Conducting Healthcare From a Distance- Evidence for Efficacy in Physiotherapy A Research Overview By: Karen Finnin Musculoskeletal Physiotherapist BAppSc(Physio), MMuscPhys, APAM Written: March 2012 Introduction eHealth refers to the progression of healthcare into the use of digital and online technologies. It is a broad term, and can include the digitizing of patient records, transmission of test results, and performance of health related consultations online. Online consultation is often referred to as telemedicine, when used for medical treatment, or telerehabilitation, when used for allied health interventions, such as Physiotherapy (Physical Therapy). Development of this new format of healthcare delivery is being driven largely by the need for improved access to healthcare in rural and remote areas. The use of telemedicine and telerehabilitation is expanding rapidly. . While there are certain limitations inherent in this format of health care, relevant research has identified an overwhelming range of advantages and effective uses.  This is certainly true for the long distance online management of musculoskeletal injuries. This research overview will:

• consider the challenges in health care that have led to the push for distance consultation

• summarise the existing areas of use for telemedicine and telerehabilitation

• identify the benefits and limitations of telerehabilitation • highlight perspectives from both patients and therapists who have used

telerehabilitation • and finally, highlight recommendations that have been made to develop

the use of distance consultation in Physiotherapy

Background A large motivating factor in the push to take health care online has been the demand for better access to healthcare for those living in rural and remote areas. ‘Rural and remote’ is an umbrella term that identifies geographical challenge to accessing services. (A range of indices exist that divide ‘remoteness’ into various subcategories of increasing difficulty of access.) Data from the Australian Bureau of Statistics shows that people who lived outside Major Cities in 2007-08 were 23% more likely to have had back pain, 20% more likely to have had asthma, and 27% more likely to have been deaf than people who lived in Major Cities. People who lived outside Major Cities were also 16% more likely to report that they had a mental or behavioural problem [1]. In general, health service availability to rural and remote areas is limited by a number of factors including distance and associated costs of travel, funding limitations, and lack of health care providers. In addition, low population densities in rural areas will not support specialist services such as Physiotherapy [2]. This paper will focus on the issues related to managing musculoskeletal injuries in remote areas, and highlight the strengths and challenges of Physiotherapy consultations performed from a distance. Pre Telehealth Issues Musculoskeletal Injuries and Remoteness Musculoskeletal conditions are defined as an interruption to the normal function of bones and/or soft tissue, such as the joints, ligaments, muscles, tendons, and nerves. Musculoskeletal conditions affect one in three Australians each year and make up a quarter of all chronic conditions after an injury. They have been reported to be the most common cause of chronic pain and physical disability in Australia [3]. To use a common musculoskeletal injury as an example, the prevalence of new ankle injuries is estimated to be 23,000 per day in the United States and in the order of 100,000 emergency department presentations per year in Australia [3]. The lack of access to appropriate and available injury management in rural and remote areas has been associated with poorer outcomes post injury when compared with metropolitan areas.

In one study, poorer outcomes for rural and remote patients recovering from knee replacement surgery were attributed in part to many of those patients foregoing outpatient rehabilitation. This resulted in sub-optimum physical outcomes and shortened lifetimes of knee prostheses [4]. Similarly, the findings from another study revealed that inadequate rehabilitation of ankle injuries also resulted in poorer outcomes, including compromised ambulation, high prevalence of re-injury, and recurrent limitations to activity [3]. Thus it seems clear that lack of access to appropriate treatment for musculoskeletal conditions has wide ranging implications on quality of life. Lack of Allied Health Workers There is a documented dearth of Physiotherapists to service the needs of those living and working in rural and remote areas. In 2004, in Australia, the ratio of Physiotherapists per 10,000 population was 6.14 for capital cities, 3.58 in outer regional areas, and 3.65 in remote areas. A 2008 study in New South Wales rural areas found the ratio to be worse, at 3.07 [2]. Poor access to Physiotherapy services is a phenomenon repeated around the world, and this access is further threatened because of the ageing of the allied health workforce, and persisting problems with recruiting and retaining allied health professionals [2]. Generic Health Information Found Online Can Be Unsafe The volume and frequency of people using the internet to seek health information is rising. For example, in 1999, the proportion of USA adults that had used the internet for health information was as high as 40-60 per cent of adult online users [5]. This is particularly concerning when considered in light of the finding of Starman et al., which revealed that a large portion of health related information posted on the internet is incomplete, misleading, or both, and can potentially endanger patient outcomes and expectations [6]. In light of the previously considered poorer outcomes for people with injuries in remote and rural areas, we cannot, and should not prevent people seeking health information online. Therefore a means must be found to tailor diagnosis and treatment advice specifically to the needs of the individual. In conclusion, musculoskeletal injuries are very common, and treatment outcomes are far worse without adequate rehabilitation. As access to treatment can be poor in rural and remote areas, individuals are increasingly turning to the internet for health information. As information found online can be generic, incorrect and even dangerous, there is a clear need to be able to

