Clinical Review: Current Concepts

Clinical Telerehabilitation: Applications forPhysiatrists

Patricia Gregory, MD†, Joshua Alexander, MD, Jennifer Satinsky, MA

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Telemedicine offers an innovative approach to increase access to rehabilitation medicineservices for patients who live in areas where physiatrists are scarce or absent. This articlereviews the current status of telerehabilitation services delivered through real-time video-conferencing to provide support, assessment, and interventions to individuals with impair-ments or disabilities. A literature review demonstrates various uses of telerehabilitation byphysical therapists, occupational therapists, speech and language pathologists, audiologists,recreational therapists, neuropsychologists, nurses, other physician specialists, and physia-trists. We also provide more in-depth examples of 2 current programs that involvephysiatrists: One furnishes telerehabilitation services to adult stroke survivors, and the otheraddresses the special health care needs of children with developmental disabilities. Wediscuss the benefits of using telemedicine via real-time videoconferencing to care forindividuals with disabilities, outline the challenges of successfully implementing a physiat-ric telerehabilitation program, and finish with a list of potential applications for physiatristsinterested in incorporating telemedicine into their practice. Further investigation of the useof telehealth technologies to deliver physiatric services, care coordination, and education isneeded. We recommend that our professional societies develop and publish guidelines tofacilitate development and use of telerehabilitation technologies to increase access tophysiatric services.

PM R 2011;3:647-656

INTRODUCTION

Physiatry is a specialty of medicine that uses an interdisciplinary approach to providecomprehensive and coordinated care delivery to patients with congenital or acquireddisabilities [1]. Physiatrists, or rehabilitation medicine physicians, are experts at diagnosingand treating pain through nonsurgical musculoskeletal interventions. They work to restoremaximum function lost through injury, illness, or disabling conditions; anticipate andprevent secondary complications associated with disabling conditions; and treat the wholeperson, not just the problem area. They lead a team of medical and allied health profession-als, and provide education on treatment and prevention strategies to patients, their families,and other health care professionals. Physiatrists perform comprehensive diagnoses ofimpairments and disabilities, and design a multidisciplinary approach to care that maxi-mizes function and minimizes secondary complications throughout a person’s lifetime.Unfortunately, there are many challenges that limit the ability to deliver this comprehensivecoordinated care to all those who might benefit from it [2-4]. Not only is there a workforceshortage within the specialty of physiatrists to meet the needs of patients [4,5], but there alsois a particular shortage of physiatrists who focus on the management of nonmusculoskeletalproblems of patients. More graduating residents are pursuing musculoskeletal spine fellow-ships [6], which leads to lower numbers of physiatrists to provide care for children andadults with stroke, spinal cord injury, and other neuromuscular conditions. Furthermore,many of the nonmusculoskeletal physiatrists practice in urban-based academic medicalcenters and do not interact as much with community-based physicians and therapists. As aresult, patients who live in remote rural areas have difficulty accessing this specialty care [7].

Patients also face many challenges to accessing physiatric specialty care. First, the

primary care providers who treat individuals with disabilities may not be aware of the scope

Sa

PM&R © 2011 by the American Academy of Physical Me1934-1482/11/$36.00

Printed in U.S.A. D

P.G. Physical Medicine and Rehabilitation,University of North Carolina at Chapel Hill,Chapel Hill, NCDisclosure: Duke Endowment (STAR Project);Clinical and Translational Science Awards,Pilot Program (Family Stroke Caregiver);AHRQ NIH 1K08HS017956-01 (GregoryK08). † Deceased

.A. Physical Medicine and Rehabilitation,niversity of North Carolina at Chapel Hill, Rm1181 UNC Memorial Hospital, 101 Manningr, Campus Box 7200, Chapel Hill, NC7599-7200. Address correspondence to:.A.; e-mail: joshua_alexander@med.unc.eduisclosure: John Rex Endowment (TelAbilityrogram/WATCH Project)

.S. Physical Medicine and Rehabilitation,niversity of North Carolina at Chapel Hill,hapel Hill, NCisclosure: nothing to disclose

eer reviewers and all others who controlontent have no relevant financial relation-hips to disclose.

