Group sees potential for telerehabilitation

Task force works on new applications, outcomes

When Steve Dawson, PT, was first approached with the idea of teletherapy four years ago, he had to laugh. Providing therapy services over a videophone to a patient in a remote location went against the very grain of his profession.

"I said, There’s a reason it’s called physical therapy. You have to be able to touch the patient,’" says Dawson, clinical development specialist for Integris Jim Thorpe Rehabilitation Network in Oklahoma City.

But in rural Oklahoma, there was a great need for therapy services for patients who were unable to travel long distances to reach clinicians. So Dawson gave it a try, and after the first teletherapy session, he was hooked. "You are in a virtual world with the patient," he says. "It’s like you can feel what they’re doing and see what’s going to happen. You can educate, consult, mentor, and treat over the videophone."

Dawson is so hooked on the idea that he not only treats patients that way, but he also recently became the co-chairman of a new special interest group on telerehabilitation for the American Telemedicine Association, based in Washington, DC.

The group has set the ambitious goal of shaping the future of telerehabilitation by exploring the potential uses of telemedicine devices in rehab, collecting outcomes data, and working for reimbursement for telerehabilitation services. Eventually, the group plans to write standards for the use of telerehabilitation.

It’s a daunting task, but Dawson says he is up for the challenge. "I am totally convinced this will work. During a conference presentation, I did a live therapy session and everyone could see the patient could do more at the end of the session than when we started. There was a standing ovation in that room. They could see how we got there. It’s very exciting."

The videophone can take still images and also can be hooked up to a VCR so therapists can have a record of the session for later analysis. The quality of the video images varies, but Dawson finds that the ability to see the patients is invaluable. "You can call somebody on a regular telephone and just hearing the information, you can fill out the FIM [functional independence measure] form, so it’s not a big stretch to watch somebody moving on a videophone and fill out some categories on the FIM form. It’s better, of course, to be able to see. The intervention makes the difference," Dawson says.

The initial patient evaluation is always done in person, but the video sessions have proven effective for follow-up treatment. In a study of 10 patients at Integris who participated in teletherapy, all 10 showed significant improvement on their FIM scores. That’s not enough data, of course, so Integris will begin a larger study to compare outcomes from traditional home health services with the telerehab program in June. The study will be done in conjunction with Blue Cross and Blue Shield of Oklahoma, the state’s Medicare fiscal intermediary.

In about 20 states, including Oklahoma, legislation has allowed for tele-encounters with patients to be reimbursed on the same level as face-to-face sessions. But uniform reimbursement will be needed if telerehabilitation is to become more widespread, Dawson adds.

"As goes Medicare, so goes the world of reimbursement," he adds. "From a Medicare standpoint, they need to see that it’s effective before they pay for it. Unless CMS [the Centers for Medicare & Medicaid] reimburses for telerehab, it won’t be feasible for people to get involved."

Dawson says he sees the effectiveness of the technology in his daily practice. He mainly works with stroke patients; many live in rural areas and would not receive services from a physical therapist otherwise.

"I connect with the patients by videophone, and I ask them to do the same things I would ask in a face-to-face visit. These are mostly people who need assistance to move, so I direct the caregiver to help move their arm or whatever," he explains. "That is much different than giving somebody a list of written instructions or pictures of what they are supposed to do. With a home program, maybe it gets done, maybe it doesn’t. But now someone is calling them two to three times a week who can see their ability level. It gives them some responsibility and accountability and also a comfort level with the exercises."

That level of accountability tends to help patients motivate themselves psychologically, Dawson says. "It’s not like they are going somewhere to get their therapy. They are more in charge; they are an active participant. That is consistent with the way health care is going."

He worked with one stroke patient in particular who convinced him that telerehab works.

Six months after completing the home program, Dawson called the patient to check in. The man answered the phone sounding out of breath, and Dawson was immediately concerned — until the man told him he had just finished packing his RV and was getting ready to head out of town for a long trip. "I said, Thank you very much; you just answered all my questions.’ This patient was living his life after six months. It was exciting to know that through this medium, you could make that much of a difference in someone’s life."

Saving in the long run

Jonathan Linkous, executive director of the American Telemedicine Association, says telerehabilitation is an emerging field with the potential to provide excellent patient care and cost savings.

"The cost is not as much as you might think," he explains. "It depends on the application. If it’s a broad-band, high-definition telemedicine application that involves a lot of peripheral vital sign devices and medical infrastructure, you’re talking about a $40,000 or $50,000 operation. But for most rehabilitation applications, it can be much lower bandwidth that doesn’t have to include all the vital sign monitoring, so it’s a fairly reasonable cost to have that installed and to operate on a regular basis. You do still have the physician’s time."

But once the technology is in place, a great potential exists to save money. "If you look into a managed care or capitated fee environment where there are substantial costs either with the patient coming in or the doctor going out or a visit to the home by a nurse, there is a huge cost-savings potential," Linkous says. "If you have a telerehabilitation program, you can run through more patients in a typical day. They tend to be scheduled better; and with the TV, the patients tend to pay better attention and there’s not a lot of waiting around."

Besides the teletherapy mentioned by Dawson, some other applications of telemedicine in rehab include:

  • A teleshoe clinic, where the patient is filmed running and walking so a rehab specialist can analyze the gait and recommend proper shoes.
  • A multimedia record that can be reviewed over time.
  • Monitoring of vital signs.
  • Speech rehabilitation, with the ability to provide the repetitive activity needed to improve and to record progress on a daily basis.
  • Video conferencing to allow patients to get access to specialists in other parts of the country.

"That gives patients greater access to care, particularly homebound patients. But also, a subspecialist who normally sees four to five cases a week all of a sudden has hundreds of cases. Their expertise increases," Linkous says.

Need More Information?

  • Steve Dawson, Clinical Development Specialist, Integris Jim Thorpe Rehabilitation Network, 4219 S. Western, Oklahoma City, OK 73109. Phone: (405) 644-5259. E-mail:
  • Jonathan Linkous, Executive Director, American Telemedicine Association, 910 17th St. N.W., Suite 314, Washington, DC 20006. Phone: (202) 223-3333. E-mail: