Shifting the rehabilitation models in changing times: Telerehabilitation and social media

COMMENTARY

By David London

Social media is changing the physical rehabilitation industry for trainers and therapists. Not only is continuing education and networking at the fingertips of rehabilitation practitioners, but online applications can also enhance clinical practice and connection with clients. The average person spends more than four hours a day using technology, including time spent on smartphones and other social media platforms (1). Social media provides an opportunity for a cultural shift in how rehabilitation, such as physical therapy and corrective exercise, is accessed by clients.

Imagine waking up and receiving your daily rehabilitation exercises delivered directly to the palm of your hands via a mobile application (or “app”). You would record your exercises with your smartphone’s camera and upload the videos to a secure application for your therapist to analyze and provide feedback. This online process is already what I do with my clients as an intern physical therapy assistant.

Most research and development in the field of rehabilitation and technology has focused on telerehabilitation. Physical therapy has traditionally involved in-person assessment and diagnosis from a registered therapist, and treatment by an intern physical therapy assistant such as myself, that includes active care and patient monitoring in clinic-based settings. But, telerehabilitation is the delivery of rehabilitation services in clients’ homes using online communication technology (2).

There is considerable evidence supporting the effectiveness of telerehabilitation and its applications for physical therapy. For example, a meta-analysis demonstrated that the client outcomes (e.g., improvement of physical function and pain) of telerehabilitation was comparable to clinic-based care for a variety of musculoskeletal conditions such as knee pain, lower back pain, and neck pain (3). The authors of that meta-analysis suggested that telerehabilitation can also be an effective add-on to clinic-based care for these conditions (3). While no evidence is yet available, these results may suggest that depending on the musculoskeletal condition, telerehabilitation could, in some cases, replace clinic-based care.

Given the emerging use of technology in healthcare, some estimates put the potential for growth of the telerehabilitation market at a rate of 56 per cent per year (4). As research and development in this field expands, telerehabilitation also has the potential to evolve.

From my experience as an intern physical therapy assistant, telerehabilitation over social media is currently best suited to treating muscular injuries such as strains, tendonitis, and acute pain. For example, suppose a patient has bicep tendonitis. The goal is to first determine the body’s tolerance to load (tissue tolerance). Once an appropriate tolerance level is determined, the goal is to progressively load the bicep tendon in pain-free range of motion.

Delivering telerehabilitation has taught me to be very specific with the type of clients I choose to work with online. I have had optimal results working on posture correction, mobility restrictions, musculoskeletal injuries, and muscular imbalances with online clients. They receive their rehabilitation exercise program delivered directly to an app where I monitor their progress via video feedback and comments. Based on their status, I can modify the program and provide feedback to ensure further progress.

But not all clients are well-suited to online therapy. Several factors must be considered when deciding whether online care or clinic-based care is more appropriate. For instance, a client requiring manual therapy (i.e., hands-on techniques) for conditions such as wrist, shoulder, or knee surgery, or shoulder impingement syndrome would be better suited to clinic-based treatment. Additionally, a client with comorbid health conditions would also benefit from a clinic setting where therapists could carefully monitor their health status. Therefore, the severity and/or number of client issues determines whether online treatment can be used as an independent adjunct to enhance clinic-based care, or not at all (2).

Currently, in order to ensure a client is a suitable candidate for online rehabilitation, in-person assessments and consultations by a registered therapist are required. Once a client is a candidate for online rehabilitation, ongoing assessment of functional movement can occur through video link. But, there is currently little to no research evidence describing the online use of standardized assessment measures, such as the ones I use in my practice. These screenings include observing posture, shoulder external rotation, and bodyweight squats. Using an application developed for functional movement screening, clients are provided with detailed instructions. They then upload a video of themselves performing the exercises. A rehabilitation specialist can then use the video to design a personalized rehabilitation exercise program for the client.

There is previous evidence to support the benefits of telerehabilitation (4,5). These benefits include cost-effectiveness and increased patient monitoring, which may improve adherence and accountability (4,5). Telerehabilitation also has benefits for individuals living in rural areas with limited access to rehabilitation practitioners (5). Additionally, for clients who have mobility impairments, telerehabilitation may allow them to participate more often in therapy (5).

Adding on the use of real-time, wearable technologies, such as gyroscopes and pedometers, can allow practitioners to monitor adherence and physical activity levels of multiple clients without requiring them to come into the clinic as often. Mobile apps partnered with these wearable technologies can be programmed to prompt clients to engage in exercise as suggested. Connecting with clients over social media as an adjunct to clinic-based therapy can also provide them with useful content such as additional exercises or nutrition information. Many companies are already successfully implementing these strategies on Instagram, Facebook, and Twitter.

Despite the benefits of telerehabilitation, there are challenges to adapting therapy models to new technology platforms. Clients may have concerns over privacy of medical information shared with apps from their online screening and treatment (6). The technological savvy (or lack thereof) of the client or provider can also potentially limit the quality of the service. The lack of face-to-face communication may reduce the quality of the relationship between client and provider (6). Furthermore, telerehabilitation does not support hands-on care, such as manual therapy, during the assessment and treatment process. Even with real-time monitoring, clients must rely on their own proprioceptive abilities and practitioners’ verbal cueing, which are not always comparable to the manual guidance they would receive in a clinic.

The social era of rehabilitation science is upon us, and more therapists and trainers now have the opportunity to leverage social media to enhance their practice. As telerehabilitation continues to advance, the challenges of accurate, in-depth assessment and client adherence will need to be addressed through research and development. Ultimately, the continuing interaction of telecommunications and rehabilitation may help create a healthier tomorrow, as social media continues to emerge as the next frontier in telerehabilitation.

Acknowledgements

Author David London owns and operates an online-based rehabilitation company. He has not received any funding for this commentary.

References

  1. Lipsman A. Mobile Matures as the Cross-Platform Era Emerges [Internet]. comScore, Inc.; 2017 [cited 2018 Feb 1]. Available from: https://www.comscore.com/Insights/Blog/Mobile-Matures-as-the-Cross-Platform-Era-Emerges.
  2. Russell TG. Physical rehabilitation using telemedicine. Journal of Telemedicine and Telecare. 2007;13(5):217–20.
  3. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clinical Rehabilitation. 2017;31(5):625–38.
  4. Market Research on TeleMedicine – United States [Internet]. Final Step Marketing; 2015. Available from: https://finalstepmarketing.com/wp-content/uploads/2015/07/Telemedicine_Research.pdf.
  5. Schmeler, M. R., Schein, R. M., Mccue, M., & Betz, K. Telerehabilitation Clinical and Vocational Applications for Assistive Technology: Research, Opportunities, and Challenges. International Journal of Telerehabilitation. 2009;1(1):59-72.
  6. Proulx J. Limitations of Telemedicine [Internet]. Telehealth; 2009 [cited 2018 Mar 14]. Available from: https://group602d.wordpress.com/limitations-of-telehealth/.