issue tailored and accurate injury diagnosis and rehabilitation information to individuals over the internet. Current Uses of Telehealth Telemedicine and telerehabilitation are being used in a wide range of health fields. This has improved access issues for those living in rural and remote areas. Such uses include:

o The transmission of medical images for long distance evaluation in fields such as radiology, pathology, ophthalmology, cardiology, dermatology and orthopedics. [7].

o Teleconsultation with patients requiring speech therapy, mental health

services, wound care, orthopaedic assessment, neurologic rehabilitation, adjustment of assistive devices [8], psychology, oncology, surgery [3], foot care, gait assistance, orthotic or prosthetic assistance, wheelchair prescription [9], and chronic disease management [10].

In Physiotherapy, effective teletreatment has been reported for:

o Assessment of gait [11], and ankle disorders [3]

o Diagnosis of lower limb musculoskeletal disorders [2].

o Management of knee pain, post-stroke rehabilitation, elderly with loss of functional autonomy, and total knee arthroplasty (TKA) [8].

Strengths of Distance Consultation Research into distance consultation has revealed a number of strengths relating to this format of healthcare delivery in Physiotherapy. These strengths relate to the clinical outcomes of distance consultation, to the comparison of distance with ‘on site’ consultation, and finally to the logistical aspects of carrying out distance consultation. Clinical Strengths From ease of assessment, through to compliance and outcomes with treatment, and on to overall findings, research into the clinical application of distance Physiotherapy consultation has indicated convincing viability. Assessment

It can be argued that the initial patient interview in a Physiotherapy consultation is adequate to enable the examiner to formulate their diagnosis. A physical examination then simply aims to confirm or refute hypotheses generated from structured questioning in the patient interview [2]. The subjective consultation can be easily translated to an online format. This, paired with a concise range of physical assessment tools, adapted for online use, is all that is required to accurately determine diagnosis via distance consultation. A range of assessment tools have been found to be effective in a distance assessment format, such as performing manual muscles tests via observation [12], and measuring joint range of movement with a universal [13] or internet based goniometer [14].

A common conclusion drawn in the literature was that remote musculoskeletal assessment using traditional assessment instruments is technically feasible. [12]. This includes the assessment of nonarticular lower limb conditions [2], and assessments of the ankle joint complex [3]. Treatment Russell et al, in their study on distance rehabilitation after total knee replacement, found that the adaptation of therapist applied treatment techniques, to those for self-application by the patients in a distance consultation, revealed a welcome benefit. It provided the opportunity for patients to self treat outside the formal physiotherapy treatment sessions [4]. The potential of these findings can be extrapolated to conclude that treatments administered via distance Physiotherapy consultation stand to improve patient self-reliance, resulting in less dependence on health services. Continuity of Care Health care in remote areas is often associated with poor continuity. This can be due to factors such as high staff turnover, difficulty with appointment timing due to travel, and inconsistent service availability. Telerehabilitation services have the potential to improve the continuity of care for remote patients by providing a consistent service, by improving the ability to control the timing, intensity, and sequencing of a rehabilitation intervention, and by providing the additional benefits associated with the rehabilitation of patients in their own social and vocational environment [15]. The Australian Physiotherapy Association applauds the continuity of client care that can be achieved through the remote provision of services [16]. Internal Locus of Control and Compliance Research into telerehabilitation interventions has revealed that distance consultation can result in improvement in the internal locus of control of the patient, with regard to their injury recovery. High internal locus of control is

recognized as an important factor in patient compliance [15], which, in turn, improves recovery. Russell et al comment on this finding, from their research into telerehabilitation for patients post total knee replacement surgery:

Self management, together with the large educational component of the treatement programme, may have empowered the participants to take an active role in understanding and managing their condition, leading to the high compliance rates observed. This phenomenon has been observed in other studies involving electronic and Internet-based health-care, and has led one author to coin the term ‘tele-empowerment’ [4].

