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Telerehabilitation to the Rescue: Access to Exercise Rehabilitation During the Covid-19 Pandemic

Edited by: Jasleen Sekhon


Disclaimer:

The information provided in this article is not medical advice. Please speak to a healthcare professional if you are interested in exercise rehabilitation treatment or telerehabilitation.


Introduction

Every Wednesday at 4:45 pm, you greet the receptionist at your local Cardiac Rehab clinic with a cheery smile. It has been 1 year since your last heart attack, but you feel yourself getting stronger and healthier each week due to the help of your cardiologist and exercise therapist. As you are waiting for your 5:00 pm appointment, on the waiting room TV you see a bright, red banner flash across the news channel.

“BREAKING NEWS- World Health Organization declares COVID-19 Virus Pandemic.” A million questions rush through your head, but the most important one is regarding your health…

Rehabilitation is defined by the World Health Organization as, “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (1). Exercise rehabilitation is one common type of rehabilitation (1). There are many benefits to exercise rehabilitation such as reducing the impact of injuries/illnesses/diseases, minimizing the disabling effects of chronic health conditions, reducing hospitalization, and more (1). The exercise rehabilitation workforce consists of many different health professionals including physiatrists, physiotherapists, chiropractors, exercise physiologists, occupational therapists, cardiac rehabilitation specialists, exercise therapists, and more (1).

On March 11th, 2020, human history was changed forever. The World Health Organization declared the COVID-19 virus outbreak as a pandemic (2). Within the following days, many countries, including Canada, began to impose restrictions to decrease the spread of the virus. These mandatory restrictions, along with fears of the virus, had a significant impact on accessing healthcare. If you were ever an exercise rehabilitation patient, you would know that there is close contact between the patient and the healthcare provider. During the time of a highly contagious virus, exercise rehabilitation care seemed impossible to receive due to the social distancing requirement and lack of personal protective equipment.


So, during the initial phases of the pandemic, how did the access to exercise rehabilitation change?


In Ontario, Canada, the government announced the closure of non-essential businesses, including non-essential healthcare providers, on March 24th, 2020 (3). Exercise rehabilitation healthcare providers were no longer allowed to care for patients in person unless it was an emergency (3). Healthcare providers realized that many patients relied on rehabilitation care for their health and well-being. No one’s health concerns magically disappeared because of this pandemic. To address this issue, the quest for innovative and alternative approaches to providing rehabilitation during a pandemic had begun.


The Rapid Shift to Virtual Care

The virtual world became highly praised during this pandemic. This virtual world helped many students, workers, and families and loved ones stay connected from afar. Interestingly, it became a vital tool for exercise rehabilitation healthcare providers. Telerehabilitation is defined as the delivery of rehabilitation across a distance using information and communication technologies such as telephone, text messaging, email, web-based resources, videoconferencing, and wearable technologies (4). Telerehabilitation allows for the communication, asynchronous and/or synchronous, between the healthcare professional and patient without direct physical contact. Telehealth systems have existed for years, but prior to the pandemic, there were low rates of utilization for routine care (5). The use of this technology surged with the pandemic (5). During the initial lockdowns, many different healthcare professionals took advantage of this system to continue providing care.

Delivering Cardiac Rehabilitation in Canada

Cardiac rehabilitation healthcare workers were quick to switch to virtual care. Cardiac rehabilitation programs (CRP) were suspended in-person due to physical distancing recommendations during the initial stages of the COVID-19 pandemic. (6). This rehabilitation program is important to many Canadians since it reduces hospital readmissions, mortality, and secondary events in cardiovascular disease patients (6). In Canada, the second leading cause of death is heart disease (7). Additionally, prolonged closures of CRP would increase adverse events, cardiac-related emergency department visits, and burdens on acute services (6). As well, if these events were to occur, this vulnerable population would potentially be exposed to the COVID-19 virus (6). Knowing all this information, these healthcare providers responded quickly. They utilized the telerehabilitation system to provide virtual cardiac rehabilitation (6). The majority of the closed CRPs used some sort of telerehabilitation to continue providing care (8). Within two months of the COVID-19 pandemic, the importance of and need for telerehabilitation was recognized and advocated for (8).


Benefits of Telerehabilitation There are many benefits to telerehabilitation. Some benefits include, but are not limited to:

  • Telerehabilitation can deliver treatment beyond the boundaries of healthcare facilities (9). This service allows exercise rehabilitation to be more accessible to certain populations who live far from physical rehabilitation facilities.

  • Telerehabilitation is time and cost-efficient since patients would not need to spend money and/or time on transportation to healthcare facilities. (9)

  • Telerehabilitation allows patients to receive care in the comfort of their home (9)

  • Since the pandemic has decreased a lot of social interactions for people, Telerehabilitation benefits individuals by providing social interactions through a virtual setting (10).

  • Telerehabilitation supports the safe delivery of healthcare during daunting times such as the COVID-19 pandemic (4).



Limitations of Telerehabilitation

By no means is telerehabilitation perfect. Some limitations that must be addressed. These limitations include, but are not limited to:

  • It requires technology infrastructure and staff training (5). Telerehabilitation is unfamiliar to a lot of healthcare professionals, so training is essential.

  • Patients may not have access to/afford internet, a computer, or a smart device (5). As well, weak internet service may affect the rehabilitation session (8).

  • Non-verbal cues are difficult to pick up on (4)

  • There is a lack of physical exams that can take place online (5)

  • The most complex and sickest patients may not be able to participate in this care (5)

  • There may be limited access to exercise equipment (8)

  • There are limited exercises/ rehabilitative methods a patient can perform on their own without a healthcare professional (4).


