Multicomponent telerehabilitation programme for older veterans with multimorbidity: a programme evaluation.

INTRODUCTION: Older veterans with multimorbidity experience physical, mental and social factors which may negatively impact health and healthcare access. Physical function, behaviour change skills and loneliness may not be addressed during traditional physical rehabilitation. Thus, a multicomponent telerehabilitation programme could address these unmet needs. This programme evaluation assessed the safety, feasibility and change in patient outcomes for a multicomponent telerehabilitation programme. METHODS: Individuals were eligible if they were a veteran/spouse, age ≥50 years and had ≥3 comorbidities. The telerehabilitation programme included four core components: (1) High-intensity rehabilitation, (2) Coaching interventions, (3) Social support and (4) Technology. Physical therapists delivered the 12-week programme and collected patient outcomes at baseline, 4 weeks, 8 weeks and 12 weeks. Programme evaluation measures included safety events (occurrence and type), feasibility (adherence) and patient outcomes (physical function). Safety and feasibility outcomes were analysed using descriptive statistics. The mean pre-post programme difference and 95% CI for patient outcomes were generated using paired t-tests. RESULTS: Twenty-one participants enrolled in the telerehabilitation programme; most were male (81%), white (72%) and non-Hispanic (76%), with an average of 5.7 (3.0) comorbidities. Prevalence of insession safety events was 3.2% (0.03 events/session). Fifteen (71.4%) participants adhered to the programme (attended ≥80% of sessions). Mean (95% CI) improvements for physical function are as follows: 4.7 (2.4 to 7.0) repetitions for 30 s sit to stand, 6.0 (4.0 to 9.0) and 5.0 (2.0 to 9.0) repetitions for right arm curl and left arm curl, respectively, and 31.8 (15.9 to 47.7) repetitions for the 2 min step test. CONCLUSION: The telerehabilitation programme was safe, feasible and demonstrated preprogramme to postprogramme improvements in physical function measures while addressing unmet needs in a vulnerable population. These results support a randomised clinical trial while informing programme and process adaptations.

Older Veterans' Experiences of a Multicomponent Telehealth Program: Qualitative Program Evaluation Study.

BACKGROUND: There are 8.8 million American veterans aged >65 years. Older veterans often have multiple health conditions that increase their risk of social isolation and loneliness, disability, adverse health events (eg, hospitalization and death), mental illness, and heavy health care use. This population also exhibits low levels of physical function and daily physical activity, which are factors that can negatively influence health. Importantly, these are modifiable risk factors that are amenable to physical therapy intervention. We used a working model based on the dynamic biopsychosocial framework and social cognitive theory to conceptualize the multifactorial needs of older veterans with multiple health conditions and develop a novel, 4-component telehealth program to address their complex needs. OBJECTIVE: This study aims to describe veterans' experiences of a multicomponent telehealth program and identify opportunities for quality and process improvement. We conducted qualitative interviews with telehealth program participants to collect their feedback on this novel program; explore their experience of program components; and document perceived outcomes and the impact on their daily life, relationships, and quality of life. METHODS: As part of a multimethod program evaluation, semistructured interviews were conducted with key informants who completed ≥8 weeks of the 12-week multicomponent telehealth program for veterans aged ≥50 years with at least 3 medical comorbidities. Interviews were audio recorded and transcribed. Data were analyzed by a team of 2 coders using a directed content analysis approach and Dedoose software was used to assist with data analysis. RESULTS: Of the 21 individuals enrolled in the program, 15 (71%) met the inclusion criteria for interviews. All 15 individuals completed 1-hour interviews. A total of 6 main conceptual domains were identified: technology, social networks, therapeutic relationship, patient attributes, access, and feasibility. Themes associated with each domain detail participant experiences of the telehealth program. Key informants also provided feedback related to different components of the program, leading to adaptations for the biobehavioral intervention, group sessions (transition from individual to group sessions and group session dynamics), and technology supports. CONCLUSIONS: Findings from this program evaluation identified quality and process improvements, which were made before rigorously testing the intervention in a larger population through a randomized controlled trial. The findings may inform adaptations of similar programs in different contexts. Further research is needed to develop a deeper understanding of how program components influence social health and longer-term behavior change.

Rehabilitation Therapy Allocation and Changes in Physical Function Among Patients Hospitalized Due to COVID-19: A Retrospective Cohort Analysis.

OBJECTIVE: Limited staffing and initial transmission concerns have limited rehabilitation services during the COVID-19 pandemic. The purpose of this analysis was to determine the associations between Activity Measure for Post-Acute Care (AM-PAC) mobility categories and allocation of rehabilitation, and in-hospital AM-PAC score change and receipt of rehabilitation services for patients with COVID-19. METHODS: This was a retrospective cohort study of electronic health record data from 1 urban hospital, including adults with a COVID-19 diagnosis, admitted August 2020 to April 2021. Patients were stratified by level of medical care (intensive care unit [ICU] and floor). Therapy allocation (referral for rehabilitation, receipt of rehabilitation, and visit frequency) was the primary outcome; change in AM-PAC score was secondary. AM-PAC Basic Mobility categories (None [21-24], Minimum [18-21], Moderate [10-17], and Maximum [6-9]) were the main predictor variable. Primary analysis included logistic and linear regression, adjusted for covariates. RESULTS: A total of 1397 patients (ICU: n = 360; floor: n = 1037) were included. AM-PAC mobility category was associated with therapy allocation outcomes for floor but not patients in the ICU: the Moderate category had greater adjusted odds of referral (adjusted odds ratio [aOR] = 10.88; 95% CI = 5.71-21.91), receipt of at least 1 visit (aOR = 3.45; 95% CI = 1.51-8.55), and visit frequency (percentage mean difference) (aOR = 42.14; 95% CI = 12.45-79.67). The secondary outcome of AM-PAC score improvement was highest for patients in the ICU who were given at least 1 rehabilitation therapy visit (aOR = 5.31; 95% CI = 1.90-15.52). CONCLUSION: AM-PAC mobility categories were associated with rehabilitation allocation outcomes for floor patients. AM-PAC score improvement was highest among patients requiring ICU-level care with at least 1 rehabilitation therapy visit. IMPACT: Use of AM-PAC Basic Mobility categories may help improve decisions for rehabilitation therapy allocation among patients who do not require critical care, particularly during times of limited resources.

Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID-19.

BACKGROUND: Survivors of the novel coronavirus (COVID-19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in-hospital rehabilitation therapy may reduce long-term impairments. OBJECTIVE: To determine the frequency of therapy referral and treatment amongst hospitalized COVID-19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing. MEASUREMENTS: Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery. RESULTS: Amongst 6239 COVID-19-related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67-0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46-1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37-1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12-1.15, p < .01) were positively associated with referral. CONCLUSIONS AND RELEVANCE: In a cohort of patients hospitalized for COVID-19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non-Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.

Multimodal conservative management of arthrofibrosis after total knee arthroplasty compared to manipulation under anesthesia: a feasibility study with retrospective cohort comparison.

BACKGROUND: The ideal treatment of early-stage arthrofibrosis after total knee arthroplasty is unclear. The purpose of this study was to determine the treatment effect, including variability, and feasibility of a multimodal physical therapy program as compared to manipulation under anesthesia. METHODS: This was a prospective feasibility study with a retrospective cohort comparison. Ten consecutive patients (aged 64 ± 9 years, 7 females) with early-stage arthrofibrosis were enrolled 6 weeks after primary total knee arthroplasty and participated in the multimodal physical therapy program. The multimodal physical therapy program consisted of manual therapy, therapeutic exercise, and static progressive splinting delivered over 4 weeks. The outcomes included knee range of motion (ROM), adherence, patient satisfaction, and safety. Data were compared to a retrospective cohort of 31 patients with arthrofibrosis (aged 65 ± 9 years, 20 females) who underwent manipulation under anesthesia followed by physical therapy. RESULTS: Overall, knee ROM outcomes were similar between multimodal physical therapy (110° ± 14) and manipulation under anesthesia (109° ± 11). Seven out of ten patients achieved functional ROM (≥ 110°) and avoided manipulation under anesthesia with the multimodal physical therapy program. Three out of 10 multimodal physical therapy patients required manipulation under anesthesia secondary to failure to demonstrate progress within 4 weeks of the multimodal physical therapy program. Adherence to the multimodal physical therapy program was 87 ± 9%. The median patient satisfaction with the multimodal physical therapy program was "very satisfied." Safety concerns were minimal. CONCLUSION: The use of the multimodal physical therapy program is feasible for treating early-stage arthrofibrosis after total knee arthroplasty, with 70% of patients avoiding manipulation under anesthesia. Randomized controlled trials are needed to determine the efficacy of the multimodal physical therapy program and to determine the optimal patient selection for the multimodal physical therapy program versus manipulation under anesthesia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04837872 .

Practice Considerations for Adapting in-Person Groups to Telerehabilitation.

The Coronavirus-2019 (COVID-19) pandemic has shifted research and healthcare system priorities, stimulating literature on implementation and evaluation of telerehabilitation for a variety of patient populations. While there is substantial literature on individual telerehabilitation, evidence about group telerehabilitation remains limited despite its increasing use by rehabilitation providers. Therefore, the purpose of this manuscript is to describe our expert team's consensus on practice considerations for adapting in-person group rehabilitation to group telerehabilitation to provide rapid guidance during a pandemic and create a foundation for sustainability of group telerehabilitation beyond the pandemic's end.

How New Technology Is Improving Physical Therapy.

PURPOSE OF REVIEW: As rehabilitation patient volume across the age spectrum increases and reimbursement rates decrease, clinicians are forced to produce favorable outcomes with limited resources and time. The purpose of this review is to highlight new technologies being utilized to improve standardization and outcomes for patients rehabilitating orthopedic injuries ranging from sports medicine to trauma to joint arthroplasty. RECENT FINDINGS: A proliferation of new technologies in rehabilitation has recently occurred with the hope of improved outcomes, better patient compliance and safety, and return to athletic performance. These include technologies applied directly to the patient such as exoskeletons and instrumented insoles to extrinsic applications such as biofeedback and personalized reference charts. Well-structured randomized trials are ongoing centered around the efficacy and safety of these new technologies to help guide clinical necessity and appropriate application. We present a range of new technologies that may assist a diverse population of orthopedic conditions. Many of these interventions are already supported by level 1 evidence and appear safe and feasible for most clinical settings.