Kairy et al, in their systematic review of articles researching the efficacy of telerehabilitation, further support this observation by stating that:

There is a trend from one fair quality RCT and six quasi-experimental studies with and without control groups of good attendance at programmes and good compliance with recommendations when a programme is offered by telerehabilitation [17]

Outcomes There are a number of positive findings, in terms of outcomes, from the research into distance Physiotherapy consultations. Tousignant et al, following an investigation into satisfaction with in home telerehabilitation, believed that they could affirm, with robust data, that teletreatment is a suitable alternative to onsite consultation; “it is not just a feeling, but an evidence based statement”. [8] In their study on remote rehabilitation post total knee arthroplasty, Russell et al found that all participants had significant improvement on all outcome measures. They believe that their study provides empirical evidence that certain technology can be used to provide effective rehabilitation services after acute postoperative care for patients who have undergone total knee arthroplasty [15]. In another study, Russell found that, for nonarticular lower limb musculoskeletal conditions, telerehabilitation had acceptable criterion validity, intrarater reliability, and interrater reliability [2]. Comparison Strengths An important means to gauge the effectiveness of distance Physiotherapy consultation is to make direct comparison to ‘on site’ consultation, with regards to a number of key criteria. Comparisons in terms of diagnostic

accuracy, outcome measures, treatment outcomes and satisfaction levels have been reported. Diagnosis Accurate diagnosis is clearly a critical step for a successful distance consultation. Evidence shows that diagnostic accuracy is favourably comparable to accuracy with on site diagnosis. For Russell et al, in their study on distance diagnosis of lower limb musculoskeletal disorders, consistency with face-to-face comparison studies implied that the introduction of the telerehabilitation mode of delivery did not introduce any further difficulty in reaching a common diagnosis than that experienced by two face-to-face clinicians [2]. They state that any potential source of disagreement in their study is likely to be due to the clinical reasoning process of the therapists. This effect is not unique to telerehabilitation, as doctors presented with identical clinical information for musculoskeletal low back pain have shown 22-28% disagreement in diagnosis [2]. Diagnosis discrepancies (in either on site or distance situations) do not necessarily have an impact on appropriateness of treatment, as exemplified by Russell at al, in their study on distance management of ankle disorders: “Regardless of the exact physical diagnosis developed… rehabilitation programmes would have a similar focus” [3] Outcome Measures It has been found that a number of clinical outcome measures, normally used in ‘on site’ consultation, can be used as effectively in a distance consultation setting. These include the National Institutes of Health stroke scale, the Kohlman Evaluation in Living Skills, the Canadian Occupational Performance Measure, joint range of movement measures [12], and gait assessment [11]. Rehabilitation Outcomes In their systematic review on the telerehabilitation literature, Kairy et al stated that no studies reported worse outcomes with telerehabilitation than in the control group. They felt there was a consistent trend in the literature supporting the efficacy and effectiveness of telerehabilitation, with similar or better clinical outcomes when compared to conventional interventions. They concluded that the evidence consistently demonstrates that similar outcomes can be obtained using telerehabilitation as compared to a face-to-face or other control intervention, with possible positive impacts on some areas of healthcare utilization [17]. Russell was involved in two studies that illustrated these findings more specifically:

