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Jeanine: Hi, I'm Jeanine Kolman, a specialist in the practice department at the American Physical Therapy Association. Today I'm here with some special people to talk about a new clinical practice guideline from APTA, telerehabilitation and physical therapist practice. This CPG is now available on PTJ: Physical therapy and rehabilitation journal website. We'll put links to the CPG, its translations in Spanish, Chinese and French, and other resources like CPG plus summary and Pocket guide in the notes for this episode so you can check it out.

In this episode, I'll be speaking with two of the lead authors of the CPG, as well as three clinicians with various experience with telerehabilitation. First, I'd like to welcome the lead authors, Doctor Alan Lee and Doctor Trevor Russell. Alan and Trevor, could you please tell us a bit about yourselves and how you got involved with this project?

Alan: Yes, thanks, Jeanine. My name is Alan Lee. I'm a professor of physical therapy at Mountain St. Mary's University in Los Angeles. I'm also the current director of Technology and Innovation for the Academy of Leadership and Innovation at APTA, and also the past secretary of the American Telemedicine associations telerehab special interest group where met Doctor Trevor Russell. Trevor would you like to introduce yourself?

Trevor: Thanks very much, Alan. Yes, my name's Trevor Russell. I'm a professor of PT also and I'm the director of the Recover Injury Research Centre at the University of Queensland in Brisbane, Australia. So I am co-chair with Alan on the CPG.

Jeanine: Thanks for taking the time to speak with us today. Alan, can you explain the impetus for creating the CPG and why the decision was made to include international authors?

Alan: Sure. Well, APTA selected the CPG topic based on multiple factors, and it came forth during 2020 during the height of the COVID-19 pandemic. APTA sought after key experts like Trevor and others and really talked within the departments of Scientific Affairs, Public affairs, and advisory committees. And we need to acknowledge Doctor Bill Boissonnault and the former senior VP at APTA who encouraged us to look at telerehabilitation and its impact on not only our profession, but for our society. I also like to acknowledge others outside of our profession, such as Nicki Perisho, an RN, the program director at the Northwest Regional Tele Resource Center who also allowed us to seek out other experts out of the profession, such as the physiatrist as well as the FSBPT in terms of finding our consumer member for the CPG. So during 2020 and now we were really able to skim through the best evidence for the future practice and telerehab in physical therapy.

Jeanine: Thanks. Now let's chat about key findings and recommendations of the CPG, Trevor.

Trevor: Yeah. So the CPG is split up into three different areas, each containing a number of recommendations. So the first area was called telerehabilitation in physical practice. So this recommendation in this area is based on the evidence that patient satisfaction, attendance rates and adherence to a home exercise or management program is at least equivalent, if not better, than in-person care when that care is delivered via telerehabilitation. So this first recommendation supports the use of telerehabilitation or hybrid care, which is when you do some telerehab and some in-personal care. So it's based upon these factors.  

So the next area is called telerehabilitation preparation and there are three recommendations in this area which encourage conversations with the patient around the cost effectiveness of telerehab in the context of the patient specific circumstances. Recommendations that promote the reduction of barriers from the patient's perspective, from the clinician's perspective, from organizational perspectives to the offering of telerehab and also to the promotion of facilitators to telerehabilitation, so that those services can be offered and easily accessed by the patient.

The third area then is called telerehabilitation implementation, and this area offers three recommendations, which are really at the heart of the CPG. So these are based on the evidence that assessment and diagnosis can be performed with comparable accuracy to in-person visits for certain health conditions. That telerehab can be used to achieve similar outcomes to in-person visits for certain health conditions, and there's also a recommendation in this section around the anticipation, management and documentation of any adverse events which may occur which are specific to telerehab, although the evidence shows that these are minor and infrequent, so they are a bit of a summary of the three different areas and some of the recommendations from those in the CPG.

Jeanine: Great, now that we know some of the key findings, let's bring in some clinicians to talk about telehealth and practice. Christian, Lisa and Andrew, can you tell us a little bit about yourself?

Kristen: Sure. My name is Doctor Kristen Kouvel. I have been a pediatric physical therapist for 15 years, and I've spent the past twelve of those at the Children's Hospital of Philadelphia.

Lisa: My name is Lisa Donahue and I have experience in a variety of clinical settings and I am currently the Director of Clinical Services at Evolution Devices.

Andrew: My name is Andrew Duong. I've been a physical therapist for about 11 years. I'm a regional director for an outpatient company, Spine and sports physical therapy based in San Diego.

