Telerehab has become popular with physiotherapists this year in the wake of the current pandemic – however it has existed well before 2020 and will likely continue long after. The advantages, when done right, are huge and research(1) has(2) shown similar outcomes in clinical success between telerehab and in-person therapy.
In this article I share 8 tips to enable you, and your patients, to get the most out of your telerehab.
1: Have your equipment near you
One of the best ways to make your telerehab process more efficient is to have your desired equipment readily accessible. This applies to both you and your patient and can include:
- Weights and/or therabands for strengthening exercises
- A bed or couch if doing exercises in a lying position
- Foam rollers
- A chair with legs (not wheels!) or a counter if doing balance exercises
- A dowel/broomstick if assessing or teaching movements and/or if teaching shoulder ROM exercises
2: Have easy to assess, reproducible outcome measures
One of the turn-offs of telerehab for clinicians and patients is the lack of an in-person, hands on assessment. This can be valid in certain situations, such as if a client has a ruptured ACL or a L4 nerve root deficit that may make them a surgical candidate, but in many situations a telerehab assessment is fine.
That said – to document objective progress, especially if you deal with insurance companies and/or patients who are pessimistic, it is nice to have some objective ways to measure improvement. These can include:
- Ortho Toolkit has numerous questionnaires that can be filled out online.
- Side note: please make sure the nature of Ortho Toolkit fits within the rules and regulations of the regulatory body that you practice under!
- For balance:
- Single leg stance
- mCTSIB and BESS tests (you can use a pillow instead of a mat)
- 4 Item Dynamic Gait Index (just the first four items of the original Dynamic Gait Index)
- For strength:
- Upper body: max repetitions on wall pushups or floor pushups
- Lower body: max repetitions on weighted squats, split squats and/or calf raises (single or double leg)
- Core: max plank or side plank times (can be done against a wall for lower-functioning clients)
- For balance and lower body strength:
- 5 Time Sit To Stand Test or 30 Second Chair Stand Test
Also – understand that these tests may not be 100% done the exact same way as they are done in research studies. That’s fine – just make them consistently reproducible.
3: If possible – keep work and personal life separate
I’m lucky that where I work we have separate computers and work numbers. This makes things easier to keep work and life separate and maintain a balance.
If you’re doing telehealth from home I recommend having your own separate workspace.
4: Keep appointment times consistent
One piece of feedback I got early on from patients in the telerehab process is to keep the appointment times fairly consistent. Patients, even in normal practice, like to have consistent appointment times – and it can be a pain in the butt for patients to deal with different links for different appointment times on them. It can’t always be perfect – but do the best you can.
5: If in doubt – start a bit easier
One of the big barriers I’ve found with telerehab is that some patients, particularly middle-aged or older clients who may never have exercised before in their lives, don’t always feel confident doing exercises on their own without an experienced professional physically there.
In these cases, while the overload and adaptation gods may curse me, you may need to start the client with easier exercises than you would normally use in order to gain their trust.
6: Brush up on your cueing game
One of the disadvantages of telerehab vs in-person is the absence of tactile (touch-based) cueing. This can be an issue when working with clients who have poor body awareness and difficulty executing exercises. Two of the methods I’ve found helpful to correct exercise technique are:
- Mirror coaching: where you first demonstrate what they’re doing and then how you’d like the exercise to be done. Props to Sheridan College Kinesiology Professor Trevor Cottrell for teaching me this.
- Verbal cueing: coaching them into the positions you want. While external cues have gotten all the focus & praise in the media, let’s face it, for most physio exercises that aren’t high performance based (excluding sports rehab) I’d rather you use internal cues if the external cues aren’t working.
Some examples of external cues versus internal cues are:
|Chest up (squatting)||Show me the logo on your shirt|
|Lats tight||Bend the bar|
|Butt back||Sit to the back of the chair|
One of the best resources I’ve found for exercise coaching/cueing is Nick Winkelman. He has a great open access paper at this link(3) that summarizes this information.
7: Learn MDT
MDT has gotten a bit of a bad rap in recent years – but, for clients who do have a directional preference, it can be a very easy & convenient way to simplify a telerehab assessment & home exercise program. Unfortunately it’s taught and understood so incorrectly that many people think of it as “3 sets of 10 back extensions/sloppy pushups or it doesn’t work.” In reality – it applies to all joints and all directions.
Side note: for patients who are in an acute inflammatory phase post-injury, or tend to have a heavy sensitization component to their pain (i.e. constant diffuse pain where almost everything is an aggravating factor) I am more cautious with MDT as it can flare people up.
8: Up your exercise prescription game!
I still talk to many colleagues and lay-people that ask “how can you do physio online without hands-on?” The truth is – it works well for me as I’m a predominantly exercise & education based therapist. Unfortunately – that isn’t often the case as we’ve overprioritized passive treatment so much.
If you’re looking to learn more about exercise prescription I advise you read this old article(4) of mine that provides many different resources to people & courses for progressing your exercise prescription abilities.
While it may seem daunting – telerehab can be very beneficial and these tips can make it even better. As always – thanks for reading.