Let's Take Our Practices Online! Telerehabilitation Can Transform Rehabilitation
By: Nataliya Zlotnikov, MSc, HBSc
By: Nataliya Zlotnikov, MSc, HBSc
Hindsight Is 2020
Hindsight is 2020, especially when it's 2021. A terrible joke. We can learn a lot by looking backwards, but you can't drive a car by looking into the rearview mirror.
You do need to check it every so often for perspective, but, if our focus is solely on what our practices used to look like, we will miss the opportunities that lie ahead. And this is truly what 2020 showed us.
We are still in the middle of a pandemic and how we practice may continue to change.
Today's blog will discuss the need for change and the possible direction this change could take.
This blog is based upon a recently published article from the Canadian Physiotherapy Association (CPA), Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to Action for Telerehabilitation, and Carolyn Vandyken and Sinead Dufour's online healthcare course on Embodia, Telerehab: The Vehicle for Rehabbing the Treatment of MSK Problems.
Canadian Physiotherapy Association on Telerehabilitation
A few months ago, the Canadian Physiotherapy Association (CPA) published an editorial, Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to Action for Telerehabilitation, highlighting the important role of telerehabilitation in reducing the spread of COVID-19, preventing future hospitalizations and assisting with discharge from hospitals.
This paper presents some of the evidence for telerehabilitation, key considerations and challenges for its use, and issues a call to action.
Evidence for Telerehab
We will briefly delineate the evidence presented in this article in support of telerehab:
- There is considerable emerging evidence for the effectiveness of telerehabilitation for musculoskeletal, neurological, and cardiorespiratory conditions.
- Several recent meta-analyses have demonstrated that telerehab is at minimum as effective as face-to-face therapy for improving the following:
- Physical function and pain in individuals with arthritis and spinal conditions and after elective musculoskeletal surgeries;
- Exercise outcomes for people with chronic obstructive pulmonary disease; and
- Activities of daily living, balance, health-related quality of life, and depressive symptoms after stroke.
- In some instances, telerehab has been more effective than traditional therapy.
In accordance with this scientifically-supported line of thought, Carolyn Vandyken and Sinead Dufour, in Embodia's online healthcare course, speak on telerehab as the vehicle for rehabbing the treatment of musculoskeletal (MSK) problems.
Carolyn and Sinead use low back pain (LBP) in MSK practice as their case study and example, however, the information they present can be applied to a wide range of MSK problems.
Low Back Pain Myths
To start, let us take a look at some LBP myths or unhelpful beliefs from O'Sullivan et al., 2020!
We know as a profession that low back pain is a major global challenge. But unfortunately, despite many treatment options, correlated disability continues to increase.
We also know that the majority of low back pain is not serious and cannot be linked to a specific structure.
Tissues heal. Full stop.
After 12 weeks, tissues are healed after an injury.
That means that what we are left with is: Things are tight, things are weak, or the system has become sensitized. If we keep things that simple, then persistent pain does not have to be so complicated.
In order to improve patient outcomes, we need to adopt an integrative rehabilitation practice.
What Is Integrative Rehabilitation?
Grounded in the World Health Organization's definition of health, Integrative medicine and rehab are defined as healing-oriented, taking account of the whole person, including all aspects of lifestyle. Emphasizing the therapeutic relationship between practitioner and patient. Informed by evidence and making use of all appropriate therapies.
What Is Our Current Model?
The practitioner is the authority: We fix the problem, while the patient is the passive recipient, the fixee - a unidirectional approach.
Bio-focused: Within the bio-psycho-social framework, we are really good at focusing on the bio, and despite understanding the importance of the psycho and social, we tend to inform patients that that is outside of our scopes of practice.
The research is demonstrating that social and psychological factors are important contributors associated with LBP and associated disability.
If we could rearrange the name of this framework to socio-psycho-biological in the order that the research is demonstrating the importance of these factors. Maybe we would shift our overt focus on the bio component to the other two and help patients escape the persistent loop of suffering.
We need to move away from the mostly biological framework. Instead, adopting an integrative socio-psycho-bio approach that looks at the provider as the guide and the patient as an empowered team member.