isclosure Key can be found on the Table ofontents and at www.pmrjournal.org

ubmitted for publication October 7, 2010;ccepted February 20, 2011.

dicine and RehabilitationVol. 3, 647-656, July 2011

OI: 10.1016/j.pmrj.2011.02.024647

648 Gregory et al CLINICAL TELEREHABILITATION

of services offered by a physiatrist and how the specialty maybenefit their patients [8,9]. As a result, they may not refer allthe patients who may benefit from physiatric expertise [10].Second, individuals who are referred to a physiatrist mayexperience geographic obstacles to accessing care. Theseinclude traveling a considerable distance to a large medicalcenter, locating disabled parking, and navigating the facility’slayout to find the physiatrist’s clinic. Third, financial barriers(missing work, purchasing gas and meals, meeting insurancecopays) can limit access to physiatric care. Changes in thepostacute care reimbursement also have had an adverse effecton access to care [11], which limit both home care andoutpatient services.

Telemedicine videoconferencing technology can help toovercome many of these challenges [12] and enable moreindividuals to receive the specialized care that physiatrists areuniquely qualified to provide. This article will review thecurrent status of telerehabilitation, defined as a specific spe-cialty-area application of telecommunication technologies toprovide distance support, assessment, and intervention toindividuals with impairments or disabilities [13]. Telereha-bilitation is provided by therapists, psychologists, nurses,and physiatrists. We will discuss the benefits of using tele-medicine via real-time videoconferencing to care for individ-uals with disabilities and will outline the challenges of suc-cessfully implementing a telerehabilitation program. We willprovide examples of current programs that provide telereha-bilitation services to adults who have had a stroke and tochildren with developmental disabilities. Last, we will finishwith a list of potential applications for physiatrists interestedin incorporating telerehabilitation into their practices.

BACKGROUND

Telemedicine is defined by the American Telemedicine Asso-ciation as the use of medical information exchanged from onesite to another via electronic communications to improvepatients’ health status [14]. It is closely associated with theterm “telehealth,” which often is used to encompass a broaderdefinition of remote health care that does not always involveclinical services. Videoconferencing; transmission of still im-ages; e-health, including patient portals, remote monitoringof vital signs, continuing education; and nursing call centersare all considered part of telemedicine and telehealth. For thepurposes of this article, telemedicine is defined as being asubset of telehealth that uses communication networks fordelivery of health care services and medical education fromone geographic location to another, primarily to addresschallenges posed by physician shortage and maldistributionas well as limitations on patients’ access to specialized ser-vices [15]. Telerehabilitation is defined by the ATA as reha-bilitation specialists involved in applying computer-basedtechnologies and telecommunications to improve access to

rehabilitation services and to support independent living

[16]. Although there is a growing body of evidence thatsupports the efficacy of telerehabilitation in the evaluationand provision of interventions by therapists and psycholo-gists, reports of its use by physiatrists have been limited.

TELEREHABILITATION USE BY ALLIED HEALTHPROVIDERS

Physical Therapy

Several reports illustrated that physical therapy delivered bytelerehabilitation can supplement or even be a viable alterna-tive to traditional, institution-based, outpatient, or in-hometherapy. For example, a physical therapist at a metropolitanrehabilitation center used telerehabilitation technology toprovide neurodevelopmental treatment to a patient who wasliving in a nursing home more than 100 miles from themetropolitan area [17]. After a total of 48 physical telether-apy sessions over a 24-week period, the patient demon-strated measurable improvements in physical functioningand neuropsychological status. A 12-week videoconferenc-ing exercise program for 22 patients with knee osteoarthritisat community centers in Hong Kong resulted in significantimprovement in arthritis symptoms and leg strength [18].The patients also reported that treatment with videoconfer-encing was both convenient and user friendly. Remote home-based physical telerehabilitation for 12 patients with multiplesclerosis led to significant improvement in 25-foot walk,6-minute walk, and Berg Balance Scale score [19]. In anotherreport, telerehabilitation technology was used to provideremote pulmonary rehabilitation exercise sessions for a pa-tient with bronchopulmonary dysplasia who had no localaccess to care [20]. In addition to providing therapy toremote locations, this technology has provided expert con-sultation with remote therapists. A previous study demon-strated the effectiveness of seating evaluations provided in aremote location with consultation from an expert therapistvia interactive teleconferencing [21]. A recent study that useda repeated-measures design demonstrated criterion validityand reliability of remote musculoskeletal assessments of theankle joint complex by using videoconference-mediatedphysiotherapy assessment [22]. In 2006, the American Phys-ical Therapy Association published a position paper thatstates that telemedicine is an appropriate model of servicedelivery for the profession of physical therapy when providedin a manner consistent with American Physical TherapyAssociation positions, standards, guidelines, policies, andprocedures [23].

