Joint disorders and low back pain consistently rate among the most common reasons U.S. adults visit their doctors. Physical therapy is an effective treatment for these conditions, but many patients are not able to access the care they need.
Demand for physical therapists has long outpaced supply, a trend that is only projected to continue. The shortage is especially acute in rural areas. Insurance coverage of physical therapy varies widely—many plans have high co-pays and strict limits on the number of visits covered for it—or will not cover it at all. A growing number of physical therapists do not even take insurance.
One solution experts say could bridge this gap is telehealth, or the use of technology to provide remote care. There are now a wide array of remote rehabilitation—or telerehab—options, ranging from high-tech, interactive systems to video-chat sessions with individual physical therapists to app-based programs.
Carmen Cooper-Oguz has been a physical therapist for 22 years. She lives in rural Mississippi, where, she says, most physical therapists have multiple jobs because the demand is so great. Early in her career, when she finished her day job, she would drive 30 to 45 minutes away to care for elderly patients in nursing homes. “I would go to bed feeling like ‘Did I give enough care, spend enough time with patients?’” she says. “Telerehab no doubt would have allowed me to touch more lives in a more effective manner. I could have used that 30 to 45 minutes spent driving to treat a client.”
Cooper-Oguz now serves on the American Physical Therapy Association’s board of directors and advocates for measures that would make such therapy more accessible, including getting Medicare to cover telehealth and improving direct access (meaning a referral from another provider is not required to obtain physical therapy). Direct access in combination with telehealth, she says, would significantly lower barriers to care in rural areas.
Physical therapist Lara Heimann started doing Skype sessions with clients about four years ago, although the bulk of her business remains in person. She estimates that at least half of her remote clients live in rural areas. Heimann says that when she finished physical therapy school more than 20 years ago, it was standard for caregivers to see one or two patients per hour. Now, in clinics that take insurance, low reimbursement rates force physical therapists to see many more. An increasing number of therapists are eschewing that high-volume model, opting instead to spend a full hour with each patient. But that approach means higher out-of-pocket costs, because the therapist does not take insurance or is an out-of-network provider. Telehealth is a more affordable middle ground, providing savings for the patient and efficiency-based cost reduction for the therapist. “In a one-hour Skype session, giving someone my undivided attention, I can have so much more impact,” Heimann says.
On the high-tech end of the market, a product called VERA stands out. Short for Virtual Exercise Rehabilitation Assistant, it is an in-home interactive device that guides patients through exercises and records them in 3-D video as they move. An avatar provides instruction and feedback in real time, and the platform enables virtual visits with a physical therapist, who can also review videos of the patient doing the exercises. VERA is owned or leased by hospitals, medical practices, or clinics and is temporarily placed in patients’ homes, so it has a low monthly expense rather than a per-visit charge, as in traditional therapy.
Janet Prvu Bettger, an associate professor of orthopedic surgery at Duke University, led the first clinical trial to compare VERA with in-person physical therapy. Full results are forthcoming, but the initial findings show that in patients recovering from total knee-replacement surgery, VERA was just as effective as in-person therapy. Three months after surgery, patients in the VERA group met the same benchmarks of recovery as the traditional therapy group, including pain reduction and the ability to perform basic tasks such as climbing stairs. In fact, patients using VERA had fewer rehospitalizations than those undergoing traditional therapy. The study demonstrated an average cost savings of $2,745 per patient receiving virtual therapy. The findings have been submitted for publication in the Journal of Bone and Joint Surgery.
Many patients recovering from surgery cannot drive, Bettger points out, which means that an affordable in-home option could vastly improve postsurgical care. Mary O’Connor, director of the Center for Musculoskeletal Care at Yale School of Medicine and Yale New Haven Health, says she likes VERA because it helps keep patients accountable. Traditional physical therapy also includes an in-home exercise program, but patients often struggle to adhere to this prescription.
“When someone is recovering from surgery, exercise is the most important thing when it comes to restoring them to full function,” O’Connor says. “When patients come to see me for a postoperative visit, they’re not going to tell me that they’re not doing their exercises, because they know that’s the wrong answer. With VERA, there’s a way to tell that the patient is engaged and doing the exercises. In a preprint study that O’Connor presented at a conference in March, the patients’ overall satisfaction rating was 91.2, on a scale from –100 to 100.
In that study, subjects who used VERA still had some in-person visits. “Telerehabilitation is not a complete substitute for a skilled and trained physical therapist. We use VERA as an extender of the physical therapist to make the home program more effective and care less costly,” O’Connor says.
“There may be a small percentage of patients who could do a 100 percent remote program,” Bettger says. “Some will still need 100 percent in-person care, and many could fall in the middle. This is going to be an important area of research. We need to understand which patients need which level of involvement.”
Telerehab could also address the gap in care for low back pain. Thomas Tölle, leader of an interdisciplinary pain-research group at the Technical University of Munich, conducted the first clinical trial using a back-pain recovery app called Kaia. It employs a multipart approach to pain management, including guided exercise videos, patient education and mindfulness. The trial found that Kaia was effective at reducing pain. In fact, users reported lower pain intensity at a 12-week follow-up as compared with the control group, which received in-person therapy and online education. Tölle went on to conduct an even larger trial, called Rise-uP. The study is ongoing, with full results expected early next year. Tölle says his team is in talks with a large U.S. insurance company to undertake a similar trial, signaling insurers’ interest in the cost savings of telerehabilitation.
People dealing with pain or injury should still see a clinician in person first whenever possible to make sure they are good candidates for remote therapy. Tölle is enthusiastic about the potential of telerehab, however. “For example, we know that 30 percent of people presenting with acute back pain develop chronic back pain,” he says. “With digital medicine, I see the potential to prevent [pain from becoming chronic].” With chronic pain treatment costing the U.S. upwards of $560 billion each year, better pain prevention could transform the nation’s health care landscape.