Ep 186: Adding telerehabilitation to your clinical practice, with Dr Belinda Lawford

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] We use someone who started delivering telerehabilitation for the first time during the pandemic or perhaps you're an early adopter. Have you ever wondered how effective delivering rehabilitation via a screen is versus seeing the patient in the clinic? The pandemic era physical distancing

[00:00:39] measures might have ushered in a change in the way clinicians delivered musculoskeletal care, but is it a good substitute and how do patients feel about telerehabilitation? My guest today is here to answer all those questions and more. Dr Belinda Lawford is

[00:00:54] a physiotherapist and musculoskeletal researcher at the Centre for Health, Exercise and Sports Medicine at the University of Melbourne in Australia. She has a special interest in non-surgical treatment strategies for people with osteoarthritis, in particular exercise therapy, weight loss and digital models of care. Dr Belinda Lawford, welcome to

[00:01:15] JOSPT Insights. Thank you so much for having me. It's a pleasure to be here. It's a pleasure to have you on the podcast Belinda and I'm really excited today to talk about telerehabilitation which I think certainly became very prominent in all of our minds

[00:01:30] during the pandemic. Some of the people listening to us today may have been early adopters, so to speak, of telerehabilitation and been practicing it before the pandemic. It's certainly been around for a while. And today we're focusing on telerehabilitation

[00:01:45] for musculoskeletal pain conditions, particularly in your area of expertise in osteoarthritis Belinda. What are the broad benefits of telerehabilitation for patients? So there's a few kind of obvious benefits of telerehab and I might use telihelth and

[00:02:02] telerehab kind of intermittently. I mean the same thing. I guess one of the obvious advantages is the increased accessibility of healthcare services which is obviously really important for people who might have struggled to access services in person

[00:02:15] because they had mobility issues or some kind of other issue that prevented them from going in person to clinics and also people in rural or remote areas which is really important. We're all living in Australia, there's a scarcity of healthcare services

[00:02:28] in rural and remote areas so telerehabilitation opens services up to those people. And on top of that I think it's the convenience. So you know people don't have to travel to clinics in person, then I have to be in a waiting room for a while,

[00:02:42] they don't have to find parking or be in traffic. All those sorts of things is definitely a big one that people talk about regularly. And I think a lot of people find it really easy so they're comfortable talking on Zoom with a

[00:02:53] clinician. They feel really comfortable in their own home and a lot of people especially in osteoarthritis and some of our previous research found that the feeling of being comfortable in their own home actually helped them better engage with their exercise program because they felt like they were

[00:03:08] bringing the physio or whoever it was sort of into their home even though they're on a screen and they're kind of doing the exercise program in the environment that we're doing it in anyway. So it kind of had that kind of advantage of

[00:03:20] helping them integrate that exercise into their daily routine. That all sounds great from my perspective as a patient. Most of the people who are listening today are probably clinicians. What's in it for us as musculoskeletal rehabilitation clinicians? What are the benefits of

[00:03:38] offering tele-rehab or telehealth as a service? We've done some research in this as well and again that accessibility so clinicians can access groups of patients who they maybe previously couldn't. So again, maybe those who had mobility issues or anyone who kind of found

[00:03:55] accessing their in-person difficulty kind of opens their services up for those people. And we also found that sort of surprisingly when clinicians used telehealth they found that they could spend more time focusing on education and communication because telehealth obviously takes that

[00:04:13] expectation of getting hands-on care completely away because that's not possible. So there's kind of a more personal conversation that often happens. And like I said, this bigger focus on education, which is definitely good especially for osteoarthritis because we know that

[00:04:29] education and is recommended in hands-on care isn't sort of part of the core recommended treatments. And some clinicians as well found that telehealth is convenient and easy for them as well, depending on how else they're kind of juggling other consults but then they're doing a bit

[00:04:43] of in-person and a bit of telehealth. Sounds like there's clear benefits of tele-rehab, telehealth, digital health, whatever term we want to use. Like you, I may slip into using some terms interchangeably. Patients and clinicians though are often

