Implementation and Adoption of Tele-Rehabilitation for Treating Mild Traumatic Brain Injury

Abstract

Background and Purpose:

Multimodal physical therapy for mild traumatic brain injury (mTBI) has been shown to improve recovery. Due to the COVID-19 pandemic, a clinical trial assessing the timing of multimodal intervention was adapted for tele-rehabilitation. This pilot study explored feasibility and adoption of an in-person rehabilitation program for subacute mTBI delivered through tele-rehabilitation.

Methods:

Fifty-six in-person participants [9 Males; mean(SD) age 34.3(12.2); 72(15) days post injury] and 17 tele-rehabilitation participants [8 Males; age 38.3(12.7); 75(16) days post injury] with subacute mTBI (between 2 and 12 weeks from injury) were enrolled. Intervention included 8, 60-minute visits over 6 weeks and included subcategories that targeted cervical spine, cardiovascular, static balance, and dynamic balance impairments. Tele-rehabilitation was modified to be safely performed at home with minimal equipment. Outcome measures included feasibility (the number that withdrew from the study, session attendance, home exercise program adherence, adverse events, tele-rehabilitation satisfaction, and progression of exercises performed), and changes in mTBI symptoms pre- and post-rehabilitation were estimated with Hedge’s G effect sizes.

Results:

In-person and tele-rehabilitation had a similar study withdrawal rate (13% vs 12%), high session attendance (92% vs 97%), and no adverse events. The tele-rehabilitation group found the program easy to use (4.2/5), were satisfied with care (4.7/5), and thought it helped recovery (4.7/5). The tele-rehabilitation intervention was adapted by removing manual therapy and cardiovascular portions and decreasing dynamic balance exercises compared to the in-person group. The in-person group had a large effect size (−0.94) in decreases in symptoms following rehabilitation, while the tele-rehabilitation group had a moderate effect size (−0.73).

Discussion and Conclusions:

Tele-rehabilitation may be feasible for subacute mTBI. Limited ability to address cervical spine, cardiovascular and dynamic balance domains along with under-dosage of exercise progression may explain group differences in symptom resolution.

INTRODUCTION

Telemedicine has become an increasingly popular option as digital technologies have advanced and become more accessible to those in rural communities and those in need of in-person alternatives due to the COVID-19 pandemic.^1–4 Tele-rehabilitation is a subset of telemedicine in which patients requiring rehabilitation for motor, cognitive, or psychological disorders can access care remotely, via phone calls or video conferencing. Initial tele-rehabilitation studies focused on orthopedic pathologies.⁵ However, given the need for continuous access to rehabilitation in patients with chronic neurological conditions to progress and maintain physical function, tele-rehabilitation may provide a vital alternative to in-clinic care.

There is some evidence that tele-rehabilitation may be effective for several chronic neurological patient populations. A recent systematic review and meta-analysis on tele-rehabilitation for stroke survivors, which included 12 randomized controlled trials in the pooled analysis, reported no significant differences between tele-rehabilitation and standard of care and concluded that tele-rehabilitation was a reasonable method for delivery of services in this chronic population.⁶ Another systematic review concluded that online video conferencing was the most frequently used approach and that technology-based distance physical rehabilitation had a similar effect on activities of daily life compared to usual care in people with chronic stroke.⁷ Additional studies on preventing falls in multiple sclerosis, Parkinson’s disease, and community-dwelling elderly support the use of tele-rehabilitation as an effective and feasible means for rehabilitation remotely.^8–10

Several studies on telehealth for mTBI have been published before and during the COVID-19 pandemic with most describing mTBI baseline testing, diagnosis, and acute care through telehealth platforms.^11–17 Telehealth assessments could be effective in managing patients through return-to-learn/-play and provide similar levels of patient satisfaction compared to in-person services.^13,17 One study provided assessments and prescriptions of aerobic exercise through a telehealth platform to help in mTBI recovery.¹⁶ Otherwise, studies have only recommended virtual patients to specialized care when needed and none have examined the delivery of more functional aspects of physical therapy intervention, such as functional training for balance and gait after mTBI.^12,14,17 As such, there is a need for studies that can provide a framework for delivering physical therapy through a telehealth platform for patients with mTBI, and studies are needed to determine its effectiveness.