Occupational Therapy

The successful use of telerehabilitation to deliver occupa-tional therapy services has previously been demonstrated for

both outpatient and home-based therapies by using a virtual-

649PM&R Vol. 3, Iss. 7, 2011

reality–based system and a complementary videoconferenceapparatus. Piron et al [24] provided remote motor rehabili-tation therapy to 5 stroke patients for 6 weeks to promote thelearning of arm motor abilities. A subsequent randomized,single-blind, controlled trial demonstrated that this approachled to better motor outcomes than a traditional occupationaltherapy program in adults with upper-extremity motor im-pairment due to mild stroke [25]. Another report demon-strated how an occupational therapist was able to supervise aconstraint-induced movement therapy program by usingvideoconferencing [26]. This technology also has been usedin home-based therapies. Preoperative home assessments forpatients scheduled to have orthopedic surgery were com-pleted by using remote videoconferencing [27]. Measure-ment of both activities of daily living and hand functionamong persons with Parkinson disease have been success-fully completed by using videoconferencing [28]. Even inex-pensive Internet-based videoconferencing has been used toremotely supervise a home-based functional electrical stim-ulation and an activities of daily living program for a patientwho had had a stroke 3 years earlier [29]. As a result, theAmerican Occupational Therapy Association published aposition paper in 2005 that supports the use of telerehabili-tation as a viable method of service delivery [30]. The posi-tion paper also cited that occupational therapists neededcontinued documentation, research, and publications on theuse of telerehabilitation.

Speech and Language PathologyAssessments

Interactive videoconferencing and Internet-based assessmenttools are well suited to help deliver speech language pathol-ogy as well as audiology assessments and interventions. Bren-nan et al [31] found no significant differences between astandardized speech-language pathology evaluation and oneperformed in a videoconference-based telerehabilitation set-ting. Valid and reliable assessments were made by using alow-bandwidth (128 KB/s), Internet-based videoconferenc-ing system to evaluate patients with dysarthria [32] andspeech apraxia [33]. The telerehabilitation applicationyielded valid and reliable outcomes compared with usualcare [34].

Dysphagia Assessments

An Internet-based system has been developed that can pro-vide real-time evaluation of video-fluoroscopic swallowingstudies by a therapist in a remote location [35]. Telemedicinealso has been cited for use by otolaryngologists to offerremote expertise in providing interactive fiber-optic naso-pharyngolaryngoscopy for dysphagia assessments [36].These studies can be evaluated in real time or can be stored

and examined at later dates for research purposes.

Audiology

A systematic review of telehealth applications in audiologyconfirmed that procedures such as audiometry, video-otoscopy, oto-acoustic emissions, and auditory brainstemresponses can be performed remotely with telehealth tech-nology and can still provide clinical results that are com-parable to those of conventional face-to-face visits. Inter-vention studies, including hearing-aid verification,counseling, and Internet-based treatment for tinnitus, alsodemonstrated the reliability and effectiveness of telehealthapplications compared with conventional methods [37].In addition, in Australia, early intervention services forchildren who are deaf or who have difficulty in hearinghave been delivered via remote videoconferencing since2002 [38]. For more studies in speech and languagetelerehabilitation, the reader is directed to the article“Overview of telehealth activities in speech-language pa-thology” by Mashima and Doarn [39]. The AmericanSpeech and Language Hearing Association has recentlyupdated its position paper that highlights telerehabilita-tion’s potential to improve access to speech and hearingservices [40]. The position paper also cited the need forfurther research into technical requirements, efficacy, andclient satisfaction.