In their total knee arthroplasty rehabilitation study, Russell et al found that participants in the telerehabilitation group achieved outcomes comparable to those of the conventional rehabilitation group with regard to flexion and extension range of motion, muscle strength, limb girth, pain, timed up-and-go test, quality of life, and clinical gait. Better outcomes were recorded for the Patient-Specific Functional Scale and the stiffness subscale of the WOMAC for the telerehabilitation group. They therefore concluded that the telerehabilitation intervention was not inferior to the conventional intervention and actually produced some outcomes that were clinically superior [15]. In an earlier study, Russell at al found that significant improvements were observed in all the physical and functional measurements from the pre-treatment to post-treatment assessment periods. These improvements were consistent with those commonly achieved with traditional, face-to-face treatment [4]. Logistical Strengths The administrative and technical sides of distance consultation have provided additional benefits, including improvements in access, record keeping, training opportunities, cost, and environmental impact. Access Improved access to services, resulting from the use of telehealth, is acknowledged in a number of studies, including these: A 2000 Cochrane systematic review of telemedicine versus face-to-face patient care found that telemedicine is a feasible solution to the issue of rural health service access [2]. Jennett et al, in their systematic review of the socio-economic impact of telehealth, determined that there is ‘good’ evidence (based on the Jovell-Navarro-Rubio rating scale) that interactive video-consultation is effective and efficient in rural and remote areas, and increases access to health care, in a number of fields, including rehabilitation [18].  Record Keeping The World Medical Association, in their position statement on the Practice of Telemedicine, acknowledges that the digital generated format of telerehabilitation consultations facilitates therapists to keep excellent records of the consultations [7]. Cost There were some indications in the literature that use of teleconsultation could provide potential cost savings to the individual and the health care provider.

There was one attempt at exact financial calculations. Tousignant et al studied in home telerehabilitation post hospital discharge. The calculations illustrated cost savings, but are limited in terms of generalisability.

The mean costs for the 12 sessions over 4 weeks were $487 for the telerehabilitation group and $587 for the theoretical home visit [19].

Jennett et al, in their systematic review of the socio-economic impact of telehealth, surmised that If only those costs met by the health care system are included in cost caluclations, the telehealth alternative is not always cheaper. However, if patients’ travel and lost working time are included, many of the telehealth alternatives become cost-saving from a societal perspective [18]. Another systematic review of telehealth literature discovered two quasi-experimental studies with control groups and two small pre-post studies that found lower costs for the healthcare facility when using telerehabilitation [17]. Safety Despite the perceived lack of supervision with telerehabilitation, the method has proven to be safe in a number of situations. In their study on home rehabilitation in older adults after discharge from hospital, Tousignant et al stated that no incidents or falls were documented in providing telerehabilitation interventions to the participants [19]. Education Telemedicine can provide a new method of teaching for students. The online, recordable format makes it easy for multiple trainees to participate in the examination of a single patient [20]. It can also allow examination and management to take place in a location removed from the patient, decreasing the need for students to travel to rural and remote areas. Environmental Impact There are potential positive environmental impacts for telerehabilitation. Benefits such as reduced travel are listed [21]. These impacts are unquantified at this stage. Equipment Studies have revealed that the use of technology, and low computer literacy of users, are not barriers to successful digital consultations. Russell et al recorded that attempted telerehabilitation consultations between the physiotherapist and participants were successful in all cases. This result was surprising, considering that the computer literacy questionnaires completed by participants revealed that only 29% of them had ever used a computer, and the average self rated confidence in being able to operate a computer was 0.8 out of 10 [4].

In their clinical guidelines for telemedicine, Pineau et al indicated that the main obstacles to successful telerehabilitation had to do with clinicians and patients adjusting to the technology, not with the bandwidth used or the equipment required for teleconsultations [22]. In his commentary on a Russell at al article, Gross expressed the belief that with the use of webcam techniques such as Skype, it would be possible for the physical therapist and the patients who are receiving the telerehabilitation technique to have an equally close relationship, when compared to on site care, vis-à-vis their progress [23]. Limitations of Distance Consultation There have been a number of challenges mentioned in the literature that are associated with the transition to the use of distance consultations: Logistical Limitations Communication Russell et al, in their study comparing remote and on site diagnosis for lower limb disorders, observed the possibility that some patients with poor communication skills may be more difficult to manage via telerehabilitation. They expressed the likelihood that therapists would need to develop specific communication strategies to address this issue [2]. Communication is therefore a factor for nurturing and developing in distance consultations, as it can often be the human factors that tend to determine the success or failure of telemedicine usage [24]. Consult Time In one study reviewed by Kairy et al, it was found that consultation time tended to be longer with telerehabilitation [17]. Equipment Some reference has been made in the literature to limitations with the use of certain digital equipment. Digital technologies are currently developing so rapidly, however, that technical glitches are generally quickly eradicated. Finkelstein et al had several eligible candiates refuse to participate in their study on virtual home visits by nurses to home bound patients, because of concern over the equipment. Those who actually experienced the system had more positive views than the control group. Thus it will be important to get potential clients engaged with the new systems to overcome their reluctance to ‘try something new’ [25].