Jeanine: Thanks. We're grateful to have the three of you here with us today. Let's start by hearing your impressions of the CPG, Kristen. We'll start with you.

Kristen: Sure, I thought that the CPG was a really nice synopsis and also well needed. One of the evidence and recommendations for physical therapist I was absolutely in agreement with the recommendations for further research on total healthcare cost, whether direct or indirect, as this seems to be a significant barrier for many of our patients. In addition, the necessity for psychometrically sound telerehabilitation readiness questionnaires will be extremely beneficial for therapists to guide decision making.

Jeanine: Lisa, what about you?

Lisa: I want to thank the APTA for recognizing that more guidance and research were needed in this area. I know a lot went into this, so I also want to thank the guidance Development Group for the time and effort they put into this CPG. It was interesting to read that telerehab is superior to in-person PT with respect to adherence and attendance for certain health conditions. This goes along with the recommendation for considering each patient and their specific goals and expectations of what they would like to achieve with PT.

For some persons with chronic stroke, living in long term care facilities, it is noted that one study found significant differences in satisfaction of in clinic versus tell rehab with in-clinic being higher satisfaction, while another study found no statistical difference between satisfaction of intervention. As a neuro PT the question of appropriateness for telerehab due to balance in cognition considerations has been something I've wondered about. The CPG nicely organizes all of the patient identified facilitators and barriers so that when considering telerehab, I can keep these in mind when I collaborate on the plan of care with the patient. As it states, accurately identifying the barriers and facilitators can help PTs who are learning how to incorporate telerehab into their practice consider which patients will most benefit from telerehab. If we fail to identify the barriers, it could lead to unsuccessful experiences for patients. It was nice to read that the studies found that adverse events reported for telerehab were low and not due to the mode of delivery, an adverse event occurring during a remote treatment has come up in conversation with colleagues and is a concern for some who are considering incorporating telerehab into their practice.

And lastly, I found it interesting that one article reported a significant difference in cost only when the difference from home to the healthcare center was more than 30 kilometers. The CPG then went further into describing this cost can be viewed from both the clinician and patient perspective. The cost saving for the patient includes further travel could mean better savings for the patient if they don't have to travel so far. From the clinician's perspective, it could save the cost of driving to patients' homes for home visits. It was a comprehensive way of looking at the question and I really appreciated being presented with that view of the concept.

Jeanine: Andrew, what about you?

Andrew: So there are a couple of things that I found surprising going through this. I work in the outpatient orthopedic setting. So going through this, I was surprised seeing that, you know telehealth is being used for conditions as Parkinson's, ALS, COPD, with some of them showing evidence of no difference with no in-person versus telehealth services. Another part I found a little interesting was the mention of some patient preferring audio call versus like a video call. I think there's a perception amongst some like patients and clinicians where telehealth is already a little challenging due to lack of you know being physically there and the lack of touch you know, so hearing that some people actually prefer a phone call instead, you're taking out visual feedback. That was just kind of surprising.

Jeanine: Great. And I know you guys also came up with some questions for Alan and Trevor. So Lisa, why don't we start with you?

Lisa: My first question is why were activities and participation outcomes considered to be critical and body functions and structures only considered to be important when reviewing articles for outcomes of interest?

Alan: Hey, thank you, Lisa. That's a wonderful question. Now, although the entire ICF outcomes are important throughout the continuum of care with your patients and as a neuro-physical therapist, we thought the activities and participation outcomes are critical since telerehabilitation is best when real-time activities and participation with the patient and within the client's environment can be assessed by a physical therapist or a physiotherapist via telerehab. Therefore, watching somebody perform their exercises or providing supervision or asking questions about their program within their own environments, we thought were very critical for activities and participation outcomes.

Lisa: Great. Thank you, Alan. My second question is, there seems to be a lower recommendation for performing evaluations via telerehab and insurance may not even pay for this. Do the authors anticipate any updated recommendations to this shortly or what additional evidence do they need for this particular question?

Trevor: Thanks very much, Liz, for that question. I'll, I'll take a run at this one. You're quite correct in that the quality of evidence was lower to support this recommendation and these studies that were reviewed were reasonably small and conducted in a controlled environment. Now it should be noted that this is usually the case for diagnostic accuracy study. So the quality rating tool that we use may have resulted in a slightly lower rating than perhaps warranted for these particular studies. Nevertheless, the studies were fairly specific in terms of the areas of practice that they concerned, so generally, musculoskeletal and neurological clinical populations. So we need a lot more studies which validate a a broader set of the common assessments that we use as physical therapists.