[00:04:59] a bit skeptical about tele-rehab. You recently led some work where you asked patients with chronic knee pain about how they felt about doing tele-rehabilitation. And we've published this work in JOSPT, we'll link to the paper in the show notes for people who are interested

[00:05:16] to follow up. First up, Belinda, what was a bit special about this study? And then let's talk about what you found. Most prior studies that have looked at people's perceptions about telehealth have involved people who sort of knowingly signed up for a

[00:05:32] telehealth clinical trial. So, you know, they know that the projects involve telehealth. They think they're interested in telehealth and they've volunteered for that trial. So some of those findings are a bit more biased towards people who are already willing to

[00:05:46] use telehealth and maybe already have positive perceptions about it. So this new study, we used people who had participated in a randomized control trial where they didn't know that they were going to be randomized to telehealth. So they were told that

[00:06:03] they'd be randomized to one of two groups and that the physiotherapy care would be provided in two different ways. But they didn't know that one of those ways was going to be telehealth. So then half that cohort will obviously randomize to the telehealth

[00:06:15] arm and then all found out they were going to get telehealth. And we had access to this quite unique cohort where we could ask, you know, what they felt about it when they were naive users. So we used this sample of people and we asked them what

[00:06:29] they thought about telehealth once they'd be randomized to that group. So before they started the intervention, but once they found out they got telehealth, we asked them what they thought about telehealth and why they felt that way. And then we also

[00:06:40] asked them at the end of the intervention what they then thought about telehealth then. So we kind of looked at how their perceptions changed over time. When people were enrolled, so again, before they started receiving telehealth, around one third, I think it was 36% of participants

[00:06:56] actually felt negative towards telehealth. The reasons for that were, you know, they weren't sure that it was an effective way to receive care. They thought that the physio could see or touch them and that, you know, in person care was a better

[00:07:10] way to receive healthcare for their knee pain. They also also thought they wouldn't be able to communicate effectively with the physio by telehealth. And then a bunch of people also just thought that they weren't good with technology and that, you know, they didn't want to use

[00:07:24] telehealth, but they were a bit apprehensive about that. There were around 50% of people who I felt positive about telehealth in enrollment, and then a small proportion, so 15% were neutral, so they didn't really feel positive or negative. But when we looked at how people then

[00:07:41] felt after they'd finished the intervention, around six in ten of those people who were initially negative about telehealth actually felt like it exceeded their expectations. And some of the reasons why that they found it was a lot easier than they thought it would be. They were

[00:07:56] surprised by the benefits and the effectiveness of telehealth. They found they developed a really strong rapport with the physio, which again is quite surprising to them. And again, that convenience that I spoke about earlier was definitely a factor that helps sort of shift their perceptions. But it's also

[00:08:13] worth noting that around a quarter or 23% of people were not at all or only slightly willing to use telehealth in the future after that finished the intervention. So these people, they just preferred having sort of hands on care from the physio. They

[00:08:29] felt like telehealth didn't allow the physio to sort of adequately observe them or assess their need for. And some just preferred in-person care or just didn't like telehealth. So you know, it's not for everyone, but for a lot of people, you know, their perceptions about telehealth do

[00:08:43] change up that firsthand experience. It's really interesting. And it sounds like for a group of people, there's access, there's getting over the trying to get used to the technology and understand how to access the technology. And once once I can do that, fine, this is great. And for

[00:09:01] another group, there's it sounds like there's a bit of understanding of what physio, what treatment is going to involve for me and what is actually I value care. And I guess convincing someone that not having to touch them and not

[00:09:14] physically being in the same room is still an avenue through which you can as a physio deliver, I value care for people with with chronic knee pain on osteoarthritis. And then as you say, there's another group of people for whom it's

[00:09:27] just not my cup of tea. I'm not going to doesn't matter what happens. I'm not going to go there. And then there's the others who are just like, yes, springing on this is great. And I love it. So we've got a whole

[00:09:37] spectrum. It sounds a bit like there's an opportunity here to tailor and to offer different services so people get a bit of a choice. And I think as as humans, we like to have a little bit of a choice. So what can