Considerations for Delivering Exercise Rehabilitation Virtually: Pulmonary Exercise Rehabilitation Case

Pulmonary exercise rehabilitation had been affected by the early stages of the pandemic (10). Dechman et al. discussed some considerations for delivering rehabilitation virtually in Delivering pulmonary rehabilitation during the COVID-19 pandemic: A Canadian Thoracic Society position statement. Telerehabilitation care must have the ability to assess the exercise capacity (10). Without assessments, positive outcomes cannot be measured. Some in-person assessments cannot be performed at home therefore alternative assessments must be used and/or created (10). Another important consideration is monitoring exercise responses (10). Healthcare providers must decide whether self-monitoring is sufficient, or if virtual real-time monitoring is needed (10). Finally, healthcare providers must consider the safety of their patients during telerehabilitation sessions (10). For example, clutter, insufficient space, incorrect exercise form, etc., can lead to injuries (10,11). Implementing these considerations in a telerehabilitation session can benefit both the patient and healthcare provider.

Conclusion

Exercise rehabilitation is used by many healthcare providers therefore many patients rely on this healthcare intervention. Exercise rehabilitation is an important aspect of a patient’s treatment plans. With the COVID-19 pandemic, many people have lost their access to these services, but alternative options, such as telerehabilitation exist. It is great to see that various healthcare providers, such as Cardiac Health and Pulmonary healthcare workers, have already made the switch to telerehabilitation. While exploring the benefits of telerehabilitation, it is crucial to study the limitations as well. In the future, more research on the difference between in-person care versus virtual care should be explored.

This pandemic has allowed healthcare professionals to explore their lifelong learning skills by discovering innovative ways to provide care. Telerehabilitation is something that surged in usage due to the pandemic, but it is here to stay for the long run.

Summary

  • Rehabilitation is defined by the World Health Organization as, “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.”

  • Telerehabilitation is defined as the delivery of rehabilitation across a distance using information and communication technologies.

  • The use of telehealth and telerehabilitation services surged with the pandemic.

  • Benefits of telerehabilitation include delivery of treatment beyond the boundaries of healthcare facilities, cost-efficient and time-efficient, increased social interactions, safe delivery of treatment during a pandemic, and more.

  • Limitations of telerehabilitation include lack of access to technology, cost of technology infrastructure and staff training, lack of access to exercise equipment, limited exercise/rehabilitative methods, and more.

References

  1. Rehabilitation [Internet]. World Health Organization. World Health Organization; [cited 2021Jun30]. Available from: https://www.who.int/news-room/fact-sheets/detail/rehabilitation

  2. Coronavirus Disease (COVID-19) - events as they happen [Internet]. World Health Organization. World Health Organization; [cited 2021Jun30]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen

  3. Ontario Newsroom [Internet]. Government of Ontario. 2020 [cited 2021Jun30]. Available from: https://news.ontario.ca/en/release/56435/ontario-orders-the-mandatory-closure-of-all-non-essential-workplaces-to-fight-spread-of-covid-19

  4. Signal N, Martin T, Leys A, Maloney R, Bright F. Implementation of telerehabilitation in response to COVID-19: Lessons learnt from neurorehabilitation clinical practice and education. New Zealand Journal of Physiotherapy. 2020;48(3):117–26.

  5. Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, et al. Telehealth transformation: COVID-19 and the rise of virtual care. Journal of the American Medical Informatics Association. 2020;27(6):957–62.

  6. Canadian Cardiovascular Society. Guidance from the CCS COVID-19 rapid response team- the new “virtual reality”: practical approaches to the delivery of cardiac rehabilitation care during the COVID-10 crisis [Internet]. [Place unknown]: Canadian Cardiovascular Society; 2020 [cited 2020 Dec 14]. Available from: https://ccs.ca/app/uploads/2020/12/Cardiac\_Rehab\_In\_Covid\_v2.4\_Final\_17\_May\_313.pdf.

  7. Heart Disease in Canada [Internet]. Canada.ca. / Gouvernement du Canada; 2017 [cited 2021Jun30]. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/heart-disease-canada.html

  8. Marzolini S, Ghisi GL, Hébert A-A, Ahden S, Oh P. Cardiac Rehabilitation in Canada During COVID-19. CJC Open. 2020Oct3;3(2):152–8.

  9. Nuara A, Fabbri-Destro M, Scalona E, Lenzi SE, Rizzolatti G, Avanzini P. Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines. Journal of Neurology. 2021;

  10. Dechman G, Aceron R, Beauchamp M, Bhutani M, Bourbeau J, Brooks D, et al. Delivering pulmonary rehabilitation during the COVID-19 pandemic: A Canadian Thoracic Society position statement. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2020;4(4):232–5.

  11. College of Physiotherapists of Ontario. Virtual Practice [Internet]. [cited 2021Jun30]. Available from: https://www.collegept.org/registrants/virtual-practice-in-physiotherapy

Image Links: https://www.istockphoto.com/photos/breaking-news

https://www.istockphoto.com/photos/rehabilitation

https://www.istockphoto.com/photos/telemedicine

https://www.heart.org/en/health-topics/cardiac-rehab/what-is-cardiac-rehabilitation

https://wiltonphysicaltherapy.com/telehealthblog/

https://unsplash.com/s/photos/physiotherapy

https://www.istockphoto.com/photos/telemedicine

https://shrs.uq.edu.au/article/2020/05/why-telerehabilitation-so-important-during-covid-19-pandemic

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