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Remote Revolution

Telepractice is here and growing fast, so why are physios still on the sidelines? Daloni Carlisle investigates

Anyone with a passing acquaintance with developments in health technology could not fail to be aware of the telepractice revolution that is taking place.

But if you are a UK physiotherapist trying to get involved in telecare or the related fields of telehealth, telemedicine and telerehabilitation, then you are likely to feel out in the cold.

There is no doubt that some physios are doing some exciting work using the new technology. They are assessing people for home aids such as fall detectors or using video conferencing with patients with spinal injuries, for example. However, they are few and far between and it is fair to say that the telerevolution has yet to touch the profession in any meaningful way.

For the majority of the profession this is a new area with new and sometimes confusing terminology. Understanding it is the first step to getting involved.

WIRED FOR SAFETY

Let’s start with telecare. It is developing rapidly in this country, with projects in 148 of 150 local authorities, most of them funded or pump-primed by central government money. Broadly speaking, they aim to support older or disabled people in their own homes.

The schemes include houses wired to monitor people’s movements, so that an alarm notifies a monitoring centre when a patient does not get out of bed at their regular time or open the fridge, or has a fall. The alarm triggers a response, usually a telephone call from a call centre in the first instance, escalating to a call to a nominated key holder if that gets no response.

The rationale is simple: people prefer to stay in – or return to – their own homes where they can live independently, and telecare makes that possible. It also makes good use of NHS resources.

The evidence to date on both these factors is now pretty robust and the government has repeatedly made the case for wider uptake. It is in the National Service Framework for Older People; the white paper Our Health, Our Care, Our Say; the social care reform strategy Putting People First and now the Darzi review of the NHS in England.

Alison Williams, telecare strategy manager for Tunstall, the largest equipment supplier in the UK, explains: ‘A lot of the projects focus on falls clinics, re-ablement teams and intermediate care, and physios are a major part of these teams. So one would expect physios to be involved in the process,’ she says. But by and large they are not.

‘Telecare is becoming part of the process wherever people have had some sort of incident and are trying to move back to the community,’ Ms Williams adds. ‘It is in everyone’s interest that everybody knows what the benefits are and why it may or may not be good for an individual patient.’

Physiotherapist Jo Jennings is an exception. She was involved in a telecare project in Essex prior to taking maternity leave just under a year ago. ‘I was the community matron for long-term conditions and was one of the people trained to do basic telecare assessments,’ she explains. Tunstall provided the training, which Ms Jennings topped up using their online tools.

‘I would assess whether patients needed a falls monitor or a sensor in their chair to see when they get up. I would estimate how long it takes them to cross the room and come back to the chair.’ It was well liked by the users who had a chance to try out the equipment in a special room in one of the residential homes. Physios remain involved today.

HOME MONITOR

Coming up quickly behind telecare is telehealth, which involves home monitoring of biomedical signs such as blood pressure, blood glucose, heart rate and oxygen saturation in people with long-term conditions. The aim is to improve use of NHS resources and prevent emergency admissions. Upwards of 6,000 people are now using telehealth.

So, for example, a patient with chronic obstructive pulmonary disease, diabetes or coronary vascular disease might have equipment installed at home to measure vital signs and answer a series of questions online about their health. The results are transmitted electronically to a health professional for triage. If the results are outside set parameters, this will trigger an intervention such as a home visit.

Gail McKeown, community respiratory physio at Lagan Valley hospital in Lisburn, is working on just such a project, the first with COPD patients in Northern Ireland. Her role is to assess patients’ suitability and set the parameters that trigger an escalation such as a home visit from the physio or nurse.

She likes the system. ‘It works well,’ she says. ‘We have reduced our call-outs as we are now being called out appropriately. When I do go out, I have all the information I need from the triage nurse.’

And although it is not suitable for every patient, those who have tried it like it. ‘They can get up in the morning, check themselves and if they are OK then set out for the day. It gives them confidence,’ she says.

A pilot project with 20 patients was so successful that the hospital is extending the scheme, while the European Centre for Connected Health has adopted the model and hopes to roll it out elsewhere. The results have not yet been formally published.