[00:09:50] clinicians who are listening to us today, Belinda and people who want to offer an effective tele rehab service for patients with osteoarthritis? What can clinicians do to help people feel like they're getting quality out of that tele rehabilitation appointment? So one of those key reasons

[00:10:08] people maybe apprehensive or have negative feelings about telehealth at the offset is because yeah, they feel like the physio needs to see or touch them for care to be effective. In our paper, we sort of recommended that clinicians or service providers develop essentially effective marketing and consumer education

[00:10:25] resources that reassure people that telehealth you know, we know especially in a way the area I mean that telehealth is really safe and effective for people. So this information might include some really clear messaging about the the providers but also the cons of

[00:10:40] telehealth so that can help people make a decision about whether they want to use it or not. Like I said reassurance that it is safe and it is effective and that we have quite a lot of evidence that supports that now. And to reiterate

[00:10:52] that fact that especially for osteoarthritis or OA, hands on care is not necessary or one of those core recommendations for care to be effective. And I think also offering people sort of risk free ways to try telehealth if they are apprehensive and help them make a

[00:11:08] decision about whether they do or don't want to use it. So things like having a mock consultation with people, reassurance that they you know they don't have to stick with telehealth they can maybe try telehealth if they don't like it they can go back to

[00:11:20] in-person consultations if they want or having an administrative staff member if someone's available to kind of do a mock consultation or troublesuit troubleshoot technological issues with people might help some shift some of those negative perceptions and you know promote uptake of telehealth trying to ease people into

[00:11:39] using it in a like I said a risk free way. And I guess as clinicians too we need to feel comfortable using the technology and the tech and the privacy regulation around tele rehab, telehealth in different jurisdictions will look different and I think by now probably most people

[00:11:58] are maybe even more familiar than they ever thought that they would get with those sorts of legal requirements and the technology but if you if you can't drive it as a clinician then it's not going to work clearly so getting familiar and comfortable with

[00:12:12] using the tech as a clinician is is also of course really important. Now you're part of a research group very productive research group in Melbourne in Australia doing lots and lots of work on tele rehabilitation particularly for osteoarthritis as we talked about at the start of the

[00:12:27] interview. What do you see are the key components for an evidence based plan for managing osteoarthritis whether it's got a tele rehab component or not. What are the key or the core components that clinicians where clinicians really should look to include in an effective plan for

[00:12:46] managing osteoarthritis? Poor evidence based care recommendations for OA or osteoarthritis involves long term self management of symptoms and things like education, exercise and weight loss if required and definitely education and exercise is where we as a group have focused most when we're looking at tele health

[00:13:05] and we've done a bit in weight loss as well but definitely education and exercise and they lend themselves really well to tele health we found as well because you know they don't have to be hands on and we found you know it works really well when they're not

[00:13:16] hands on because like I said there's that better ability for clinicians to focus on communication and education because there's no ability for hands-on care if people even wanted that. Clinicians say that it does help them better focus on those core management principles for people with

[00:13:34] OA as well. Focus on communication from the clinician side but also the patient side they feel like they often have a more personal conversation over tele health can really help them feel like they're getting that person centered care which we know is really

[00:13:47] important as well and building a really strong therapeutic alliance which is something that I guess initially when we started doing research in tele health we thought there was probably a misconception you can't build a strong therapeutic alliance via telephone or via video conferencing but we found that

[00:14:04] in both you can even in telephone delivered care you know when you can't even see the physio you often have quite strong therapeutic alliance so I think there's a lot of things to do with management of OA that lends itself really well to

[00:14:17] tele health. It's a really good point you bring up about the telephone versus the video conferencing because I think sometimes we forget that tele health can look as very basic as giving someone a phone call and in many cases that's that's enough and it's appropriate so

[00:14:34] it doesn't always mean that you've got to go to the next step and the really high tech or the more complex technology to deliver an effective program of care. Tele health digital health tele rehabilitation is often touted as a way to help people access health care and we

[00:14:51] talked about that earlier on one of the biggest challenges though I think is this idea of the digital divide where there's inequity in people's access to internet services or at least services that allow them to connect online and sometimes it's expensive for people sometimes it's simply that

