Providers' Shift to Telerehabilitation at the U.S. Veterans Health Administration During COVID-19: Practical Applications

Effects of telerehabilitation-based respiratory and corrective exercises among the elderly with thoracic hyper-kyphosis: a clinical trial

BACKGROUND

Aging is associated with changes in the musculoskeletal system, including increased susceptibility to spine malalignments. Utilizing corrective exercises with a therapeutic emphasis can be beneficial in the elderly with thoracic spine hyperkyphosis.

OBJECTIVE

This study aimed to investigate the effects of six weeks of telerehabilitation-based respiratory and corrective exercises on quality of life, disability, thoracic kyphosis, craniovertebral angle, shoulder angle, cranial angle, and chest expansion in the elderly with thoracic spine hyperkyphosis.

METHODS

In this clinical trial, a total of 40 participants aged 60 and above with thoracic hyperkyphosis were randomly divided into the control (N = 20) and experimental (N = 20) groups. The experimental group performed the corrective exercises for six weeks (3 sessions per week). The control group performed general stretching exercises during the same time period. We measured the outcomes of quality of life, disability, thoracic kyphosis, craniovertebral angle, shoulder angle, cranial angle, and lung expansion before and after the intervention. Analysis of covariance (ANCOVA) was employed to analyze the data. A P-value ≤ 0.05 was considered statistically significant.

RESULTS

Quality of life (P < 0.001, Effect Size (ES): 0.44), chest expansion (P < 0.001, ES: 0.56), thoracic kyphosis angle (P < 0.001, ES: 0.31), craniovertebral (P < 0.001, ES: 0.33), cranial (P < 0.001, ES: 0.38), and shoulder (P = 0.005, ES: 0.20) angles were significantly improved in the experimental group as compared with controls. However, no statistically significant difference was observed between the two groups in terms of physical ability (P = 0.251, ES: 0.04).

CONCLUSION

It is therefore recommended that online corrective exercises be used in the rehabilitation protocol to improve the quality of life, posture, chest expansion, and disability in the elderly with thoracic kyphosis.

Acceptability of Telerehabilitation: Experiences and Perceptions by Individuals with Stroke and Caregivers in an Early Supported Discharge Program

INTRODUCTION

Telerehabilitation (TR) is a promising method for facilitating the delivery and access to post-stroke rehabilitation services.

OBJECTIVE

The aim of this study was to explore the acceptability of TR and factors influencing its adoption by individuals with stroke and caregivers.

METHODS

A qualitative descriptive approach was used. Six individuals with stroke and three caregivers participated in individual online interviews. An abductive thematic analysis was employed to analyze the qualitative data, using the Unified Theory of Acceptance and Use of Technology 2 (UTAUT-2) model.

RESULTS

Participants reported positive experiences with TR, resulting in improvements in functional abilities, such as manual dexterity, balance, and positive interactions with therapists. They found the technology easy to learn and use, facilitating engagement in TR. Participants' prior experiences with technology, along with support from caregivers and therapists, facilitated acceptance and the use of TR. The COVID-19 pandemic also motivated participants to accept TR. However, technical issues, unstable internet connections, and lack of feedback were barriers to the use of TR.

CONCLUSION

Despite existing obstacles, TR can be used to provide rehabilitation services for individuals with stroke. Addressing these barriers is necessary to promote the widespread and effective use of TR in the context of stroke recovery.

Caregiver Support Role in Occupational Therapy Video Telehealth: A Scoping Review

Caregiver involvement may facilitate patient participation in occupational therapy (OT) video telehealth. However, little is known about the extent to which caregivers participate and what they do. This scoping review aims to, 1) describe the caregiver role supporting patient participation in OT video telehealth, and, 2) identify barriers and facilitators to caregiver involvement. Findings reveal caregiver involvement in a range of OT evaluation and intervention processes, with details on what caregivers did overall lacking. Barriers and facilitators are also described. This study underscores the need for clear and robust descriptions of caregiver participation to increase best practices in video telehealth.

Telerehabilitation in the Finnish Outpatient Rehabilitation Setting from the Perspective of the Socio-Technical Systems Theory

BACKGROUND

In the development of effective telerehabilitation (TR) interventions, understanding the various characteristics affecting its practice is essential. Remote connection creates a new technically shaped environment for therapy and, therefore, previous therapy methods do not work the same way as before.

OBJECTIVE

The objective of this survey was to describe the practice of TR through the socio-technical theory approach.

METHODS

The 629 respondents to the online questionnaire included music therapists, occupational therapists, speech and language therapists, physiotherapists, and neuropsychologists. The materials consisted of five open-ended questions. The analysis combined data-based and theory-based analysis.

RESULTS

In the data-based content analysis, we identified three main categories and eight generic categories, whereas in the theory-based, we categorised the main results according to the Fit Between Individuals, Tasks, Technology, and Environment (FITTE) framework dimensions. TR is everyday-life based, it requires shared participation, and the approach has to include coaching and collaboration with the client and their close associates. The everyday-life environment is one of the main dimensions that affect all the other dimensions.

CONCLUSIONS

TR can be seen as technology-mediated home-based rehabilitation, as it can integrate rehabilitation into the client's everyday life. In TR, therapy becomes multilateral and it creates a new kind of shared partnership into outpatient therapy.

Health maintenance through home-based interventions for community-dwelling older people with sarcopenia during and after the COVID-19 pandemic: A systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has greatly impacted people's lifestyles and changed the delivery of health interventions, especially interventions for community-dwelling older people with sarcopenia.

OBJECTIVE

To summarize the components and explore the effectiveness of home-based interventions for improving sarcopenia and other health-related outcomes among community-dwelling older people with sarcopenia.

DESIGN

Systematic review and meta-analysis.

METHODS

The Cochrane Library, Scopus, EMBASE, Web of Science, CINAHL, Medline (via PubMed), and PsycINFO were searched for relevant papers published from January 1, 2010 to March 29, 2022. Only papers written in English were included. The modified version of Cochrane's risk-of-bias tool was used to assess the risks of bias in the included studies. The template for intervention description and replication checklist was used to summarize the intervention components. The mean difference (MD) or standard mean difference with a 95 % confidence interval (CI) was used to determine the effect size of studies using the same or different measuring methods. Random-effects models were in meta-analyses to pool the effects of home-based interventions on the included outcomes.

RESULTS

After detailed screening and exclusion, 11 randomized controlled trials including 1136 older people with sarcopenia were included in our analyses. Three categories of home-based interventions were identified: exercise interventions, nutritional interventions, and combined exercise and nutritional interventions. The overall analysis of the outcomes (e.g., appendicular skeletal muscle mass index, lean mass, body fat mass, handgrip strength, and gait speed), showed that the effects of home-based exercise interventions were inconclusive. Compared with passive controls, home-based exercise interventions significantly improved knee extension strength (MD = 0.56 kg, 95 % CI: 0.09, 1.03, p = 0.020) and reduced the time required to complete the Timed Up and Go Test (MD = -1.41 s, 95 % CI: -2.28, -0.54, p = 0.001). Home-based nutritional interventions were effective in improving appendicular skeletal muscle mass (MD = 0.25 kg, 95 % CI: 0.02, 0.49, p = 0.030), gait speed (MD = 0.06 m/s, 95 % CI: 0.03, 0.09, p = 0.0001), and quality of life in terms of both the physical component summary (MD = 13.54, 95 % CI: 0.73, 26.34, p = 0.040) and mental component summary scores (MD = 8.69, 95 % CI: 2.98, 14.41, p = 0.003).

CONCLUSION

Home-based exercise interventions have the potential to improve muscle strength and physical function, while home-based nutritional interventions are effective in increasing muscle mass, physical function, and quality of life. Both of these can be applied at home during and after the COVID-19 pandemic to alleviate sarcopenia and improve health-related outcomes in community-dwelling older people.

Whole Health coaching to rural Veterans through telehealth: Advantages, gaps, and opportunities

Background

The Veterans Health Administration (VHA) is one of the largest providers of telehealth in the United States and continues to lead the way in transforming healthcare services. VHA has been implementing its Whole Health (WH) initiative since 2018, a proactive practice empowering patients to take charge of their health and well-being. A key facilitator of the WH initiative is the WH coach who partners with Veterans to achieve their health-related goals. A gap exists in the literature regarding the understanding of WH coaches’ use of telehealth to engage rural-residing Veterans. COVID-19 unexpectedly interrupted in-person VHA delivery of care, including WH coaching which primarily relied on in-person delivery and focused less on telehealth. During the pandemic, WH coaches had to adapt and integrate different modalities to engage their Veteran patients. We examined WH coaches’ approaches to extending coaching to rural Veterans via technology, emphasizing the advantages of telehealth, existing gaps in telehealth delivery, and opportunities for telehealth as a coaching modality.