Given the growing body of evidence that supports a multimodal rehabilitation program to address post mTBI symptoms,^18–20 it is unclear if tele-rehabilitation could be successfully used to provide treatment across multiple domains, such as balance, walking, and aerobic exercise interventions. For example, several studies have shown that vestibular rehabilitation or a combination of cervical therapy and vestibular rehabilitation was effective in reducing symptom burden, facilitating a faster return to sports, and having a positive impact on health-related quality of life.^21–24 Sub-symptom threshold aerobic exercise has also been shown to be effective in reducing symptoms and facilitating return to premorbid activity level.^25–27 In addition to targeting multiple aspects of impairment, mTBI rehabilitation programs also need the appropriate frequency, intensity, duration, and progression to promote effective recovery.^23,28,29 However, it remains unclear if each of these domains is suitable for treatment using tele-rehabilitation for people with mTBI.

In this study, we adapted a multimodal physical therapy intervention that was targeted to address individuals in the subacute phase of mTBI who still reported symptoms of impaired balance and/or dizziness. This rehabilitation program was originally designed as part of a larger study that was assessing the timing of physical therapy intervention on people with a delayed recovery (> 2–12 weeks post-injury) from mTBI (Clinical Trial NCT03479541).³⁰ The original protocol was intended to be performed in-person with a physical therapist that supervised and progressed the participant and was adapted to be delivered by a physical therapist remotely due to the COVID-19 pandemic preventing in-person rehabilitation. The multimodal program consisted of cervical, cardiovascular, static, and dynamic balance exercise. The goals of this pilot project were 1) to explore the feasibility of delivering all components of a comprehensive multimodal mTBI rehabilitation program remotely, and 2) to discuss the pros and cons of telerehabilitation compared to regular in-person rehabilitation after mTBI.

METHODS

Participants

A total of 73 people with subacute mTBI are included in this analysis; 56 were enrolled into in-person rehabilitation and 17 into tele-rehabilitation (see Table 1 for demographics). Participants were recruited from Oregon Health and Science University and local clinics. Inclusion and exclusion criteria and mTBI definitions have been previously described.³⁰ Briefly, participants were included if they: 1) had a diagnosis of mTBI made by a physician and were 2 – 12 weeks of their injury, 2) were between 18–60 years old, 3) had a graded symptom checklist total symptom severity score ≥ 15, and endorsed any symptoms on either headache, nausea, dizziness, blurred vision, or balance problems from the Sport Concussion Assessment Tool version 5, and 4) no more than minimal cognitive impairment (≤ 8 on Short Blessed Test).³¹ This study was approved by the Joint Institutional Review Board Committee of Oregon Health and Science University and Veterans Administration Portland Health Care System. The original clinical trial study enrolled participants from July 2018 to March 2020 when in-person research stopped due to the COVID-19 pandemic. To continue the clinical trial, we transitioned to a tele-rehabilitation program and enrolled participants from April 2020 to September 2020, before the clinical trial returned to in-person testing and rehabilitation.

Table 1.

Participant Demographics at Study Enrollment

	In-person n = 56 Mean (SD)/n (%)	Telerehabilitation n = 17 Mean (SD)/n (%)
Age, y	34.33 (12.23)	38.34 (12.72)
Sex, male/female	9/47	8/9
Height, cm	167.71 (9.59)	174.81 (8.95)
Body mass, kg	71.85 (14.57)	74.68 (15.96)
Days since injury before rehabilitation	66.82 (31.3)	61.06 (36.95)
Number of previous mTBIs
0	35 (63%)	13 (76%)
1	8 (14%)	2 (12%)
2	6 (11%)	0 (0%)
≥3	7 (13%)	2 (12%)
Mechanism of Injurya
Bike	3 (5%)	2 (12%)
Fall	13 (23%)	2 (12%)
Motor vehicle crash	17 (30%)	4 (24%)
Sports	13 (23%)	6 (35%)
Other	10 (18%)	3 (18%)

Abbreviations: mTBIs, mild traumatic brain injuries; SD, standard deviation.