Recreational Therapies

There have been limited reports of videoconferencing use todeliver recreational therapy services to persons with disabil-ities [41]. However, the Defense and Veteran Brain InjuryCenter has begun to develop a network of cutting-edgetechnologies to assist with community reentry, and includesrecreational therapy techniques used by physical and occu-pational therapists for injured soldiers [42].

Neuropsychology

A randomized, clinical trial evaluated the efficacy of a tele-analogy–based problem-solving program for persons withacquired brain injury [43]. The trial concluded that thisapproach effectively improved cognitive function compara-ble to results achieved with other modes of delivery, such asface-to-face training. The American Telemedicine Associa-tion has established practice guidelines for the practice oftelemental health [44]. Common applications include pre-hospitalization assessment and posthospital follow-up care,scheduled and urgent outpatient visits, medication manage-ment, psychotherapy, and consultation.

Nursing

A randomized trial of patients with newly injured spinal cordshowed that monitoring via real-time videoconferencing re-

sulted in 2 fewer hospital days compared with those moni-

650 Gregory et al CLINICAL TELEREHABILITATION

tored via telephone and almost 5 fewer days compared withpatients who were monitored by using the standard approachto care [45]. In another study, nursing follow-up with care-givers of patients with traumatic brain injury when using avideophone resulted in fewer patient hospital days and im-proved management at home [46]. The Veterans AffairsMedical System has demonstrated the cost-effectiveness ofusing a telemedicine care coordination system to manage andsupport veterans with chronic disease states [47]. Telemedi-cine also has been successfully used to monitor and managepressure ulcer wound status among 8 patients with spinalcord injury [48]. Telemedicine has been used to completewound care assessment in the home, which was thought to becomparable to a face-to-face clinic assessment [49]. TheNational Council of State Board of Nursing issued a positionpaper in 1997 that recognized nursing practice provided byelectronic means as the practice of nursing and thus assertsthat it is regulated by boards of nursing [50]. The ATA, inconjunction with the Telehealth Nursing Special InterestGroup, supports the work of nurses in clinical, administra-tive, educational, and research settings; all of these nursesplay vital roles in advocating for patients receiving health careservices via telehealth technologies [51].

Telemedicine Use by Physician Specialists

Published studies have highlighted the use of telemedicine bymultiple specialties, including dermatology, ophthalmology,radiology, and psychiatry [52]. Telemedicine programs es-tablished by neurology and emergency physicians allow neu-rologists to evaluate patients in the first few hours of strokesymptoms and to identify the need for immediate transfer toa tertiary care center [53-57], which has allowed rural hos-pitals to increase the use of tissue plasminogen activator andhas eliminated the need to place the patient in transport forseveral hours, during which time the window of opportunityfor receiving tissue plasminogen activator might expire.

Telemedicine Use by Physiatrists

Few studies have detailed the use of telemedicine by physia-trists to deliver remote care [58-60]. The few publishedreports mention its use for providing outpatient consulta-tions [58, 60-62]. Even in National Institutes of Health–sponsored telerehabilitation programs, there is a paucity ofphysiatrist involvement. For example, only 2 of the 35 inves-tigators listed on the current Rehabilitation Engineering Re-search Center on Telerehabilitation are physicians, and onlyone of these 2 is a physiatrist [63]. Physiatrists should jointheir allied health colleagues in using recent advances intelemedicine and telerehabilitation technology to deliverphysiatric care to patients who would otherwise have limited

access to their expertise. In the following section, we describe

our clinical telerehabilitation applications that seek to ac-complish just that.