It's pretty hard to get funding to do these types of studies, though, which is probably why there were only eight of them included in this review. And I think all of them were unfunded studies, so. You know, we need more research, we need more research in different clinical areas with different clinical assessment tools and the CPG will be updated and to include any new studies as we update the CPG and hopefully this will strengthen the recommendations even more in the future.

Jeanine: Speaking of assessment tools, I know, Andrew your question had to do with that.

Andrew: Yeah. So there was a section mentioning evidence supporting assessing range of motion via telehealth. So I'm just curious what methods are being used to assess this and to make them more objective?

Trevor: Thanks, Andrew. Yes, the studies in this CPG used an on-screen goniometer to assess range of motion. So this relies on the clinician essentially using a computer mouse to identify anatomical landmarks that you would traditionally use with a standard goniometer in clinical practice. So the difficulties in telehealth are twofold. So, one you have to make sure that the body segments that form the angle that you're trying to measure are perpendicular to the camera. Otherwise, if the camera's off axis, you start to introduce some parallax error and the second thing is identifying those landmarks without the ability to palpate the patient can be a little bit more difficult. But despite these challenges, the remote range of motion assessment by telehealth in the research that we've looked at does seem to be very accurate and very reliable.

Jeanine: Kristen, I'll turn it over to you for some more questions.

Kristen: Yeah, absolutely. Thank you. Now, you highlighted some various patient, provider and organizational barriers and facilitators that may affect delivery of telerehabilitation services within the CPG. Can you please speak to some of the barriers and suggestions for how to overcome them? And then can you also speak to some of the facilitators and ways to promote that?

Alan: Sure, Kristen, that's a great question as well. You highlight some key areas and the most obvious barrier for us being such a hands-on profession is the lack of hands on ability to interact with your patients and clients. However, this barrier might be mitigated with additional support or hands on from assisted or augmented by another person at the patient's environment such as you in pediatrics working with maybe caregivers or parents could be an opportunity. And the key is to consider the most safe and the effective way to use telerehabilitation, which surely is just a tool in using your physical therapy, critical thinking and judgement skills to overcome those barriers. Now, however, if they what we call a caregiver or an E-helper is not available, then you must consider potentially a hybrid approach where you have an in-person and a telehealth visit as a follow up or a telehealth eval and then a in-person visit, such as a hybrid approach that we would consider as well. And as we all experienced during COVID and during the pandemic. On the positive side, as for facilitators, if an E-helper or caregiver can assist the patient and client. Obviously, as we would use a medical interpreter in terms of those individuals who speak another language, it is a must that you should utilize that support system much as possible. In addition, you need to consider patient preferences in using telehealth or telerehab for addressing timely access.

And as Lisa had mentioned, potentially the geographic distance which can be a facilitator, if a certain distance is unable to be met or a commute time is very difficult for the patient. In addition, you want to think about payment or licensure, or universal licensure or licensure portability for regulation to allow for coverage of telerehab as a facilitator as well.

Kristen: Thank you. Thank you very much for going through all of those. I think that's really important to note. My next question for you is what are ways to help physical therapists determine if telerehabilitation is appropriate for their patients? I know this is something that comes up with so many of our therapists. So what are ways that you would recommend?

Trevor: I may take a run at that question. Thanks very much for that. It's a very important question and this is a question that wasn't necessarily addressed head on with the CPG, but in reviewing the literature, it's clear that studies have been conducted across many, many different areas of clinical practice. So musculoskeletal, neurocardiogenic, orthopedics, etcetera. So and across all of those, the results have been demonstrated to be really positive. So this is a question that I'm often asked, and I'd like to remind those asking the question that, as PTs, we do a whole lot of things which are quite easy to do via telehealth. So. So, you know, we talk to our patients, we educate our patients, we observe movement and diagnose function and you can observe movement very well in in some of these technologies that we have where you can record the patient and you can watch it back in slow motion and so forth. We also teach and prescribe exercises to our patient. We educate patients in how to self-manage and what exercise or management strategies they need to do at home to get better and we make recommendations and referrals so I think you know, we do some of these things for all of the patients that we see, really, we would do some of those activities and for that reason I think telerehab is appropriate for all patients at least to some degree. So sure for some patients we also provide physical touch and manual therapy and we facilitate movements so forth and these can be really important aspects of their care. And as Alan mentioned before, in these circumstances maybe a hybrid approach can be really important where you combine some in-person sessions with some telehealth sessions.