^aMechanism of injury percentages add to 99% due to rounding within the In-Person column. Mechanism of injury percentages add to 101% due to rounding within the Telerehabilitation column.

Protocol

Before any rehabilitation for both in-person and tele-rehabilitation, participants completed a baseline patient-reported evaluation of mTBI-related symptoms measured with the Neurobehavioral Symptom Inventory (NSI).^32,33 The NSI includes 22 items and each item is rated from 0 (none) to 4 (very severe). The NSI is comprised of a total score and subscale scores, including vestibular and sensory, mood and behavior, and cognitive, which can be calculated from the 22 items.³² The assessment has good internal consistency and stability.^34,35 Participants filled out the NSI within 7 days before they started the 6-week rehabilitation program. Participants that received in-person care filled out the NSI on paper while tele-rehabilitation subjects were emailed an electronic version of the NSI and provided verbal responses over the telephone. Within 7 days of completing rehabilitation, participants completed the NSI with similar instructions. Additionally, those that performed tele-rehabilitation completed a tele-rehabilitation satisfaction questionnaire.

Measures

Feasibility:

Feasibility was assessed by comparing the tele-rehabilitation group to the in-person group for the number of participants that withdrew from the study, adverse events, rehabilitation session attendance, home exercise adherence, and level of exercise progression throughout rehabilitation. Physical therapists determined attendance based on the number of visits during the 6-week intervention (target attendance for physical therapy sessions was 8 total sessions over 6 weeks). To determine participant satisfaction with tele-rehabilitation, we used a satisfaction questionnaire that incorporated components and themes recommended for acquiring telemedicine use satisfaction.³⁶ Participants completed the satisfaction questionnaire after they finished the final rehabilitation session and rated their agreement level on satisfaction with the ease of use, level of care, level of convenience, level of comfort, and whether it helped with their recovery on a 5-point Likert scale (1 = “strongly disagree”, 5 = “strongly agree”). Additionally, we asked participants if they had used some form of telehealth before.

Intervention

Interventions for both in-person and tele-rehabilitation groups consisted of 8 visits with a licensed physical therapist, either in-person or virtually, completed over 6 weeks. The frequency of visits began with 2 visits in the first 2 weeks each, and then was reduced to once per week for the remaining 4 weeks. Each visit was 60 minutes and included subcategories of 1) cervical spine, 2) cardiovascular, 3) static balance, and 4) dynamic balance with approxiamtely15 minutes devoted to each subcategory (Figure 1). We chose to include all 4 subcategories as well as to standardize the timeframe for physical therapy, since this intervention was part of a larger randomized controlled trial.³⁰ Our inclusion criteria ensured that all people had some level of balance and/or dizziness complaints and in order to continually challenge participants that did not show obvious deficits in each of the 4 subcategories, we designed the intervention to include increasingly complex exercises tailored by the physical therapists to avoid a ceiling effect. Furthermore, there is typically considerable overlap in each of the areas and most mTBI patients demonstrate deficits in more than 1 category.^20,37,38 All participants started the exercises at the first level for each subcategory and were progressed based on the quality of movement as observed by the physical therapist and reported symptoms.

Figure 1:

Overview of the rehabilitation program for in-person care with included exercises and progressions. Bolded text indicates aspects of the in-person rehabilitation that was modified for tele-rehabilitation. Bolded text and circled in grey text indicate aspects of the program that were removed completely. Modifications for tele-rehabilitation are provided.

The original protocol for in-person rehabilitation took place within an academic hospital setting while the tele-rehabilitation protocol was provided to participants virtually through internet-based video conferencing (Webex). This platform allowed physical therapists to see the participant performing the intervention exercises in the participant’s home environment and monitor performance. For example, physical therapists asked the participant to position themselves in front of their cameras to allow for a view of their eyes during ocular motor exercises and postural sway during balance exercises.

