exercises. Barriers to system use were all logistics-related, such as the lack of physical space at home, which impeded effective use, and poor internet connection at home.
Conclusions: The telerehabilitation system studied provides patients with home-based access to games, exercises, education, and therapists. Based on participants’ qualitative feedback, it is a promising tool to deliver stroke rehabilitation therapies effectively and remotely to patients at home.