[00:15:10] they live in an area where there isn't good mobile phone reception lots of different reasons for the digital divide. How do you think musculoskeletal rehab clinicians can continue to work towards equity in the care that we provide because really I think what we're talking about with

[00:15:26] overcoming the digital divide is about bringing more equity into how people access health care. Guess that the first thing to acknowledge like we've already touched on is you know telehealth isn't for everyone you know some people literally can't do it because they don't have you know phone

[00:15:41] reception in their home or they don't have internet and like we said some people just just don't want to use it as well so it's not that we think telehealth can kind of replace in person services it's more sort of a good option for people

[00:15:53] who might want to use it. And like I mentioned we did find in in our study that many people were apprehensive about using that technology especially if they never use Zoom before. They just weren't that confident in their skills using a computer. But again as I mentioned after

[00:16:11] that had first hand experience a lot of those people actually were quite positive about telehealth and they found that the technology was a lot easier to use than they thought if there's a way to help sort of ease patients into using that technology.

[00:16:25] So in in our study all participants were provided with quite detailed instructions on how to download Zoom, how to use Zoom, how to check that their audio is working. All those sorts of things help them you know have confidence that they would work and that

[00:16:38] they would know how to use it. And they were also given the option to you know try out their connection with a research staff member as well if they just wanted to double check that they knew how it would work before the actual first physio consult.

[00:16:50] So I think that's a way to help those people who are yeah maybe a bit apprehensive about using Zoom or whatever tele-rehab technology. Now the thing that you did just speak about is telephone, which is sometimes kind of forgotten when we talk about telehealth and it's definitely

[00:17:05] you know another option and some of our work has been in telephone and to tell you about delivered care which we found has similar advantages to video conferencing. So people generally really liked using it. They found it was really easy to use. They found they had these

[00:17:19] really personal conversations with their physio. So it's definitely another option for people who either don't have internet access or they're just not confident using a computer or using Zoom. They're great suggestions and I like the idea of telephone. It's a lower cost device or good ideas, I think.

[00:17:38] Belinda as we start to wrap up what are your key messages for clinicians who are thinking about getting more into tele-rehabilitation or have been considering how it might fit into their clinical practice if at all? It's important to acknowledge as well that a lot of clinicians

[00:17:54] are apprehensive about using telehealth and there's a lot of really good evidence now that telehealth is effective and it's not worse than in-person care. The paper that we've been talking about today that just got published in Joe SPT, it was nested within like I said this

[00:18:10] randomised control trial that I'll mention it was published a couple of months earlier this year in the Lancet and it was really the first non-inferiority trial that compared telehealth consultations to in-person consultations. So the first one that's done that in Neostrathrata, so chronic knee pain at least,

[00:18:27] and they found that telehealth was non-inferior to in-person consults. They also found that telehealth had some additional benefits so people who were in the telehealth have adhered better to their exercise program and they also had greater improvements in physical activity. I think a final thing

[00:18:44] to highlight was that telehealth actually had some cost effectiveness benefits as well that was superior to in-person care. So there's like I said, a lot of really strong evidence out there now that you know, telehealth is effective. So I guess hopefully that helps

[00:18:57] clinicians who are still a bit skeptical about its effectiveness. There's some really good food for thought there, Belinda and thanks for sharing the Lancet trial. We'll link to that one in the show notes as well for people to find. Dr. Belinda Loughard, it's been so great having you

[00:19:13] on the podcast to share what's going on in telerehabilitation and osteoarthritis and giving us some ideas about how we can incorporate these sorts of technologies better into our clinical practice to ultimately provide the best quality care that we can for patients. Thanks for joining me on JOSPT Insights.

[00:19:32] Thanks so much. It was great to chat to you. Thanks for listening to this episode of JOSPT Insights for more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice. Subscribe to JOSPT Insights on Apple Podcasts, Spotify, Tune In, Stitcher, Google

[00:19:54] or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and raid on reviewers. To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter, we're at JOSPT and Facebook, we're JOSPT official.

[00:20:10] Talk with you next time.