Participants were asked to perform a daily home exercise program (HEP) and completed a log to track their adherence and actual performance. The HEP consisted of similar intervention subcategories and levels of difficulty (see Supplementary Appendix from Parrington et al., 2020).³⁰The HEP was progressed based on patient performance during rehabilitation and reported symptoms (headache, dizziness, nausea, and fogginess indicated on a visual analog scale). The following sections explain the components of the subcategories and how each was adapted for tele-rehabilitation (Figure 1).

Cervical

Cervical treatment included stretching, joint position sense exercises with a laser light, strengthening, and motor control exercises.²¹ In addition, manual therapy including joint and soft tissue mobilization was performed as needed for pain management and to improve active range of motion.¹⁷ Cervical treatment was modified for tele-rehabilitation by removing manual therapy and joint position sense training. Participants were instructed on cervical stretching, strengthening, and motor control exercises, similar to the in-person sessions. Self-mobilization techniques were added in place of manual therapy.

Cardiovascular

For the cardiovascular component, participants were assessed using the Buffalo Concussion Treadmill Test (BCTT) Protocol.²² They were then prescribed to walk or jog on a treadmill at 80% of their symptom-provoking heart rate (HR) for each session as determined by their initial visit BCTT test results.²⁶ Participants were progressed by increasing their HR 5 beats per minute (BPM) every 5 minutes by increasing either treadmill speed or incline with minimal increase in symptoms (≤ 2 points).²⁶ In place of the BCTT for tele-rehabilitation, the physical therapist assessed the participant’s current cardiovascular fitness program and symptom provocation through a structured interview. Questions regarding exercise frequency, intensity, time, type, and if or how exercise provoked mTBI symptoms helped the physical therapist tailor instructions on cardiovascular exercise performance to the patient. Participants exercised outside of the tele-rehabilitation session according to the feedback provided during the structured interview. If the patient had access to an HR monitor, they were instructed to use it during exercise and to maintain a given HR zone based on their symptom reports. This was progressed based on symptom response by 5–10 bpm per week. If the participant did not have an HR monitor, they were instructed in the use of the Borg Rating of Perceived Exertion scale (6–20), and exercise intensity was progressed with this instead. Each subsequent visit included this structured interview and verbal instruction in the progression of exertional level (either HR or Borg level) on their cardiovascular fitness program based on reported symptom provocation. Finally, if the patient did not have symptoms with cardiovascular exercise they were instructed to exercise at 85% of their age-predicted max HR as it has been shown that high-intensity exercise may contribute to mTBI recovery.³⁹

Static Balance

Static balance exercises included quiet stance with feet together with varying sensory information (eyes open/closed and stance on firm/foam (Airex) surfaces). Static balance exercises incorporated head turns, oculomotor exercises (smooth pursuit and saccades), gaze stabilization exercises (vestibular-ocular reflex - VOR and visual motion sensitivity - VMS), and cognitive dual-task training. Examples of exercise progressions include increasing the head velocity and altering sensory conditions. The static balance component of the tele-rehabilitation protocol remained largely unchanged other than adaptations for safety and equipment. Two exercises that involved tossing a ball were removed due to concern for lack of equipment at home. Static balance exercises were adapted to start with standing with feet apart for additional safety (for in-person rehabilitation, these exercises began in a narrow stance and only adapted to feet apart based on participant need). These exercises were then progressed to a narrow stance based on observed postural stability. Exercises originally performed on an Airex foam surface were adapted to standing on a compliant surface in the subject’s home (i.e. a pillow or folded yoga mat).

Dynamic Balance

Dynamic balance exercises included walking with head turns, with eyes open or closed, and on firm or foam surfaces. Dynamic balance progressions incorporated gaze stabilization, backward walking, cognitive dual tasks, tandem walking, and various bending, squatting, and lunging exercises. The dynamic balance exercise component was significantly modified for tele-rehabilitation due to safety concerns over performing walking with eyes closed without in-person supervision. All exercises that involved a foam-compliant surface for walking and eyes closed were removed from the protocol.