Methods

This project was implemented as part of a larger mixed methods evaluation regarding WH coaching for rural Veterans; this manuscript presents the findings from the qualitative data from the larger study. The qualitative dataset is comprised of data collected using three different qualitative methods: four focus groups (n = 11; 3–4 participants per group), in-depth individual interviews (n = 9), and open-ended responses from a national web-based survey (n = 140). Focus group, in-depth interview, and open-ended survey data were collected sequentially and separately analyzed following each wave of data collection. Findings from the three analyses were then collaboratively merged, compared, reorganized, and refined by the evaluation team to create final themes.

Results

Three final themes that emerged from the merged data were: (1) Advantages of Telehealth; (2) Telehealth Gaps for Rural Veterans, and (3) Strategies for Bridging Telehealth Gaps. Themes explicate telehealth advantages, gaps, and opportunities for rural Veteran WH coaching.

Conclusion

Findings highlight that video telehealth alone is not sufficient for meeting the needs of rural Veterans. Digital technologies hold promise for equalizing health access gaps; however, both human factors and broadband infrastructure constraints continue to require WH coaches to use a mix of modalities in working with rural Veterans. To overcome challenges and bridge gaps, WH coaches should be ready to adopt a blended approach that integrates virtual, in-person, and lower-tech options.

Clinicians' Experiences of Implementing a Telerehabilitation Toolkit During the COVID-19 Pandemic: Qualitative Descriptive Study

BACKGROUND

Although the COVID-19 pandemic resulted in a rapid implementation and scale-up of telehealth for patients in need of rehabilitation, an overall slower scaling up to telerehabilitation has been documented.

OBJECTIVE

The purpose of this study was to understand experiences of implementing telerehabilitation during the COVID-19 pandemic as well as using the Toronto Rehab Telerehab Toolkit from the perspective of rehabilitation professionals across Canada and internationally.

METHODS

The study adopted a qualitative descriptive approach that consisted of telephone- or videoconference-supported interviews and focus groups. Participants included rehabilitation providers as well as health care leaders who had used the Toronto Rehab Telerehab Toolkit. Each participant took part in a semi-structured interview or focus group, lasting approximately 30-40 minutes. Thematic analysis was used to understand the barriers and enablers of providing telerehabilitation and implementing the Toronto Rehab Telerehab Toolkit. Three members of the research team independently analyzed a set of the same transcripts and met after each set to discuss their analysis.

RESULTS

A total of 22 participants participated, and 7 interviews and 4 focus groups were included. The data of participants were collected from both Canadian (Alberta, New Brunswick, and Ontario) and international sites (Australia, Greece, and South Korea). A total of 11 sites were represented, 5 of which focused on neurological rehabilitation. Participants included health care providers (ie, physicians, occupational therapists, physical therapists, speech language pathologists, and social workers), managers and system leaders, as well as research and education professionals. Overall, 4 themes were identified including (1) implementation considerations for telerehabilitation, encompassing 2 subthemes of "infrastructure, equipment, and space" and "leadership and organizational support"; (2) innovations developed as a result of telerehabilitation; (3) the toolkit as a catalyst for implementing telerehabilitation; and (4) recommendations for improving the toolkit.

CONCLUSIONS

Findings from this qualitative study confirm some of the previously identified experiences with implementing telerehabilitation, but from the perspective of Canadian and international rehabilitation providers and leaders. These findings include the importance of adequate infrastructure, equipment, and space; the key role of organizational or leadership support in adopting telerehabilitation; and availing resources to implement it. Importantly, participants in our study described the toolkit as an important resource to broker networking opportunities and highlighted the need to pivot to telerehabilitation, especially early in the pandemic. Findings from this study will be used to improve the next iteration of the toolkit (Toolkit 2.0) to promote safe, accessible, and effective telerehabilitation to those patients in need in the future.