Below is an infographic depicting rehab as it currently is, versus reframed rehab.
Reframed Rehab Inforgraphic
Telerehab provides us with the important opportunity to provide integrative rehab.
The time has come, we need to start reframing how we look at MSK pain, virtual care will help us make that transition.
Rehabbing Rehab with Telerehab
Telerehab facilitates the application of integrative rehab and yields results!
- Privacy: Integrating the social and psychological aspects of the bio-psycho-social framework requires asking some often uncomfortable and probing questions. If your practice does not have a private office, it may be difficult (or quite awkward for both patient and practitioner) to ask some of these questions.
- Less confrontational elements: The screen removes some confrontational issues, thereby allowing us to touch on sensitive issues with greater ease and comfort.
- Cannot rely on passive care: We cannot touch patients during virtual visits, therefore we are forced to step away from passive care, allowing patients to become much more active participants in their own care.
Case Study Evidence From Course
In this course, Carolyn Vandyken spoke about a case study patient, Mr. Smith, who came in for LBP but had numerous other comorbidities.
Carolyn saw Mr. Smith virtually for 4 visits before she saw him in person for their 5th visit (a pelvic health exam).
During the first 4 sessions, Carolyn and Mr. Smith were able to quite considerably reduce some of his pain and self-reported emotional distress.
To understand this case study in greater depth, learn more about virtual pain management, learn about the research supporting virtual care and integrative rehab as well as learn some virtual care practical considerations, follow our link below.
Tools for Telerehab
Video content becomes of the utmost importance when you are seeing clients virtually.
Both Carolyn and Sinead use Embodia for Home Exercise Prescription with their patients and consider it to be an integral part our their practice (we didn't pay either of them to say that).
Check out the following video from the course in which Sinead discusses some practical considerations of virtual care.
Virtual Care Practical Considerations
Learn More About Embodia HEP
To learn more about our home exercise prescription, we invite you to take a look at our blog or course below:
Course: Embodia for Home Exercise Prescription
Telerehab Call to Action
While COVID-19 continues to spread throughout the world, telerehab may be the new norm.
Many clients are open! A survey of 254 individuals with chronic respiratory diseases found that 57% were technologically competent and 60% were willing to use telerehab (Quigley et al., 2020).
Telerehab offers rehabilitative professionals opportunities to provide innovative, integrative, safe and effective treatments.
Let's take our practices online!
Quigley, A., Johnson, H., McArthur, C. (2020). Transforming the provision of physiotherapy in the time of COVID-19: a call to action for telerehabilitation. Physiotherapy Canada: 20200031.
Carolyn is the co-owner of Reframe Rehab, a teaching company engaged in breaking down the barriers internationally between pelvic health, orthopaedics and pain science. Carolyn has practiced in orthopaedics and pelvic health for the past 34 years. She is a McKenzie Credentialled physiotherapist (1999), certified in acupuncture (2002), and obtained a certificate in Cognitive Behavioural Therapy (CBT) in 2017.
Carolyn received the YWCA Women of Distinction award (2004) and the distinguished Education Award from the OPA (2015). Carolyn was recently awarded the Medal of Distinction from the Canadian Physiotherapy Association in 2021 for her work in pelvic health and pain science.
Carolyn has been heavily involved in post-graduate pelvic health education, research in lumbopelvic pain, speaking at numerous international conferences and writing books and chapters for the past twenty years in pelvic health, orthopaedics and pain science.
Dr. Sinéad Dufour is Assistant Clinical Professor in the Faculty of Health Science at McMaster University. She teaches and conducts research in both the Schools of Medicine and Rehabilitation Science. She completed her MScPT at McMaster University (2003), her PhD in Health and Rehabilitation Science at Western (2011), and returned to McMaster to complete a post-doctoral fellowship (2013). Her current research interests include: conservative approaches to manage pelvic floor dysfunction, pregnancy-related pelvic-girdle pain, and interprofessional collaborative practice models of service provision to enhance pelvic health.
Sinéad stays currently clinically through her work as the Director of Pelvic Health Services at The World of my Baby (the WOMB) in Milton, Ontario.