But I think you know, as clinicians, if we're considering offering telehealth, it's important to really think about the specific needs of that client and then match those needs against what we can and can't offer via telehealth via that modality, which as Alan mentioned, is just a tool. And then make a decision about whether telehealth alone or a hybrid approach or purely an in-person approach is need. So I guess my take on this is that you can do some telerehab for every patient that you will see. It's just the amount of care that you can offer which will vary from patient to patient and we need to use our our clinical reasoning to make that decision.

Kristen: Thank you. Yes, I found the same thing as well. You know, in the research that I've done on telerehabilitation and the preference for therapists to utilize this hybrid approach. So thank you for speaking to that. I was also wondering if you found any regional or socioeconomic differences and provider or patient perspectives on telerehab when evaluating the literature. If so, what are they? And then really, how do they impact the overall outlook on telerehab?

Alan: Sure. And let me take a stab at that, Trevor. It's Alan Lee and definitely I'm in the United States so there are regional differences in healthcare overall. Therefore, there are differences in telerehab and telemedicine as well. In fact, as I mentioned, resource centers like the national telehealth resource, federally funded centers provide assistance on telehealth to address socioeconomic differences in the region, because Los Angeles, CA is quite different than Boise ID. For example, in rural regions like Idaho and Wyoming, improving digital equity for that population is addressed through telehealth capabilities in local libraries and as physical therapists we need to be mindful of not only what we do but what our own regions are capable of doing in terms of technology. As we mentioned, the CPG, the cost of that technology for patients and providers and also how it may be deployed best within the region.

And as Lisa mentioned, distance does matter for all of us. In that study of total knee replacement and home visits compared to telerehab in Canada, that 30 kilometers, which is about 18 miles round trip for that patient, the further away they were from the clinic, more significant outcomes or cost savings there were for that patient and the provider on direct and indirect costs and studies in Canada were validated in the United States and esteemed professors like Doctor Trevor Russell here in Australia with other studies.

Now what I must say here with the CPG is again, Doctor Russell did abstain from some of the judgment of the deciding on the literature as well. So it was not biased. But we also think the evidence can be utilized in the United States and other regions internationally to develop future codes and payment for telehealth as we move forward, as you alluded to there, Kristen, that we as PTs, OTs and speech therapists can collaborate with other associations in medicine and nursing to really address those societal needs and access to care, innovation and other arenas that we need to really address for our patients and clients in society. And in fact APTA in the past have advocated for CMS codes which were possible for remote patient therapeutic monitoring because some of the evidence that were already developed in telerehab. So thank you for that question.

Jeanine: Yeah. Great questions and great answers. What's one piece of the guideline that really resonated with you, Andrew?

Andrew: For me it was the first one where it says telerehabilitation and physical therapist practice or telerehabilitation is at least equivalent to in-person physical therapy in regards to acceptability and satisfaction, as well as adherence to in respect to adherence and attendance for certain conditions. I think for us we started using telehealth, you know, when COVID started and I always kind of looked at as an as an option for when I couldn't come into the clinic you know, so after reading over this. You know, I never really looked at it as something that is similar or even superior to any aspect and you know, so I think this, this is something that just popped out to me after going through this article.

Jeanine: Lisa, what about you?

Lisa: There were so many little things that I took from this CPG that I'm going to incorporate into thinking about telerehab. My most comprehensive take away from the authors is that this should not be considered a fixed recommendation. Sometimes when we learn something new, we think we have to do it exactly like it says, but this reminds us that we need to consider the individual and the circumstances. So I think of telerehab as another tool in our toolbox. It is important to keep in mind that the patient should be included in the decision making process for determining whether or not to incorporate telerehab and the section on facilitators and barriers emphasizes that a facilitator or barrier could be PT or PTA's skill and knowledge of providing care via telerehab platforms.

So just as when in the clinic we're not as comfortable with a specific technique, we may not use that technique until we feel comfortable with it. The use of telehealth may not be as beneficial if the clinician does not have the experience using it. So using the CPG as guidance is a way that a clinician can increase their knowledge to improve their skill to be able to incorporate telerehab into their practice.

Jeanine: Great. And what about you, Kristen? What's one thing you taken away?

Kristen: Yeah, I I found it really interesting that the literature supported that telerehabilitation improved adherence to treatment and completion of prescribed tasks. So I know I have found this to be true with the subset of pediatric patients that I work with, but I'm wondering if the literature supported this for pediatric patients as well or if it was more so related to the adult populations.

