Traditional Physical Therapy is in need of an overhaul. A profession that was once built around manual treatments like massage & joint mobilizations along with modalities such as heat, ice, and electrical stimulation has evolved to recognize that movement is truly the medicine that PTs provide for their patients. For a majority of musculoskeletal injuries, the expertise that PTs can provide is the ability to prescribe movements that will allow you to improve your strength and range of motion, decrease your risk of reinjury, and allow healing of the injured area to occur. While the session-based model was perfectly designed to deliver massages & modalities, it is often found wanting when it comes to delivering effective exercise prescriptions. Fortunately for patients, this recognition comes at a time when technology is providing previously unimaginable opportunities for delivering the musculoskeletal care that they need.

This article will detail 3 major reasons to strongly consider Telehealth Physical Therapy.

The Case for Digital Delivery Mechanisms:

Musculoskeletal injuries place a huge burden on the healthcare system. A majority of people will experience some sort of musculoskeletal injury at some point in their life. Due to the variety of barriers that exist between the onset of a musculoskeletal injury and a visit with a physical therapist, many of these people never have their injury treated by a physical therapist. Telehealth offers an opportunity to expand access to care for people in a variety of locations and at an earlier time point in their recovery, a key predictor of a successful outcome. Additionally, it also offers opportunities to reduce healthcare costs for all parties. 

 

Telehealth offers: accessibility and affordability, but the question is… does it work? 

 

Some of the best evidence supporting the efficacy of telehealth comes from Australia through a multicenter, randomized controlled trial called the REFORM trial (2). This series of studies randomized 210 patients with a variety of musculoskeletal disorders into 2 groups a “supported home exercise group” (TH) & “face to face physiotherapy group” (PT).  The PT group received the usual standard of care at the 5 public hospitals included in the study. The TH group, on the other hand, received 1 face to face initial evaluation and then a remotely delivered custom home exercises program. The exercise program was provided via an app which included patient reported compliance as well as weekly automated text messages generated to encourage compliance. The TH group also received check-in phone calls at 2 & 4 weeks. Outcomes were measured based on the Patient Specific Functional Scale (PSFS) which asks patients to rate their ability to perform 5 functional activities they deemed most important to them on a scale of 0-10. This outcome measure was re-assessed at 6 & 26 weeks.

 

 

The results were pretty astounding concluding that “remotely delivered physiotherapy for people with MSK conditions is as good as face to face physiotherapy” with no clinically significant difference at 6 & 26 weeks (2). 

While these results included 1 face to face session for the telehealth group they also included automated weekly check-in text messages rather than custom ones, their app included pictures of exercises rather than videos, and did not allow the opportunity for patients to upload videos of themselves for feedback leaving a great deal of opportunity for improvement in the digital delivery mechanism. 

 

 

A similar study in the UK utilizing a program called PhysioDirect (3) which included simply an initial telephone assessment & advice from a physiotherapist without any of the additional features outlines above led to the conclusion that “Patients allocated to PhysioDirect received treatment more quickly than those allocated to usual care, and had equivalent clinical outcomes (4).”

The results of these studies are extremely encouraging, particularly as we look at them with the understanding that the current technology of telehealth can offer so much more. Let’s look at some of the top reasons that telehealth can be a benefit for some people.

 

Reason #1: Progress comes from Programs, not Lists of Exercises: 

The term “home exercise program” or HEP is outdated. To most people an HEP means a laundry list of paper handouts that are simply copies of the exercises you performed in the clinic without any clarity on when & how often to integrate these exercises into your week or how to progressively overload them. As any strength coach will tell you, repeating the same exercises with the same sets and reps daily for weeks on end is not the best path to the results you are looking for.

LEARN MORE ABOUT OUR EXERCISE LIBRARY

If you are a clinician or healthcare provider looking to elevate how you design programs, look no further than our [P]rehab Exercise Library! With over 3500+ exercises to pick from, there is something for everyone! 

 

Digital delivery allows PTs & Coaches to deliver programs that can vary across the week thus allowing you to work different relevant muscle groups on different days of the week. Furthermore, it allows for easier tracking of progress and the opportunity to progressively overload individual exercises or movements, something that is critical for success in rehabbing many injuries. 

A program that is designed to be performed at home rather than simply a repeat of what you did in the clinic also allows it to be tailored to your equipment access. One of my favorite sayings is this “One exercise, one time has no value” Exercises only present value as a part of a larger, comprehensive, progressively overloaded program. The goal of any MSK rehab is to calm the injured area down and then build it back up. While in-person PT often presents more opportunities to calm things down through manual treatment & modalities, digital delivery affords many more opportunities to build things back up through a more comprehensive program & plan. 

 

Reason #2: The Best Program is the one you will do:

As any PT will tell you, even when you are going to in-person PT, the progress you make occurs with the work you do at home, not just during your face-to-face sessions. In fact, compliance with home programs is one of the biggest barriers to success with PT.  Many patients find themselves confused on how to integrate their HEP into their daily life or have questions & issues arise that prevent them from performing their exercises as prescribed. This lack of clarity can lead to home exercises that simply don’t get done. Furthermore, lack of remote support can lead to a lag in motivation to perform exercises. This phenomenon led researchers to investigate whether an app with remote support led to better compliance to home exercises than paper handouts. Unsurprisingly, researchers noted that there was a statistically significant increase in compliance for the group that was randomly assigned to the app with remote report (5).

