Presentation on Tele-Rehabilitation made at Tata Memorial Centre at 2nd International Conference on Cancer Rehabilitation (Can Rehab 2019). The presentation discusses technology and clinical research for telerehabilitation, and practical experiences while treating patients online.

1. 1
Tele- Rehab
Clinical Research & Practical Experiences
26th January 2019
Tata Memorial Hospital

2. #10yearchallenge: Digital India
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Our assumptions need to change
• India 2008
– 340 mn mobile
subscribers
– ?? Smart phones, 44
mn in 2013
– ?? Data consumption,
0.26 GB/ person in
2014
• India 2018
― 1150 mn mobile
subscribers (3.4X)
― 337 mn smart phones
(7.7X)
― 4 GB/ person (15.4X)

3. Education &
Prescription
What is Telerehab
3
Communication
network
Skype
Doxy
Whatsapp/ Phone
Google forms
Exercise prescription
Youtube
Website
3D motion sensor
Webcam/ phone/ ipad
Pedometer/ fitbit
HR monitor/ watch
Information/
conversation
Supervise
Telerehabilitation is the delivery of rehabilitation services over
telecommunication networks and the internet.

4. Components of Rehabilitation
4
History Yes
Visual Observations Ok. Physical is supereior
Palpations Not possible
Special tests Some are possible. May need assitant with patient
Goal Setting Yes
Education Digital could be better
Electrotherapy Not possible
Manual Therapy Self management in some cases possible
Exercise Therapy Yes
Cryo/ Hot packs Yes, self management
Others (dry needling, taping.) Not possible
Motivation/ Community Yes
Remote administration
AssessmentTreatment
Key Components
Most components in an ‘active’ rehab can be delivered
through telerehab

5. Benefits of Telerehab
• Access to therapy
– Not just about smaller towns & villages
– Post TKR, 3rd floor – no lift
• Cost of delivery
– Telerehab can reduce therapy costs by 50%
– Facility costs are a large component of clinical costs
• Convenience/ compliance
– Increased convenience improves compliance by patients
• Quality
– Superior control on protocols, plan of care, education through recordings/ pre
programming
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Significant benefits for a country like India

6. Clinical Evidence?
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7. Large body of Clinical Research
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Significant amount of clinical research conducted
globally
Source: https://www.journalofphysiotherapy.com/article/S1836-9553(17)30092-9/pdf
• Telehealth RCTs and Systematic reviews indexed on PEDro, 2017

8. Research has been increasing
• Most of the research is 2014 onwards – in line with bandwidth and
devices availability
• Number of pages in International Journal of Telerehab,
https://telerehab.pitt.edu
– Vol 10, No 2 (2018): 104
– Vol 9, No 2 (2017): 82
– Vol 8, No 2 (2016): 82
– Vol 5, No 2 (2013): 36
– Vol 3, No 2 (2011): 38
– Vol 2, No 2 (2010): 34
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we shall increasingly get more & more evidence that
it really works
3X in 5 years

9. International Associations
• APTA (USA): “telehealth is an appropriate model of service delivery for
the profession of physical therapy…”
• APA (Australia): “we strongly advocate for the inclusion of private health
insurance rebates for video consultation”
• CAPR (Canada):
– Published guidelines for Telerehab (Sept 2017)
– Tele-rehabilitation resource guide (April 2018)
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Leading international associations support Telerehab

10. Following a journey
• Michel Tousignant, Helene Moffet, Patrick Boissy, Helen
Corriveau
– They have conducted significant research on Telerehab for TKR since
2009
– University of Sherbrooke, Quebec, Canada
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They have studied, not just clinical effectiveness but also
patient satisfaction and PT satisfaction with telerehab

11. Date Publication Title of paper Conclusion
Fall
2009
International
Journal of
Telerehabilitation
In-Home
Telerehabilitation for
Post-Knee Arthroplasty:
A Pilot Study
Telerehabilitation seems to be a practical
alternative to home visits by a physiotherapist for
dispensing rehabilitation services. Future
research is needed with a randomized controlled
trial to measure the efficacy of this novel way of
delivering rehabilitation services
March
2011
Journal of
Telemedicine and
Telcare
A randomized controlled
trial of home
telerehabilitation for
post-knee arthroplasty
There was no intergroup difference between the
telerehabilitation and conventional rehabilitation
at T1 and T2, meaning that the participants
improved equally in both groups.
June
2011
Telemedicine and e
Health
In-Home
Telerehabilitation and
Physiotherapists'
Satisfaction Toward
Technology for Post-
Knee Arthroplasty: An
Embedded Study in a
Randomized Trial
Satisfaction for healthcare services provided was
also high for both groups. No significant
difference was observed between the Tele and
the comparison groupThe Tele group participants
were thus as satisfied with the services received
as the Comparison group
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Pilot in 2009, followed by first RCT in 2011

12. Date Publication Title of paper Conclusion
March
2015
Journal of
Medical Internet
Research
Cost Analysis of In-Home
Telerehabilitation for Post-
Knee Arthroplasty
Under the controlled conditions of an
RCT, a favorable cost differential was
observed when the patient was more
than 30 km from the provider
July
2015
The Journal of
Bone and Joint
Surgery
In-Home Telerehabilitation
Compared with Face-to-
Face Rehabilitation After
Total Knee Arthroplasty: A
Noninferiority Randomized
Controlled Trial
Our results demonstrated the
noninferiority of in-home
telerehabilitation and support its use
as an effective alternative to face-to-
face service delivery
Aug
2016
Telemedicine
Journal and
eHealth
Patient Satisfaction with In-
Home Telerehabilitation
After Total Knee
Arthroplasty: Results from
a Randomized Controlled
Trial.
These results, in conjunction with
evidences of clinical effectiveness and
cost benefits demonstrated in the
same sample of patients, strongly
support the use of telerehabilitation
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…followed by a second non-inferiority RCT in 2015

13. Practical experiences
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14. Background
• ReLiva is an early adopter of using tele-physiotherapy for MSK patients
– Digital exercise prescription for 2 + years. Telerehab for over an year
– Working on cloud based tele-physiotherapy platform called ePhysio
(https://reliva.physio)
• Started to address issues of Corporate employees
• Seen many cases of tele-physiotherapy with good success
– ACL rehabs, TKR
– Post fracture rehab
– Trigger finger
– OA knee
– Back & neck pain
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ReLiva is an early adopter in using technology and tele-
physiotherapy for delivering care

15. Benefits Observed
• Saves travel time and cost
• Improves adherence to the treatment by reducing the cost of
the barriers for the patients
• We can see the patients in their own home environment
where the patients are usually more comfortable and less
anxious and hence benefits ergonomically too
• Facilitates more active patient role
• Daily monitoring can also be done if needed
• Improved utilisation of clinical resources
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16. What works well in telerehab
• Subjective assessment
• Observational analysis of the functions- posture, gait,
movement quality, range of motion, tolerance and irritability
• Education- plays an important role in treating chronic cases
• Identify needs for investigations prior to attending the patient
face to face if needed
• Exercise reviews and program upgrades + Longer rehab
durations
• Reminders/ notifications
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17. Barriers to telerehab
• Diagnosis in some cases is a challenge
– Manual tests like checking the muscle strength, reflexes, sensations
– Performing special tests
– Motor control assessment
• Connectivity issues/ technical issues
• Patient safety risks – balance/fall risks; transfers; gait
• Word of caution
– use yourprofessional judgment if telerehab is appropriate for the patient
• Decision should be case to case dependent
• Not every patient is appropriate (hearing or vision deficits, comprehension deficits)
– Therapist must understand the system/ technology capabilities and limitations
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18. Overcoming these Barriers
• Consider teaming up with local/ home care physiotherapist for the
assessment if required
• Be conservative and If needed, referral to the local GP/physio for further
physical examination
• Composite treatment
– Consultation at clinic/ hospital
– Subsequent treatment and supervision is online
– Face to face review monthly/ fortnightly
• Home care physiotherapist in collaboration with clinic/ hospital
• At the clinic or hospital
– Useful for patients who skip the OPD Rehab and goes straight home from IPD
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19. Endnotes…
• India is turning into a digital nation
• Technology basis for telerehab is getting better and advancing
rapidly
– Bandwidth, Devices, Pedometers, HR, BP sensors, cameras, 3D motion
sensing….
• Penetration of devices will continue to increase
• Telerehab delivers:
– Desired outcomes
– AT lower costs
– WITH improved access
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Consider Telerehab

20. Thank you
subodh.gupta@reliva.in
9820307393
www.reliva.in
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