As an additional safety measure for tele-rehabilitation, participants were instructed in the adaptation of their home environment for safety and tolerance - patients were instructed to perform exercises near a wall, corner, or chair for balance support. They were also given information to help with screen sensitivity related to computer use for the web-based sessions. These instructions included steps for lowering contrast and brightness, using a blue light filter program, moving computers away from windows and using shades to reduce glare, and using tabletop lighting instead of fluorescent lighting.

Statistical analysis

Descriptive statistics were calculated for demographic, feasibility measures, and NSI data for both in-person and tele-rehabilitation groups. To explore symptom resolution for each group, we estimated Hedge’s G effect sizes on changes in the NSI questionnaire. We interpreted the magnitude of the effect sizes as none (G < 0.2), small (0.2 < G < 0.5), medium (0.5 < G < 0.8), and large (G > 0.8). Effect sizes were calculated using the Measures of Effect Size Toolbox in MATLAB (Version 2020b).⁴⁰

RESULTS

Feasibility

A total of 73 participants were enrolled; 56 in the in-person group and 17 in the tele-rehabilitation group. Of the 73 enrolled participants, 9 people withdrew with a similar rate between the in-person (13%) and tele-rehabilitation (12%) groups (Table 2). The study flow for in-person and tele-rehabilitation with participant reasons for withdrawing from the study are provided in figure 2. Both tele-rehabilitation (97% ± 7%) and in-person (92% ± 13%) had similar and high intervention attendance, but the tele-rehabilitation group adhered less to the HEP (38% ± 28%) compared to the in-person group (61% ± 29%). Participants in the tele-rehabilitation group completed less of the intervention for the cervical stretching and range of motion, dynamic balance eyes closed firm, eyes open foam, and eyes closed foam subcategories compared to the in-person group (Figure 3). Finally, neither group reported any adverse events during the intervention (Table 2).

Table 2.

Feasibility for Participants Receiving Rehabilitation Through In-person or Telehealth

	In-Person	Telerehabilitation
Total enrolled, n	56	17
Total withdrawing from study of enrolled, n (%)	7 (13%)	2 (12%)
Total completing rehabilitation of enrolled, n (%)	49 (88%)	15 (88%)
Rehabilitation attendance, mean (SD), %	92% (13%)	97% (7%)
Home exercise adherence, mean (SD), %	61% (29%)	39% (28%)
Adverse events, n	0	0
Prior telehealth use of completed rehabilitation, n (%)		10 (67%)
Satisfaction questionnaire, mean (SD)
0 = strongly disagree, 5 = strongly agree
Easy to use		4.27 (1.10)
Satisfied with care		4.73 (0.46)
Convenient to use		4.67 (0.49)
Comfort with using		4.53 (0.64)
Helped recovery		4.73 (0.59)

Abbreviations: SD, standard deviation.

Figure 2:

Study flow diagram for participants that were enrolled, withdrew, completed, and were analyzed for the current study according to in-person rehabilitation and tele-rehabilitation. The reasons for participants that withdrew from the study are provided.

Figure 3:

Average exercise progression within each subcategory for in-person (grey) and tele-rehabilitation (white). Dashed lines indicate +/− 1 SD. Abbreviations: EO, eyes open; EC, eyes closed.

After completing rehabilitation, the tele-rehabilitation group rated their satisfaction with receiving their rehabilitation virtually and indicated if they had prior telehealth experience. Sixty-seven percent indicated that they had used some form of telehealth previously. On average the tele-rehabilitation group found the program easy to use, were satisfied with the level of care, were comfortable using the virtual methods, and thought it helped with recovery (Table 2).