LONG DISTANCE REHAB

Another way in which new technology is being used in healthcare is known as telerehabilitation – delivering rehabilitation services over the internet. This is most developed in the US and Australia. As far as physiotherapy goes it is very much in its infancy in the UK, with only small-scale pilots to date.

One such was carried out at Salisbury Spinal Centre in 2006 and involved weekly video conferencing with patients immediately after discharge home. Mostly this was with a nurse or occupational therapist but physios were involved too in a generic therapist role.

Occupational therapist Helen Pain was the research officer on what was a randomised controlled trial. ‘The process of fortnightly goal-setting and raising questions was well received by the patients, although the results did not produce any statistical difference,’ she says.

The results are awaiting publication – the study was run in partnership with European colleagues – but Ms Pain says several themes emerged. One was that when discussing confidential issues, such as sexual dysfunction, through video conferencing, the usual technology was not sufficiently secure. Bespoke software was required, which had resource implications.

NEED FOR CHANGE

Then there was equity – the service can really only be provided to people who have a broadband internet connection at home. Nor is it clinically appropriate for every patient. Clinicians at the hospital are now thrashing these and other issues out as they attempt to take the project forward.

In Perth and Kinross, Jane Dernie, head of physiotherapy for the community health trust, is looking at different models. In September, she hopes to launch a teleconferenced pulmonary rehab programme. Instead of going to the main hospital, patients will go to their local community hospital where they will access a regular rehab session over a two-way video link.

‘Patients still have the benefits of a group but do not have to travel to get the service,’ Ms Dernie says. ‘We will be testing technical issues such as whether we can get a link on every occasion as well as patient outcomes and satisfaction.’

So there are physios involved in the telepractice revolution. But the numbers are tiny and there is a long way to go before it is part of mainstream practice. Margaret Hastings, chair of the CSP’s information management and technology committee, says: ‘As a profession we have not grasped this nettle.

‘I am not quite sure if we are resisting change because we believe we have to be near a patient and have our hands on them. I think there is a real change going on in the way we use technology and we need to grasp this.’

As with any change in practice, telepractice throws up huge issues for the profession, including the potential benefits and pitfalls for individual patients, clinical standards, ethics, liability and malpractice, privacy and confidentiality. The debate is in its infancy and can only get hotter.

FURTHER INFORMATION Dr Russell’s work (see panel) can be seen at

www.uq.edu.au/telerehabilitation

For more about telecare, see the Disabled Living Foundation website www.telecaremadeeasy.com

For more on telehealth, see the King’s Fund website: www.wsdactionnetwork.org.uk

Adapting to a virtual environment

One of the main reservations physios have about telerehabilitation is the extent to which it would change the interaction with patients.

Ruth Parry is senior research fellow at the Institute for Science and Society at the University of Nottingham and is carrying out research on physiotherapists’ communication.

‘In contrast with medicine there is very little known about how we communicate with patients,’ she says. ‘For example, we don’t know much

about the techniques that physios use, such as touching or gazing at the arm that he or she wants the patient to move.

‘The issue then for telerehab is now much of that non-verbal communication is likely to be lost and what alternative skills both patients and therapists will need to use in order to communicate with each other’

Dr Trevor Russell, senior lecturer in physiotherapy and co-director of the telerehabilitation research unit at the University of Queensland in Australia has not looked into this question specifically but does agree that practice needs to adapt when it’s used online.

‘The need for a hands-on approach in some areas of rehabilitation is one of the main reasons for professional scepticism towards telerehabilitation as an alternate service delivery model,’ he says.

Nevertheless, he argues that physios can rely on the same knowledge base; they just need to adapt their methods. For example, consultations can be carried out with the expert at one end of the telephone/video line and an assistant at the patient end.

Dr Russell adds: ‘Other strategies such as the self-application of manual techniques, exercise training, education and other self-management strategies can be used and have been demonstrated to be effective in many areas of telerehabilitation practice. Fortunately, physiotherapists already have an excellent grounding in these treatment strategies and are able to adapt them in a virtual environment extremely well.’

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Article Information

Author(s)

FL

Issue date

3 September 2008

Volume number

14

Issue number

15

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