Russell et al, from their study on telerehabilitation for ankle disorders, had an interesting commentary regarding the audio challenges of a digital consultation:

A different conversational etiquette exists between face-to-face and videoconference conversations and the examiners found that it was essential to be clear and concise when using the eHAB system as non-verbal communication was significantly removed. The videoconference etiquette required users to take turns at speaking and to talk slowly and clearly as the signal is often not clear. Subsequently participants appeared more reserved in their conversation and less personal in their response [3].

It must be remembered that rapid technological development can often make long-term studies irrelevant because the equipment is outdated by the time the results are published [26]. Security Understandably, National and International bodies have concerns over the security of health related information being transferred via technology. The World Medical Association observe in their telemedicine guidelines that online consultations, or tele-consultations, in which there is no pre-existing physician-patient relationships or clinical examination, carry certain risks. Among these are uncertainty concerning reliability, confidentiality and security of information exchanged, as well as the identity and credentials of the physician [7]. The Australian Physiotherapy Association Position Statement for Telerehabilitation enforces that appropriate privacy and security measures should be taken when using any form of online or electronic communication or consultations with clients. The Association warns that practitioners should be aware of medico-legal implications in the practice of telerehabilitation. Physiotherapists must abide by all state and federal privacy, security and record keeping legislation [16]. Fiscal Limitations It is easy to perceive of the potential cost savings possible with distance consultation, yet it has proven to be difficult to quantify, for an intricate combination of reasons.  Durfee at al, in their telerehabilitation feasibility study, observe that a financial feasibility analysis for remote services is complicated by the rapidly changing costs of technology and broadband communications, and changing attitudes towards reimbursing teleconsults [12].

 Rebates Reimbursement for telerehbailitation services is limited in health care systems throughout the world and remains one of the most significant barriers to the expansion of telerehabilitation in the private sector [27]. The Australian Physiotherapy Association observes that third party payers such as private health insurers, Medicare Australia, state and territory Workcover authorities and Motor Accident authorities have not traditionally provided rebates to the clients of physiotherapists for telerehabilitation services. The Association feels that this attitude should be changed [16]. Clinical Limitations Assessment Tools Despite the many obvious benefits of telemedicine, the lack of proximity to the client and the futility of conventional assessment tools challenges the performance of accurate physical assessments [14]. New methods of patient self-examination are needed, to enable diagnosis [2]. Jull and Moore, in their open letter about online therapy, identify that we need to adapt our examination and treatment methods to be performed through observation and patient instruction online [28]. Russell, in his article titiled ‘Telerehabilitation’, offers that to circumvent the need for the Therapist to use their hands on a client, self-applied techniques, the use of a carer’s or spouse’s hands, or the use of alternate exercise or self management strategies can be considered [21]. Clinician Experience Some studies found that clinician experience played a role in the success of the remote consultation. According to Nitzkin et al, in their study on the reliability of telemedicine examination, found that experience and knowledge of the limitations of the telemedicine system were strongly correlated with the reliability of examination. Their findings raised doubts about the reliability of occasional telemedicine consultations by clinicians inexperienced in the technology [20]. Condition Types Not all patients can be managed by telerehabilitation, as observed by Pineau at al in their clinical guidelines for Telehealth:

Telerehabilitation is contraindicated in a patient who refuses this treatment modality or who has a physical impairment preventing coherent communication or a health problem that cannot be evaluated via this technology or supervised from a distance [22].

Research A number of sources identify challenges to telehealth, in terms of research quality and availability. Russell, in his summary article on Telerehabilitation in 2009, expressed that he felt research was needed to set minimum technical specifications and standards, validate clinical protocols, investigate the effectiveness of interventions, report client and therapist satisfaction, and establish the cost-effectivenenss of telerehabilitation [21]. Mair et al make a summary from their systematic review into satisfaction with telemedicine:

Most existing telemedicine research has had a technological focus. We know a great deal about bandwidths and resolution, but little about the human dimensions that make the practice possible [29]:

and this from another Telehealth systematic review, this time regarding socio-economic factors, by Jennett et al:

There are still relatively few good studies that address clinical and other non-economic issues. For example, patients’ views and interests, social effects, quality controls and wider organizational effects have seldom been considered. Plus, there is the continuing problem of limited generalizability [18].