TELABILITY

Currently, there are only 165 physicians in the United Stateswho are board certified in pediatric rehabilitation medicine[64]. Although states with relatively large populations, suchas California (n � 15) and New York (n � 13) are covered bya dozen or more pediatric rehabilitation medicine physicians,more than half (26) of the states in the United States have one orno pediatric physiatrists. In North Carolina, the 6 practicingpediatric physiatrists are spread thinly across the state, whichrequires families of children with developmental disabilities totravel long distances to see a pediatric physiatrist (Figure 1). Thisled one of the authors (J.A.) to develop TelAbility, a telehealthprogram for young children with disabilities, which has nowbeen in operation for 12 years [65]. TelAbility is a community-oriented, interdisciplinary program that uses real-time video-conferencing and Internet technologies to provide care acrossNorth Carolina to children with disabilities. This program hasdeveloped an Internet-based, real-time videoconferencing net-work that provides physiatric specialty care to these children bylinking with multiple providers at early intervention centers,developmental day care centers, and private practices wherethey receive therapy. Families are accompanied, at the remotesite, by their local therapists who facilitate the patient’s muscu-loskeletal examination under the direction of the physiatrist.Movement patterns and visual gait analysis also are assessed anddiscussed in real time, with modifications made during the visit.In addition to allowing more individuals (family members, localtherapists, early interventionists, home health nurses, and oth-ers) to attend the doctor visit, these telemedicine visits enhancecommunication and care coordination among members of thechild’s rehabilitation team and enable these patients and theirfamilies to access physiatric expertise and care without travelingto a tertiary care center. Visits are charged by using a telemedi-cine (GT) modifier, and insurance reimburses the physiatrist atrates equal to face-to-face office visits.

Analysis of the last 100 visits performed by the pediatricphysiatrist who pioneered this program reveals that familiessaved an average of 205 miles of car travel per visit (range,16-437 miles) by using interactive videoconferencing fortheir follow-up appointments (J.A., unpublished data). Datacollected by the program also show high levels of satisfactionand comfort reported by families and practitioners. Duringthose same 100 visits, average 5-point Likert scale scores forsatisfaction and comfort were 4.91 and 4.98, respectively.

Stroke Telemedicine Access RecoveryProject

The Stroke Telemedicine Access Recovery Project, which is

newly developed, aims to use Internet-based videoconferenc-

pscit

651PM&R Vol. 3, Iss. 7, 2011

ing to provide access to stroke recovery services for a remoterural population of stroke survivors in North Carolina. Inaddition to acute-care services that reduce morbidity andmortality, stroke survivors need stroke rehabilitation thera-pies to minimize the effects of a number of other impairmentsthat limit their ability to live independently [66,67]. Al-though there are limited studies on access to postacute strokerehabilitation, Buntin et al [67] showed in one study that

ostacute disposition is often affected by the availability ofervices and agreement among facilities. Despite the Ameri-an Stroke Association recommendations of standard screen-ng evaluations to determine the appropriate rehabilitationherapies [68] and the Center for Medicare and Medicaid

Services’ Pay for Performance Program requires physicians todocument consideration of stroke rehabilitation services[69], these evaluations are not always completed. Access topostacute stroke rehabilitation is often affected by the avail-ability of such services as acute inpatient rehabilitation facil-ities, skilled nursing facilities, home health therapies, outpa-tient physical therapies, occupational therapies, and speechtherapies [11]. There are a limited number of certified reha-bilitation facilities within North Carolina. The Council onAccreditation of Rehabilitation Facilities has certified 18 fa-cilities, the majority of which are located in the center of thestate (Figure 2). Also, physiatrists, who help to identify theappropriate level and intensity of needed therapies and fol-

Figure 1. Projected number of children with developmentalCarolina.

low the patient’s progress across the course of recovery, are

important team members in proper poststroke rehabilitation.However, the 156 practicing physiatrists in North Carolinaare concentrated in the major metropolitan areas, whichleaves rural areas, such as Robeson County, largely under-served (Figure 2).

Stroke-management resources are limited within thecatchment area of Southeastern Regional Medical Center; a337-bed hospital located in Lumberton, North Carolina, thecounty seat of Robeson County. There are more than 200stroke patients admitted to Southeastern Regional every year.However, this hospital is not a Joint Commission - accreditedprimary stroke center, does not have a dedicated stroke unitfor patients, and the 2 physical medicine and rehabilitationspecialists on staff focus their practice on electromyographyand pain management.

The Stroke Telemedicine Access Recovery Project aims toprovide physiatric care for patients after acute stroke viareal-time Internet-based videoconferencing. Not only willthis enable patients to receive evaluations and recommenda-tions from a physiatrist specializing in the care of strokepatients, it also will increase the ability of the physiatrist towork as part of an interdisciplinary team to help the patientand family negotiate the local health care system. By usingthis application, telemedicine can help to counter the short-age of physiatrists in rural counties by extending the reach ofrehabilitation specialists elsewhere to these underserved ar-

lities and location of practicing pediatric physiatrists in North

disabi

eas [70].

litation

652 Gregory et al CLINICAL TELEREHABILITATION

POTENTIAL CHALLENGES TO INITIATINGAND SUSTAINING A PHYSIATRICTELEMEDICINE PRACTICE

Costs of Implementation

In the past, there have been a number of obstacles to imple-menting a clinical telemedicine practice. Concerns wereraised that the high start-up costs of installation and equip-ment purchase impeded installation [71]. Years ago, imple-mentation often was hindered by the high costs of establish-ing reliable connectivity, providing technical infrastructureand/or support, and purchasing equipment [72]. As technol-ogy has continued to advance, costs have decreased; how-ever, there still is a need for further research studies thatinclude cost analysis to further support telemedicine’s use[73]. These obstacles have been faced by all medical special-ties in the past and have likely limited more robust adoptionby physiatrists as well. As a solution, the National Institutesof Health has recognized these challenges and is seeking tofund implementation research and to create informationresources [71].

Lack of Telemedicine Protocols

Additional challenges to implementation include overcom-ing workflow challenges and ensuring accurate and efficientexchange of information [71,74]. To be effective, physiatristsneed to develop, establish, and adhere to protocols for deliv-

Figure 2. Stroke prevalence and rehabi

ery of rehabilitation medicine services via telemedicine to

ensure that quality and standards of care are maintained,including staff education and training.

Reimbursement

Telemedicine services have been available for many years, yetwidespread implementation has been hampered by reim-bursement issues [75]. Lack of reimbursement has limitedthe expansion of these programs in the past. However, since2006, Medicare has reimbursed providers for telemedicinecare in 3 areas: remote patient face-to-face services seen vialive videoconferencing; non–face-to-face services that can beconducted either through live videoconferencing or via store-and-forward telecommunication services; and home tele-health services [76,77]. Eligible services include outpatientclinic visits and consultations. Providers who are eligible tobe reimbursed for telemedicine services include the follow-ing: physicians, nurse practitioners, physician assistants,nurse midwives, clinical nurse specialists, clinical psycholo-gists, clinical social workers, and registered dietitians ornutrition professionals. In 2010, the Centers for Medicareand Medicaid Services added 3 codes for initial inpatienttelehealth consultations. The Centers for Medicare and Med-icaid Services also expanded the definition of follow-up in-patient telehealth consultations to include services to patientslocated in hospitals or skilled nursing facilities [78]. Al-though some states reimburse allied health professionals forservices delivered via telemedicine, most therapists are notcurrently authorized to bill for services provided through

resources by county in North Carolina.

interactive videoconferencing [79].

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653PM&R Vol. 3, Iss. 7, 2011

Technical Challenges

A number of technical challenges must be overcome to estab-lish and maintain a telemedicine network; these challengesinclude, but are not limited to, connectivity issues at remotesites, compatibility of platforms and interfaces of differentvendors, and overcoming firewalls at the hub and remotesites [71,80]. With advanced telemedicine technology, con-nectivity has rapidly improved. In particular, the evolution ofcoder–decoder software programs has improved the videoand sound delivered at lower connectivity rates. Workingwith experienced information technology staff at all sites isthe key to overcoming these challenges.

Privacy and Security Issues

When setting up a telemedicine network, it is important toensure that the established network protects patient privacy.The main purpose of the Health Insurance Portability andAccountability Act (HIPAA) guidelines is to protect the pa-tient’s privacy and to regulate health care operations. In thepractice of telemedicine, HIPAA requires physicians to obtainconsent before any use or disclosure of confidential healthinformation for treatment, payment, or any other operation.Specific details about HIPAA guidelines for telemedicinehave been published [81]. Ensuring that the network isencrypted, secure, and not vulnerable to spyware attacksagain involves working closely with information technologyexperts.

Patient Acceptance

Despite telemedicine’s ability to decrease patient travel timeand expenses, some patients may have a preference for in-person care and may not accept the use of telemedicine forcare delivery [71,80]. Providers should be aware of this,cknowledge their patients’ concerns, and provide ampleducation to both patients and staff.

Physician Acceptance

Physiatrist acceptance of the use of videoconferencing tech-nology to provide telemedicine services may be limited bymultiple factors, including lack of knowledge about, skepti-cism of, or discomfort with videoconferencing technologies.Workflow issues may limit the ability to integrate telemedi-cine into the physiatrist’s busy clinic day. The physiatrist alsomay desire to personally perform every physical examinationinstead of relying on a facilitator (physician, nurse, therapist)at a distant site. The first 2 hurdles can now be overcomethrough education, support, and protocol development, andthe last one may be solved in the future through the use ofhaptic transmission that will enable a physiatrist to manipu-late and sense the resistance of a patient’s limbs during a

virtual physical examination [82].

Licensure and/or Medicolegal Issues

Additional concerns raised by specialists have included themedicolegal challenges associated with rendering care toindividuals at remote locations [75]. For example, if theremote site is located in another state, then there are issuesrelated to practicing across state lines. There also may beissues related to credentialing at remote institutions. Theseissues are still in the process of being resolved. The AmericanTelemedicine Association continues to support and worktoward the establishment of a national telemedicine licen-sure. In addition to licensure and credentialing, there alsomay be issues of liability coverage. Physiatrists must recog-nize the limitations of virtual visits and adjust care deliveryaccordingly.

CONCLUSION

Although there still are some challenges in providing clinicalrehabilitation medicine services via telemedicine, these chal-lenges can be overcome to increase access to specializedmedical services for all and is especially important for indi-viduals with impairments and disabilities, the populationserved by physiatrists. Thus, there are numerous potentialapplications of this technology to the practice of physiatry.Examples of potential applications for physiatrists includeproviding care in skilled nursing facilities, arranging homevisits for debilitated patients, holding multipoint interdisci-plinary team meetings, and following up with patients afterinjections. Telemedicine offers an innovative approach toincrease access to clinical rehabilitation medicine services.There is a significant need for physiatrists to join their col-leagues in allied health to document, research, and publishon the efficacy of consultation, intervention, and follow-upservices provided when using telerehabilitation technologies.Further investigation of the use of telehealth technologies inprofessional development and supervision is needed to clar-ify effectiveness and efficiency, because demand for services,particularly in rural areas, threatens to exceed services avail-able [30]. In addition, the professional societies should de-velop and publish guidelines to facilitate use and develop-ment of telerehabilitation programs to increase access tophysiatric services.

ACKNOWLEDGMENT

The authors mourn the loss of Patricia Gregory, MD, leadauthor for this article. After successfully obtaining funding toestablish a telerehabilitation research program and whileworking on this review, Patricia suddenly and unexpectedlypassed away at UNC Hospital. She was an assistant professorof physical medicine and rehabilitation at the University ofNorth Carolina at Chapel Hill, a wife, and mother of 3children, and a blessing to all who knew her. “Dr Gregory was

an outstanding physician scientist and a national leader

654 Gregory et al CLINICAL TELEREHABILITATION

working to reduce health disparities,” said Michael Y. Lee,MD, MHA, chair of UNC Physical Medicine and Rehabilita-tion. “She was one of a limited number of physiatrists engag-ing in health services research and was finishing a masters inpublic health to promote interdisciplinary research. Herpassing is a loss to multiple fields of study working toimprove access to care.”

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CME QuestionCurrent factors which should facilitate physiatrists’ use of telerehabi

a. improved coder-decoder (CODEC) software programs.b. resolution of Medicare physician telehealth reimbursement.c. availability of haptic technology and transmission.d. specific HIPAA guidelines for telemedicine.

Answer online at me.aapmr.org

82. Carignan C, Krebs H. Telerehabilitation robotics: bright lights, bigfuture? J Rehabil Res Dev 2006;43:695-710.

This CME activity is designated for 1.0 AMA PRA Category 1 Credit™ andcan be completed online at me.aapmr.org. Log on to www.me.aapmr.org,go to Lifelong Learning (CME) and select Journal-based CME from thedrop down menu. This activity is FREE to AAPM&R members and $25 fornon-members.

include all of the following EXCEPT:

litation