BLOG: Telerehabilitation postoperative care after COVID-19
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Editor’s note: In response to the COVID-19 pandemic, telehealth use exploded in 2020 as an integral patient communication modality for many health care systems. Telehealth not only provides the ability for virtual communication between provider and patient, but also may be used to remotely manage a patient’s physical therapy needs. This blog reviews the use of telehealth for postoperative joint arthroplasty rehabilitation.
- Sam Dyer, PA-C, MHS
PAOS president
The success of total joint replacement surgery is highly dependent on postoperative rehabilitation to regain strength and range of motion.
In addition to varying protocols, meeting the demand for postoperative physical therapy (PT) is already challenging for many reasons including a nationwide shortage of therapists, decreased access to appointments as our population ages and the need arises, health insurance limits on the number of PT visits and costly out-of-pocket PT visits. More recently, the challenge of formal in-person rehabilitation has been further complicated by COVID-19 resulting in the need to avoid in-person contact, enclosed crowded spaces and the need for social distancing.
Rehabilitation realm
Virtual health care visits have become a reality and are extending into the rehabilitation realm. Telerehabilitation is an overarching term for virtual PT utilizing various methods with categories including video conferencing, web-based therapy, telephone-based therapy and game-based therapy with visual feedback. These systems incorporate internet-based platforms with 3D tracking, motion analysis, video, web or telephone communication, gaming systems like the Nintendo Wii and virtual avatars, and applications on mobile devices to achieve at home services. With the current increase in video-based communication due to COVID-19, this method has become increasingly attractive as a way to allow immediate feedback and assessment, as well as to monitor patients to determine who may need additional in-person services quickly. Although it has been evolving during the last 20 years, current circumstances have forced the progress of this innovative method at a faster pace. Telerehabilitation has become a new focus in orthopedics in terms of clinical outcomes, patient satisfaction and cost savings in comparison to in-person rehabilitation.
Clinical outcomes
Several studies comparing clinical outcomes between telerehabilitation and in-person rehab after total knee arthroplasty have determined both groups to be equally beneficial on functional status. Some actually found improvements in climbing stairs, walking, physical function, stiffness and pain after 2 months and decreases in difficulty with squatting, running, jumping, twisting/pivoting and kneeling in the telerehabilitation group. Clinical outcomes regarding range of motion (ROM), strength, timed get up and go test (TUG), and gait are important for ensuring return to baseline after surgery. Many studies demonstrated that whether patients use telerehabilitation or in-person rehab after TKAs, neither was inferior to the other in all categories with an improvement in quadriceps strength in the telerehabilitation group. Overall, virtual and in-person therapy consistently show these are nearly equal in regard to clinical outcomes of functional status, ROM, strength, TUG test and gait.
Patient satisfaction is essential in maintaining motivation, compliance and stamina in the long recovery process after total joint arthroplasty. One study determined patient satisfaction with telerehabilitation services in categories including audio clarity, contentment with method, perceived benefit, visual clarity, likelihood of having treatment again and likelihood of recommending to friends with high satisfaction scores of greater than nine in a 10-point scale in all categories. Another expanded on the satisfaction of various aspects of the virtual platform, analyzing the satisfaction of the patient with health care services received, perception of telehealth in regard to installation and removal, and health care professional’s satisfaction with the technology which showed all aspects of patient satisfaction equally as highly rated between virtual and in-person therapy.
Health care professionals rated the quality and performance of the technology with an average rating of satisfactory or good at least 95% of the time in reliability, voice/image synchronicity, refresh rate, sound quality and operability of the peripherals. In current research, patient satisfaction of virtual therapy seems to measure up to that of clinic-based therapy.
Managing health care costs continues to be a priority, and finding a reliable and cost-effective way to manage postoperative therapy is vital. This leads to, perhaps, the best push for virtual rehabilitation at this time. A Canadian study found that for total intervention cost, telerehabilitation saved the health care system 18% of the cost incurred for in-person home rehabilitation when the patient lived farther than 18.6 miles. Cost was then further explored in another U.S. study analyzing the primary outcome of total health care costs for the 12-week post-hospital period showing that virtual PT had lower costs than in-office PT with a median price of $1,050 compared to $2,805, respectively. Although these costs only included billable expenses, these results provide a small window into the added benefits of telehealth on payers and patients.
Greater awareness
COVID-19 has brought greater awareness of telerehabilitation, with the unavoidable increase in need for at-home therapy and rapid, large-scale integration of telehealth. With many studies showing virtual rehabilitation being equally effective as in-person rehab in regard to patient satisfaction and clinical outcomes, the significant decrease in cost should add to the benefit of continuing to implement virtual rehabilitation into postoperative care.
This is not to say that telerehabilitation should become the only option of therapy; however, it can be used adjunctively with in-person therapy or exclusively. Furthermore, the already high demand for at-home therapy should prompt research on the various methods of telerehabilitation to find cohesive guidelines for postoperative management, as well as to investigate patient and health care professional’s preferences.
Other aspects possibly leading to further benefits include zero wait time in starting therapy after surgery, engagement in more frequent and regular in-home exercises, the use of telerehabilitation to reach patients in rural areas, and to encourage more opportunity for patients to manage their own health and well-being. With the uncertainty of how COVID-19 will continue to impact the specialty of orthopedics, the continued need for innovative approaches of providing non-contact care should be explored through telerehabilitation.
References:
Bini SA, et al. J Telemed Telecare. 2017;doi:10.1177/1357633X16634518.
Moffet H, et al. J Bone Joint Surg Am. 2015;doi:10.2106/JBJS.N.01066.
Piqueras M, et al. J Rehabil Med. 2013;doi:10.2340/16501977-1119.
Prvu Bettger J, et al. J Bone Joint Surg Am. 2020;doi:10.2106/JBJS.19.00695.
Russell TG, et al. J Bone Joint Surg Am. 2011;doi:10.2106/JBJS.I.01375. PMID: 21248209.
Tousignant M, et al. Telemed J E Health. 2011;doi:10.1089/tmj.2010.0198.
Tousignant M, et al. J Med Internet Res. 2015; doi:10.2196/jmir.3844.
Wang X, et al. BMC Musculoskelet Disord. 2019; doi:10.1186/s12891-019-2900-x.
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