Trevor: Thanks for that question I might take a run at that. Since we completed this CPG, we've also done another separate systematic review and meta-analysis on this topic, which confirms the results that we found in the CPG. So from memory, none of the papers in the CPG or the systematic review actually involved pediatric patients. However, you know your experience doesn't really surprise me. I think the emphasis that we put on the patient and also parent education that we make in telehealth consultations, along with you know, teaching exercises and management strategies in the actual environment that they'll be performed in the home in. I think that leads to the improved adherence that we see with that home program and of course the convenience of attending a telehealth session, you know, not having to get into a car and travel and go through traffic and pay for travel and all of those sorts of things, I think that facilitates then the attendance to the session. So if you're getting comparable outcomes in a convenient way of accessing care, I think you know that helps with the satisfaction rating also. So definitely more research is needed in that pediatric population to confirm this. But I think it's a very positive thing.

Alan: And if you allow me to add a little bit here, Doctor Russell that I mean during COVID and prior to COVID, there's so much work that was done by APTA, APA, the Canadian Physiotherapy Association, World Physio. I just want to make sure the listeners and then the readers of the CPG understand that the Academy of Pediatrics has a telehealth task force that develop wonderful resources from diagnosis to prognosis that's available. In orthopedics and private practice. There are key resources that are available for musculoskeletal and private practice physical therapists and physiotherapists. And also in neurology, the vestibular special interest group have developed for their academy key telehealth resources as well. So most of all academies, including where I belong, the Academy of Leadership and Innovations Technologies SIG have resources for our listeners that you can draw on beyond the CPG.

And again, we're developing future, as Doctor Russell said, future additions and I would say pocket guides for the CPG, that'd be really helpful for you to implement the best practice from the recommendations.

Jeanine: Speaking of the APTA Academies and special interest groups, I want to quickly list all of the authors who contributed to this CPG from APTA and from around the world: Dr. Robert Latz from APTA Leadership and Innovation, Dr. Kelly Sanders from APTA Private Practice, Dr. Michele Wiley from APTA Pediatrics, Dr. Judith Deutch from APTA Academy of Research, Dr. Sandra Kaplan from the pediatric and research academies, who served as the methodologist for this project, Dr. Jennifer O'Neil from Canada, Dr. Lesley Holdsworth from the UK, Dr. Oscar Ronzio from Argentina, and Dr. Heidi Kosakowski from World Physiotherapy.

Additionally, these authors were joined by physiatrist Lennox McNeary and consumer representative Michelle Sigmund-Gaines. We also want to shoutout Anita Bemis-Dougherty, APTA senior advisor, scientific affairs, whose leadership and support helped us complete the CPG in a timely manner.

Now, I have one final question for our clinicians what (if anything) are you going to do differently from now on? We'll start with you, Lisa.

Lisa: I'm going to consider the facilitators and barriers for each individual patient to help determine if telerehab is the right choice for them.

Jeanine: How about you, Andrew?

Andrew: I don't think I would do anything differently, but like moving forward, my mindset on telehealth has definitely change where seeing how it's beneficial to both the patient and provider and can be equal to services provided in the clinic.

Jeanine: Kristen.

Kristen: Thank you. Yeah. So, you know, I don't think I'm necessarily going to do too much different. I'm a huge advocate for telerehabilitation, and I just love the fact that we now have this evidence to guide and support our decision making and hopefully it will help to influence our researchers and policy makers.

Jeanine: Wonderful. Thank you all for your expertise and perspectives. This will certainly be an area to watch in the future. I wanted to let everybody know that APTA has a digital health and practice web page with additional information and resources for PTs and PTAs. We also have some consumer education articles that you can share with patients: six reasons to consider telehealth physical therapy and answers to frequently asked questions about telehealth physical therapy. We'll put those links in the show notes and you can check them out. One final note on this topic is that Medicare's pandemic era authority to reimburse PTs, PTAs, and other therapy providers for telehealth services is scheduled to expire at the end of 2024. APTA continues to advocate in support of bipartisan legislation that would make PTs, PTAs, and other therapy providers in private practice, as well as in facility based outpatient therapy providers under Medicare Part B, permanent authorized providers of telehealth under Medicare.

Last summer, APTA successfully lobbied to secure introduction of the Expanded Telehealth Access Act in both houses of Congress. APTA members can urge their legislators to co-sponsor these bills by going to a APTA's Legislative Action Center, and consumers can do the same thing through our Patient Action Center, which is open to all. We'll put links to the expanded Telehealth Access Act and APTA's two legislative action centers in the notes for the show to make it easy for you to advocate for interventions that can help people get better, faster. Once again, thank you, Alan, Trevor, Kristen, Lisa and Andrew for sharing your time and expertise with us today.