The lockdown during the coronavirus hit hard physiotherapy facilities: Rehab centres were limited to treating only existing patients, while private practices suffered from a tremendous decrease in the number of clients. At the end of the day, COVID-19 showed that we were not ready to digitalize physiotherapy. Moreover, the majority of rehab professionals could think about video calls with patients as an only mean to continue treatment remotely (spoiler: it is not). Many scientific articles have been written about the benefits and possibilities of telerehabilitation as a complement to therapy in a facility or an independent service. But how to put this into practice? Let’s try to find out this together.

Scientifically proven

Back in 2017 Alessandro Peretti, PhD together with his colleagues from University of Camerino (Italy) has already done impressive research of different aspects of implementing telerehabilitation in his article Telerehabilitation: Review of the State-of-the-Art and Areas of Application (1). They retrieved and analyzed more than 400 articles and 45 books on telerehabilitation or related topics and came to the conclusion that telerehabilitation together with telemonitoring is an interesting and prospective area. The main disadvantages discovered during the research were the following: healthcare providers and therapists were not ready; no standard procedures or protocols developed; possible loss of human contact. But in terms of practice, we see the biggest problem is the following: scientific researches are done for one or several concrete tasks of rehab process (for example, only for patient training) that does not help practising therapists to find the holistic approach for implementing full-scale remote physiotherapy. So we decided to describe the whole process how it should be to help physiotherapists to continue their practice even in such a severe situation as a lockdown.

Remote patient examination & course creation

Of course, nothing can replace an examination in person, when you can see and touch the patient. However, some of the examinations can be done online. You can conduct the patient interview via video or phone call or even with the help of messaging (email, Skype, Zoom, WhatsApp – if you do not have special software at your facility).

There are also several services across the web that provide already digitized surveys with in-built calculators – for example, you can do a Barthel Index for Activities of Daily Living and several others on www.mdcalc.com or Modified Ranking Scale on www.modifiedrankin.com. The only thing is that there are dozens of surveys in the world, and mostly you will need to spend some time on finding them all online on different websites. To track patient progress you can ask a patient to undergo surveys more often, but mind that this data will still be subjective. For precise training tracking physiotherapy sensor-based solutions can be used – they send a therapist data about quantity of repetitions and time.

Creating a program for a patient takes time even if you work with him/her in person in a gym. But how to do it remotely? Writing a list of exercises, then finding links for video instructions on how to do them correctly – that will take a lot of time. For your convenience, you can use ready-made templates of exercises that have already been created and published by your colleagues (for example, on www.m.kp.org, www.physiomed.co.uk or www.verywellhealth.com). But there is the problem – those templates are not personalized. So you will need to send links to different websites and comment on each training exercise.

How to motivate a patient without personal contact

The effectiveness of building rehabilitation process around the patient goal is confirmed by multiple pieces of research. For example, a research “Goal-oriented feedback on motor behavior in VR-based stroke therapy – A case study using the Rehabilitation Gaming System” states that “ego goals… may add to its long-term effectiveness” (2). For many people, the main goal of therapy is “To return to normal”. Identifying a broader purpose for being in good health is a great way to stay committed to the regimen. When a patient links the treatment to the kind of person he/she wants to be, it can help stay motivated for the long haul. Ride horses again, play piano, return to favourite fishing hobbies – these are all great goals. But.

The broad goal is sometimes far, and it is hard to measure it, feel it and fully understand it. 

Setting smaller goals along the way can be very helpful, especially during home rehabilitation when it is very hard to measure the progress. 

Also putting goals according to the SMART methodology (Specific, Measurable, Achievable, Realistic, Time-related) can bring big benefits. This method is widely used for goal setting in business development. Why do you not use it in your rehabilitation process? “Eat by myself in 2 weeks”, “play Moonlight Sonata on the piano till April”, “plant flowers without back pain next weekend” – these are all good examples of SMART goals. A wide variety of methodologies for goal settings can be found in “Physical Management for Neurological Conditions” book by Sheila Lennon, Gita Ramdharry and Geert Verheyden (3).

According to dozens of scientists and physios, the best way to make rehabilitation funny is to gamify it. You can get one of home rehab solutions that hide boring exercises behind video games you play games by doing your exercises while the camera or sensors track your body movements and translate them into commands in a game. It can sound surprising, but gamification works not only for young people. According to Gamification of Older Adults’ Physical Activity: An Eight-Week Study (4), people over 50 “exhibited more engagement and interest in performing physical activity facilitated by technology”. Our colleagues from Deutsches Forschungszentrum für Künstliche Intelligenz (5) also found out that gamification works for patients 75+, but special content is needed – “the main motivation to play is socializing, that participants avoid competition and prefer collaboration and care-taking”.

Sometimes music can be a good motivator, so you can use music to stay motivated in physical therapy. Have you noticed that often there is music playing in the background in the physical therapy clinic? Choose your favourite track for exercising, and you will see how it can improve your mood and give a positive effect on rehabilitation.

Other people adore doing exercises while watching TV. This can also work well during the coronavirus outbreak, especially with a lot of content available now for free – from movies to seminars.

Physiotherapy applications might save time

Despite implementing the digital applications in the German healthcare system was out of the standards for a long time and they were not reimbursed by state insurance, now the situation is about to change after the Digitale-Versorgung-Gesetz (DVG) was signed in 2019. According to it, digital applications will get a fast way to be reimbursed already in 2020. While several private insurances are already reimbursing them. 

Even if you only use your computer for checking email, reading news and watching movies, you should try one of those physiotherapy applications for telerehabilitation that are now appearing on the market. In the times when user experience is in the first place, they are already quite easy to master and do not require any specific computer skills. If choosing wisely, you can save a lot of your time on using a bunch of different apps and websites and get all in one telerehabilitation. Video calls and messengers, examination tests, course creation templates, calendar of appointments, remote exercise monitoring and course correction – this is not a full list of functions you can now find in telerehab apps.

Anna Bezrodna, Toni Muffel

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References

  1. Research: Peretti, Alessandro & Amenta, Francesco & Tayebati, Seyed Khosrow & Nittari, Giulio & Mahdi, Syed. (2017). Telerehabilitation: Review of the State-of-the-Art and Areas of Application. JMIR Rehabilitation and Assistive Technologies. 4. e7. 10.2196/rehab.7511. 
  2. Research: Marwecki, Sebastian & Ballester, Belén & Duarte, Esther & Verschure, Paul. (2017). Goal-oriented feedback on motor behavior in VR-based stroke therapy – A case study using the Rehabilitation Gaming System. Journal of Disability and Rehabilitation. 3. 
  3. Buch:  Sheila Lennon, Gita Ramdharry, Geert Verheyden. Physical Management for Neurological Conditions E-Book. Elsevier Health Sciences, Jul 28, 2018 
  4. Research: Kappen, Dennis & Mirza-Babaei, Pejman & Nacke, Lennart. (2018). Gamification of Older Adults’ Physical Activity: An Eight-Week Study. 10.24251/HICSS.2018.149.
  5. Conference: Altmeyer, Maximilian et al. “Investigating Gamification for Seniors Aged 75+.” DIS ’18 (2018).

The original article published in the biggest German journal for therapists pt – Zeitschrift für Physiotherapeuten.