Post-Rehabilitation Symptom Changes

All pre and post-rehabilitation measures and subscales for the NSI for the in-person and tele-rehabilitation groups are presented in Table 3. On average both the in-person and tele-rehabilitation groups reported a decrease in symptoms following their respective rehabilitation programs (Table 3). However, the in-person group had a large effect size (−0.94) in decreases in symptoms following rehabilitation, while the tele-rehabilitation group had a moderate effect size (−0.73; See effect sizes Table 3).

Table 3.

Means and Standard Deviations for the Neurobehavioral Symptom Inventory and Their Subscales at Pre- and Postrehabilitation Time Points on Participants Receiving In-person or Telerehabilitation Care^a

	In-Person			Telerehabilitation
NSI	Prerehabilitation Mean (SD)	Postrehabilitation Mean (SD)	Effect Size (95% CI)	Prerehabilitation Mean (SD)	Postrehabilitation Mean (SD)	Effect Size (95% CI)
Vestibular and sensory (out of 44)	14.77 (7.16)	8.82 (5.43)	−0.91b(−1.20, −0.68)	12.80 (5.86)	9.73 (5.40)	−0.52c(−1.04, −0.08)
Mood and behavior (out of 28)	12.19 (5.85)	7.16 (5.18)	−0.88b(−1.24, −0.61)	10.93 (5.55)	7.33 (4.03)	−0.72c(−1.22, −0.35)
Cognitive (out of 16)	7.38 (3.81)	4.73 (3.53)	−0.69c(−0.98, −0.45)	7.67 (2.29)	5.47 (3.81)	−0.67c(−1.58, −0.25)
Total score (out of 80)	34.33 (15.24)	20.71 (12.70)	−0.94b(−1.27, −0.70)	31.40 (11.79)	22.53 (11.46)	−0.73c(−1.32, −0.31)

Abbreviations: CI, confidence interval; NSI, Neurobehavioral Symptom Inventory; SD; standard deviation.

^aEffect sizes from pre- to postrehabilitation and 95% CI are presented for each group.

^bLarge effect.

^cMedium effect.

DISCUSSION

In this pilot study, we demonstrated that an evidence-based, multimodal physical therapy program to treat people in the subacute recovery phase from mTBI could be safely delivered through virtual means with minimal required materials for treatment. The tele-rehabilitation sessions utilized a protocol similar to the in-person program, but some components were modified or completely removed due to safety concerns and the lack of equipment/materials. These changes required for tele-rehabilitation provide insight for clinicians who may need to shift to remote therapy to treat patients. The development of safe and challenging exercises related to cervical, cardiovascular, static, and dynamic balance to administer virtually may be important for an effective mTBI rehabilitation program. We found that the in-person group that had a more comprehensive rehabilitation program with more challenging exercises also demonstrated a larger reduction in symptoms. However, we cannot determine with certainty what accounts for this observation.

Telerehabilitation Pros and Cons - the Patient Perspective

We found that tele-rehabilitation had both benefits and barriers to care for the patient. Benefits included reduced travel time for appointments as participants could attend sessions from home, work, or vacation.¹² This level of convenience was confirmed in our telehealth satisfaction survey. Additionally, travel by car may be unsafe with a previous study demonstrating slower response times during driving simulations.⁴¹ Therefore, tele-rehabilitation allows patients to avoid driving when symptomatic. On the other hand, treating virtually could be seen as both a barrier or benefit depending on the conditions. Some participants may have found the home or workplace to be a quieter environment more conducive to easing concussion symptoms than the typical busy physical therapy clinic.¹² In contrast, some homes were filled with many distractions in the form of work, pets, children, and roommates, which increased attentional demands and may have made session participation more difficult. While access to digital technologies that enable tele-rehabilitation has increased in the last decade,^1,2 geographic and socioeconomic factors can both influence access to adequate WIFI broadband and smartphones, tablets, or computers required for tele-rehabilitation.^42,43 First, adequate broadband access is often limited in rural and underserved settings with 33% of rural Americans lacking access to high-speed broadband internet to support video-based telehealth visits.⁴⁴ Second, low median household income can limit access to both the necessary broadband access and technologies needed for virtual visits. Previous research has shown that 29% of adults living with annual household incomes less than $30000 do not have smartphones, 44% do not have home broadband, and 46%do not have computers.⁴³ The shift to telehealth and reliance on virtual visits during social distancing for those in rural locations and the economic hardships experienced during the COVID19 pandemic may have created additional health disparities for these groups of people.^42,43 Further research would be needed on how access to tele-rehabilitation technologies can be improved for those in rural areas and urban low income settings.⁴⁵