Just like medication, when it comes to exercise the 2 most important things are: the dosage and the fact that you actually take it. Digital delivery appears to offer advantages in both of these areas.

LEARN MORE ABOUT OUR  HOME FITNESS PROGRAM

 

Reason #3:  PT’s believe in it: 

While much of the research cited above is based on non-operative musculoskeletal injuries, PT’s have long felt limited in their ability to provide the comprehensive care that patients need after an orthopedic surgery. From running out of insurance visits, to being unable to answer important patient questions that arise between sessions, there is a huge gap between what PT’s are able to provide in a session and what they’d like to be able to provide to their post-surgical patients. In fact, a recent study out of Yale University found that 83% of PTs believed there was a “rehab gap” between the end of in-person care and the completion of rehab for their patients who’d undergone ACL reconstruction. 84% of PTs agreed that there is a role for digital rehab in addressing that rehab gap. 95% of PTs agreed that standard commercial insurance was not enough to allow sufficient rehab after this surgery (6).

These numbers are astounding. A majority of patients are not told that their insurance is unlikely to give them the care their PT feels they need to achieve success. Fortunately, the rise of telehealth and digital delivery mechanisms offers a unique opportunity to fill this “rehab gap” after ACL surgery. Similarly, telehealth after total hip & total knee replacement has been shown to have equivalent outcomes & patient satisfaction when compared to in-person PT (7).

LEARN MORE ABOUT OUR  TOTAL HIP REPLACEMENT REHAB PROGRAM

 

Closing thoughts: 

Telehealth is not right for everyone. Medically complex patients, those who require wound care, as well as a variety of other reasons make face to face PT a vital part of our healthcare system. However, telehealth and remotely delivered exercise programs utilizing an app has been shown to be as effective as in person PT for a variety of musculoskeletal conditions. Furthermore, it has been shown to improve patient compliance with their home exercise program, a vital part of patient success. 

Additionally, when surveyed PT’s saw a glaring need for the growth of this system particularly in their post-op patients where it has been proven to be effective. Telehealth also offers opportunities to reduce healthcare costs & improve access to care for patients in a variety of locations. If you are dealing with a musculoskeletal impairment you may want to strongly consider utilizing some sort of telehealth. 

 

References

1. Withers HG, Glinsky JV, Chu J, et al. Face-to-face physiotherapy compared with a supported home exercise programme for the management of musculoskeletal conditions: protocol of a multicentre, randomised controlled trial-the REFORM trial. BMJ Open. 2021;11
2. Withers HG, Glinsky JV, Chu J, et al. Remotely delivered physiotherapy is as effective as face-to-face physiotherapy for musculoskeletal conditions (REFORM): a randomised trial. J Physiother. 2024;70(2):124-133. doi:10.1016/j.jphys.2024.02.016
3. Salisbury C, Foster NE, Bishop A, et al. ‘PhysioDirect’ telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial. BMC Health Serv Res. 2009;9:136. Published 2009 Aug 3. doi:10.1186/1472-6963-9-136
4. Salisbury C, Montgomery AA, Hollinghurst S, et al. Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems. Br J Sports Med. 2014;48(18):1391. doi:10.1136/bjsports-2014-f43rep
5. Lambert TE, Harvey LA, Avdalis C, et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial. J Physiother. 2017;63(3):161-167. doi:10.1016/j.jphy
6. Gardner EC, Podbielski C, Dunphy E. Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers. Telemed Rep. 2024;5(1):18-35. Published 2024 Feb 13. doi:10.1089/tmr.2023.0022
7. McKeon JF, Alvarez PM, Vajapey AS, Sarac N, Spitzer AI, Vajapey SP. Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review. JBJS Rev. 2021;9(9):e21.00016. Published 2021 Sep 13. doi:10.2106/JBJS.RVW.21.

 

[P]rehab Writer & Content Creator

Tommy Mandala is a Doctor of Physical Therapy, Board Certified Clinical Specialist in Sports & Orthopedics, and Certified Strength and Conditioning Specialist in New York City. He is the founder of ALL IN ACL, a digital coaching platform dedicated exclusively to helping ACLers return to the life they had before their injury with full confidence in their knee. Prior to that, he worked in the sports clinic at Hospital for Special Surgery, the #1 Orthopedic Hospital in the country. While there, he had the opportunity to hone his skills as an ACL specialist working closely with world renowned surgeons and evaluating patients from all over the world. He completed his sports residency training at the University of Delaware where he had opportunities to work with many of their Division I sports teams as well as the Philadelphia 76’ers NBA G-league affiliate, the Delaware Blue Coats. He also trained at Champion Sports Medicine in Birmingham, Alabama where he had the opportunity to learn from researchers in the American Sports Medicine Institute. Currently, Tommy works exclusively with ACLers through his digital coaching model. While many of these clients are athletes, Tommy works with ACLers of all different abilities helping them to build the strength they need to overcome this unique injury. One of his favorite aspects of his job is taking active clients who have never been a “gym person” before and showing them the amazing things that happen when they learn to strength train.

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.