Patient Perspective of Distance Consultation Pivotal to the adoption of distance Physiotherapy into mainstream healthcare, is the satisfaction of the patient with the service. A high level of satisfaction is likely to increase the patient’s motivation, and hence improve treatment compliance [8]. A number of studies have explored patient satisfaction in relation to telerehabilitation. In their systematic review into research addressing patient satisfaction with telehealthcare, Williams et al found that reported levels of satisfaction with telemedicine were consistently greater than 80%, and frequently reported at 100% [30]. In patient satisfaction examples relating to individual studies, findings were also largely positive. For Russell at al, in their study on telerehabilitation for patients following total knee replacement, patients reported a high level of contentment with the service and indicated that they would have this method of rehabilitation again and recommend it to friends [15].

In an earlier study for Russell, with a similar population, consistently high ratings were recorded by participants on the satisfaction questionnaire relating to their perceived benefit of the treatment, their contentment with the treatment method and whether they would recommend this method to their friends or have it again if the opportunity arose. In fact, a number of participants expressed a preference for the telerehabilitation method of rehabilitation over the traditional, face-to-face model, as they thought the treatment was more ‘personalized’ via the computer system. Positive comments were received, such as ‘I found that I concentrated more and pushed myself more with the telerehabilitation treatment’ [4]. In their report on health technology assessment, Williams et al found that patients are generally accepting, and may even prefer telemedicine modes of service delivery to face-to-face interactions [26]. For the distance based physical rehabilitation consultations performed by Lemaire et al, it was found that all clients were comfortable with and had confidence in the teleconsultations [9]. Some studies identified challenges, with respect to the technical execution or the overall perception of distance consultation. This affected patient satisfaction. Russell at al reported that a high level of satisfaction was observed for all satisfaction questionnaire items, with the exception of question 4, which related to the visual quality of the videoconference [15]. In his other study, on diagnosis of lower limb disorders, Russell stated that the participants indicated a good level of satisfaction with all questions, except question 3, where they clearly preferred face-to-face assessment. Despite this, they stated that they would be happy with a telerehabilitation consultation if face-to-face therapy was not available [2]. Williams et al, in their systematic review of patient satisfaction in telehealthcare, identified an important point to consider with regard to patient satisfaction. They noted that responses to patient satisfaction surveys conducted at health-care delivery sites may be influenced to some degree by the patients’ concerns about the impact that any negative feedback may have on the services that are available to them [30]. It is a factor that must be considered when assessing data on patient satisfaction.

In general, the research reports that satisfaction with telerehabilitation services is high. Even if potential telerehabilitation patients are apprehensive about trialing the new format, satisfaction seems to increase with exposure to the service. It seems that once individuals have experience with this type of delivery of treatment, they are more receptive to it [26] [25]. Telerehabilitation services must be increasingly utilized in ‘real life’ settings, in order to continue to breed acceptance.

Therapist Perspective of Distance Consultation Therapist satisfaction with their involvement in distance consultation is paramount for the acceptance and widespread use of this health care format. Even if the new treatment method is promising in terms of cost, time and efficency, if it does not meet all of their needs well, Physiotherapists will never embrace the technology [8]. Kairy et al, in their systematic review of telehealth research, surmised that satisfaction ratings regarding the use of telerehabilitation were very high from both patients and therapists, regardless of the patient population, setting or study design, although it was higher for patients than therapists [17]. For Russell et al, in their study assessing satisfaction post distance rehabilitation for total knee arthroplasty, the telerehabilitation system was well received by the study physiotherapists, who reported that they were able to deliver effective and timely treatment for subjects with this mode of delivery. The therapists were content with the rehabilitation that patients achieved via the system [4]. Tousignant et al, in their study - also on distance rehabilitation post total knee arthroplasty - found that their Physiotherapists’ satisfaction with regard to goal achievement, patient-therapist relationship, overall session satisfaction, and quality and performance of the technological platform was high, concluding that the health care professionals appeared satisfied with the service-delivery mode without a face-to-face session [8]. Tousignant et al did note, however, that Therapists felt there was room for improvement with regards to the technologies used. Concerning the reliability of the technological environment, the physiotherapists found it satisfactory for 45.5% of the time and good for the rest of the time (54.5%) [8]. In another study by Tousignant, assessing in home rehabilitation for older adults following acute hospital stay, health professional satisfaction with use of the technology was a mean of over 70% for all subjects for the 12 sessions [19]. The rapid rate of technology development deems these concerns regarding the technological platform used in the distance consultations to be of low concern. These concerns do, however, highlight the need for continued testing and innovation with regards to digital consultation. Recommendations for Distance Physiotherapy Within the research articles, systematic reviews, position statements and clinical guidelines regarding telerehabilitation, a number of recommendations are made. These recommendations outline the steps required to move

telerehabilitation forward in terms of broadening useage, increasing regulation, and improving viability. Jennett et al, in their systematic review of the socio-economic impact of telehealth in Canada, have suggested that an international body or national telehealth society should take an overall coordination role in running trials, performing evaluations and disseminating results [18]. In Australia, the Clinical Informatics Committee recommends that the Australian Physiotherapy Association (APA) encourage and support telerehabiltiation research by its members [27]. Williams et al, and also Russell expand on this, by recommending that research needs to move out of the research lab, and into more qualitative and ‘real world’ contexts, with well controlled research methodologies and large patient cohorts [31].This would provide a completely different but equally robust, basis for evidence about telehealthcare [26]. Mitchell, in his report on eHealth for the Australian Government, identifies that there is an increasing need for the private sector to show initiative, to invest and to partner government [5]. The Clinical Informatics Committee of the Australian Physiotherapy Association, via their position statement on Telerehabilitation, recommends that the APA engage in discussion with insurers regarding reimbursement for telerehabilitation services in Australia [27].  Distance Physiotherapy Summary The Australian Government envisages an Australia where consumers and providers of healthcare, wherever they are located, have online access to clinical advice, specialist referrals, diagnostic tests, results and other telehealth services [5]. With the development of telerehabilitation for distance injury management, this vision is rapidly moving closer to actualization. There is overwhelming evidence that distance Physiotherapy consultation provides a compatible equivalent service when compared with on site Physiotherapy consultation. The implications for rural and remote access to quality injury management are considerable. Acknowledgement of expert recommendations must be carried out in order to increase useage, acceptance and funding for distance injury management. Documented ‘real world’ use of telerehabilitation is an important progression, as is initiative for platform development from within the private sector. Finally, advocacy for private health insurance rebates for distance Physiotherapy consultations from the Australian Physiotherapy Association, and other regulatory bodies, is required.

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11.   Russell,  T.G.,  Jull,  G.A.,  Wootton,  R.,  The  diagnostic  relieability  of  internet  based  observational  kinematic  gait  analysis.  J  Telemed  Telecare,  2003.  9(Suppl  2):  p.  S48-­S51.  

12.   Durfee,  W.K.,  Savard,  L.,  Weinstein,  S.,  Technical  feasibility  of  teleassessments  for  rehabilitation.  IEEE  Trans  Neural  Sys  Rehabil  Eng,  2007.  15:  p.  23-­29.  

13.   Cabana,  F.,  Boissy,  P.,  Tousignant,  M.,  Moffet,  H.,  Corriveau,  H.,  Dumais,  R.,  Interrater  Agreement  Between  Telerehabilitation  and  face-­to-­face  clinical  outcome  measurements  for  total  knee  arthroplasty.  Telemedicine  and  eHealth,  2010.  16(3):  p.  293-­298.  

14.   Russell,  T.G.,  Jull,  G.A.,  Wootton,  R.,  Can  the  internet  be  used  as  a  medium  to  evaluate  knee  angle?  Manual  Therapy,  2003.  8(4):  p.  242-­246.  

15.   Russell,  T.G.,  Buttrum,  P.,  Wootton,  R.,  Jull,  G.A.,  Internet-­based  outpatient  telerehabilitation  for  patients  following  total  knee  arthroplasty:  a  randomized  controlled  trial.  J  Bone  Joint  Surg  Am,  2011.  93-­A(2):  p.  113-­20.  

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28.   Jull,  G.,  Moore,  A.,  Open  letter  –  Delivery  of  musculoskeletal  therapy  online?  Manual  Therapy,  2001.  6(2):  p.  65.  

29.   Mair,  F.,  Whitten,  P.,  Systematic  review  of  studies  of  patient  

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