Meeting the Needs of Rural Veterans: A Qualitative Evaluation of Whole Health Coaches' Expanded Services and Support during COVID-19

The purpose of this qualitative study was to explore perspectives of Whole Health (WH) coaches at the Veterans Health Administration (VHA) on meeting the needs of rural Veterans during the COVID-19 pandemic. The evaluation design employed a qualitative description approach, employing focus groups and in-depth interviews with a convenience sample of WH coaches across the VHA system. Fourteen coaches who work with rural Veterans participated in either one of three focus groups, individual interviews, or both. The focus group data and in-depth interviews were analyzed separately using thematic analysis, and findings were then merged to compare themes across both datasets. Four primary themes were identified: bridging social risk factors for rural Veterans, leveraging technology to stay connected with Veterans at-a-distance, redirecting Veterans to alternate modes of self-care, and maintaining flexibility in coaching role during COVID-19. One overarching theme was also identified following a post-hoc analysis driven by interdisciplinary team discussion: increased concerns for Veteran mental health during COVID-19. Coaches reported using a variety of strategies to respond to the wide-ranging needs of rural Veterans during the pandemic. Implications of findings for future research and practice are discussed.

Manifestation of Generalized Anxiety Disorder and Its Association With Somatic Symptoms Among Occupational and Physical Therapists During the COVID-19 Pandemic

Purpose

The purpose of the study was to examine the level of generalized anxiety disorder among occupational and physical therapists during treatment sessions and its association with somatic symptoms during the COVID-19 pandemic.

Methods

A descriptive cross-sectional design was used in this study. Data were collected during the month of April 2021, and the study included occupational and physical therapists who practiced during COVID-19 from March 2020 to March 2021. The generalized anxiety disorder scale (GAD-7) and a modified patient health questionnaire (mPHQ-15) were used to examine self-reported anxiety and somatic symptoms among the study participants. The independent t-test was used to determine differences between groups based on GAD-7 and mPHQ-15 results. Spearman's correlation test and chi-squared test were used to find the relationships between different variables such as anxiety and somatic symptoms.

Results

The study (n = 98 participants) included 56 occupational and 42 physical therapists. An 84% response rate was achieved. GAD-7 final score was μ = 9.21 ± 5.63 with 27% reporting no anxiety, 14% mild, 38% moderate, and 21% severe. Independent t-tests on GAD-7 scores showed significant differences between therapist specializations [t₍₉₆₎ = −2.256; p = 0.026] and between therapists residing with or without their parents [t₍₉₆₎ = −2.536; p = 0.013]. The mPHQ-15 final score was μ = 9.52 ± 5.54 with 13% reporting no symptoms (n = 13), 20% mild (n = 20), 38% moderate (n = 37), and 29% severe (n = 28). GAD-7 and mPHQ-15 scores were moderately positively correlated [r₍₉₆₎ = 0.569; p <0.000]. The chi-squared test showed a significant association between GAD-7 levels of anxiety and mPHQ-15 levels of somatic symptoms [x²_{(9, N = 98)} = 70.62 p <0.000]. Therapists reported that the quality (76%) and effectiveness (20%) of their rehabilitation services were negatively impacted by the COVID-19 pandemic.

Conclusion

The majority of study participants experienced moderate to severe anxiety and associated somatic symptoms. During COVID-19, ongoing psychological counseling of healthcare professionals such as occupational and physical therapists is required to maintain positive mental health. Implications for practice are presented.

Listen to Me! - A Mixed-Methods Study of Thoughts and Attitudes Towards Participation in Pulmonary Telerehabilitation Among People with Severe and Very Severe COPD Who Declined Participation in Pulmonary Rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) is a key standard treatment for people with chronic obstructive pulmonary disease (COPD) with documented effect on symptom relief, improved physical function, and quality of life. However, referral, uptake and adherence rates remain low. Pulmonary telerehabilitation (PTR) is a safe and effective alternative to conventional PR. This study explores associations, thoughts and attitudes towards PTR in patients with COPD who decline referral to outpatient hospital-based routine PR.

METHODS

A mixed-methods study with integration of survey data (n=84) and semi-structured interviews (n=9).

RESULTS

We found a significant association between belief of effect of PTR and willingness to participate. Increasing age was significantly associated with reduced odds of daily use of central processing unit (CPU) or tablet. One-third of the participants were undecided about potential participation in PTR. Qualitative findings highlight that participants perceived participating in PTR as more convenient and had preferences for individualized, supervised, and monitored rehabilitation.

CONCLUSION

Those willing to participate in a PTR program believed in the benefits, were comfortable with technological devices, had preferences for exercising at home, and saw opportunities in the social setting. Future PTR programs should include monitoring, preferably managed by a familiar health care professional (HCP).