By Kohle Merry & Megan MacPherson
More than one in four Canadians over 12 are affected by a musculoskeletal (MSK) condition annually (1). The MSK system is composed of bones, muscles, tendons, ligaments, joints, cartilage, and connective tissues and functions to facilitate movement and stability of the human body (2). Common MSK conditions include back pain, repetitive strain injuries, osteoarthritis, and fibromyalgia (2).
A cornerstone of MSK physical therapy (PT) treatment is exercise therapy (3), defined as the prescription of specific exercises to correct impairments, restore MSK function, and promote overall well-being (4). Non-surgical management of MSK conditions using exercise therapy has demonstrated positive effects for chronic pain (5), osteoarthritis (6), sarcopenia and peripheral arterial disease (7), and tendinopathies (8), to name a few. With that said, access to PT services (9) and the costs associated with ongoing appointments remains a burden for much lower-income and rural dwelling Canadians seeking care. Specifically, the lack of rural physiotherapists working in MSK rehab, coupled with the physician referral process, clinic location, and a client’s socioeconomic status, may hinder rates of access and uptake of PT services in rural communities (10).
Supplementing in-person rehab with a home-based exercise program is a commonly used approach to improve health outcomes while decreasing reliance on healthcare practitioners and overall treatment costs (11,12). However, without a clinician present, safety remains an issue as clients have no assurance that they perform exercises as prescribed, and program adherence is often low (13,14). Remote rehabilitation, or “tele-rehab,” may offer a solution to improve patient adherence and safety while making healthcare more accessible to all Canadians. This article expands upon the role of tele-rehab within the Canadian healthcare system, describes current challenges of tele-rehab solution development, and offers recommendations for evidence-based tele-rehab development.
Tele-rehab, defined as providing rehabilitation services at a distance through telecommunications technologies such as videoconferencing or mobile phone applications (apps) (15), offers an opportunity to bolster adherence amongst home-based exercise therapies. The rapid transition to PT tele-rehab services across Canada (16) in the past year highlights the feasibility of remote service delivery using digital health technologies, wide availability of tele-rehab infrastructure, and willingness to engage with such tools by those delivering receiving care (17). Given its widespread accessibility and adoption (18), tele-rehab will likely remain a primary means of delivering healthcare and is likely to play a significant role in Canada. More than 7 million Canadians live in rural communities, many of which lack access to healthcare providers (9). That being said, there were over 325,000 health-related apps on the Apple and Google Play app stores in 2017 (19).
Moreover, little guidance is available for rehab clinicians and clients on which apps may be based on current practice guidelines, resulting in clinicians lacking confidence in their ability to prescribe effective and evidence-based tele-rehab services (20). Further, clients are often unaware of how to find tele-rehab solutions that meet their needs (21). As noted by clinicians, the main barrier to use is a lack of knowledge regarding if an app is based on current evidence (22). Additionally, many tele-rehab service developers prioritize deployment speed over rigorous development using end-users and efficacy/effectiveness testing (23). Without thorough evaluation and the incorporation of diverse stakeholders throughout the design process (e.g., clients, clinicians, insurers, etc.), tele-rehab solutions may not suit the needs of end-users or function as intended (24). Taken together, this can lead to an abundance of low-quality tele-rehab solutions which are not evidence-based and often incorporate features that the development team values, rather than relying on end-user testimony or behaviour-change science to inform features (25).
The development of cost-effective tele-rehab solutions based on best practice guidelines represents an imperative but challenging process towards improving access to effective PT services.
To improve the utility of tele-rehab for both clinicians and clients, researchers and tele-rehab developers should design services based on 1) evidence-based behaviour change techniques (BCTs) (26) shown to improve rehab outcomes and client engagement, and 2) wants and needs of those who will be using the service (e.g., clinicians, clients, insurers). By incorporating end-user feedback throughout the formative research, design, and evaluation stages of tele-rehab app development, it is likely that uptake and engagement will improve (27). When rigorously designed based on these tenets, MSK tele-rehab has been shown to be comparable to a baseline of traditional in-person rehabilitation (28,29), providing an avenue to deliver equivalent or better PT services to more people with fewer resources (30,31). In particular, elements such as improved outcomes, ease of use, low cost, and decreased travel time, among others, have been linked to patient satisfaction with tele-rehab (32,33).
BCTs are defined as the observable components (or the “active ingredients”) within a behaviour change intervention and must be distinct (i.e., non-redundant), irreducible, and replicable (34). Several clinical trials have reported increased adherence to therapeutic exercise when using tele-rehab solutions, which incorporate BCTs, such as self-monitoring and goal setting, within the interventions (35,36). For tele-rehab developers, this highlights a potential therapeutic target for promoting adherence: by incorporating BCTs previously found to elicit positive changes to physical activity behaviours, such as prompts (e.g., push notifications, SMS) (37), rewards (e.g., gamification) (38), and biofeedback (e.g., via force plates, accelerometers, heart rate monitors) (39), developers may improve engagement and therefore adherence.
Developers should take an additional step to consult stakeholders (i.e., end-users and other related parties such as insurers) throughout the development process. Not only does this step promote intervention sustainability by addressing stakeholder-specified needs (40), but it also aids in optimizing behaviour change features within tele-rehab programming. For example, researchers can create a diverse committee of stakeholders across all levels of the care pathway (e.g., client partners, clinicians, regulatory agencies, and insurers) to aid in decision-making. Using a User-Centered Design approach (41–43), which continuously engages stakeholders throughout the intervention development and iteration process, the resulting tele-rehab solution will better suit real-world needs and improve uptake into clinical practice.
Including evidence based BCTs, which end-users have vetted, is likely to promote engagement with the tele-rehab service by those providing and receiving care.
Although COVID-19 has forced the rapid transition of traditional healthcare services to digital delivery, little attention has been paid to client or clinician perspectives and how best to pivot in-person delivery to tele-rehab models. While this article is conceptualized within the context of MSK in Canada, these suggestions on developing effective tele-rehab can be extended beyond these conditions and locations to improve healthcare access and services. By developing tele-rehab solutions in collaboration with end-users and basing programming on evidence-based techniques shown to improve health behaviours, tele-rehab has the potential to improve accessibility and availability of PT services in the rural and remote areas of Canada. Further, the strategies suggested here aim to promote shared decision-making and sustainable implementation while encouraging client adherence to exercise therapy. Taking these steps within tele-rehab intervention design can help improve access to effective rehabilitation.
Featured illustration by Ashlyn Fieldhouse for rehabINK.
To refer to this article, it can be cited as:
Merry K, MacPherson M. Developing Effective Tele-rehab to Promote Adherence to Home-Based Exercise Therapy. rehabINK. 2022:Issue12. Available from: https://rehabinkmag.com
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