Telerehabilitation Pros and Cons - the Physical Therapist Perspective

Tele-rehabilitation allows for specialists in mTBI to treat patients with limited access to care due to transportation barriers, rural locations, or without access to specialization, provided the patients have the necessary technological resources.^12,43,46 Another example of the benefit of tele-rehabilitation was that the therapist could provide more customized instruction in performing home exercises by seeing precisely what space and equipment were available to patients.^47,48 While this should, in theory, reduce barriers to adherence to HEP, this was not reflected in the HEP adherence of the tele-rehabilitation group. The low HEP adherence could have been due to the increased use of technology with the emailed compliance log versus the printed version for the in-person rehabilitation group. It is difficult to know if the HEP was performed less or if the method of reporting contributed to the lower reporting of compliance. Alternatively, a decrease in HEP performance may have contributed to a smaller reduction in symptoms (NSI) at follow-up in the tele-rehabilitation group. One potential downside to tele-rehabilitation was the limited ability to progress patients to more challenging exercises. The physical therapists were more cautious in advancing exercises due to concerns of falls. In addition, several exercises were removed entirely from the tele-rehabilitation program due to safety and equipment concerns (Figure 1). While the number of exercises in static balance performed was similar in the two groups, the inability to utilize a high-density foam with eyes closed conditions likely decreased sensory weighting and isolating the vestibular system, which decreased the challenge of the exercises. Fifty percent of the possible exercises were removed from the dynamic balance portion due to safety concerns, which may explain the reduction in total exercises performed and progressed in the tele-rehabilitation group (Figure 1 and Figure 3). The additional presence of a support person in the home may allow for exercises of greater difficulty to be performed safely. Limited equipment was a barrier for cardiovascular assessment and progression. However, personal HR monitors have increased in popularity and may aid in the prescription of cardiovascular exercise in rehabilitation.^16,39 While there have been concerns about access to and use of telehealth technology,¹² we found that only one participant had difficulties downloading the application, and that was resolved with support provided over a phone call.

Symptom reduction after interventions

While symptoms improved for people receiving tele-rehabilitation, there was less reduction than the in-person group for overall symptoms and vestibular-sensory related symptoms. This might be explained by the difference in the programs. First, the physical therapist was unable to provide manual therapy to the cervical spine and muscles and joint position sense training was removed from the tele-rehabilitation program (Figure 1). Many mTBI symptoms can be a function of cervical dysfunction.²¹ While tele-rehabilitation participants received instruction for self manual therapy, they may have not received the same level of treatment that can be provided by an experienced clinician for helping reduce mTBI symptoms. Second, we were unable to provide supervised aerobic exercise for the tele-rehabilitation program, which is known to help decrease symptoms.²⁷ Using a graded and proactive exercise prescription, like the BCTT, may decrease post mTBI symptom severity in those with persistent mTBI symptoms.²⁷ Other studies have used activity trackers, like Fitbits (Fitbit LLC; San Francisco, CA), to prescribe and track daily exercise intensity and frequency for reducing post mTBI symptoms.¹⁶ Lastly, the decreased ability to practice dynamic balance in the tele-rehabilitation group may explain fewer improvements in symptoms. Evidence supports the use of static and dynamic balance exercises, as well as vestibular rehabilitation therapy, as an effective way to reduce dizziness symptoms and balance deficits for those recovering from an mTBI.^18,23,29 People in the tele-rehabilitation group only completed progressions of eyes open dynamic balance on a firm surface due to equipment and safety concerns. This meant that the tele-rehabilitation group missed more challenging balance exercises that could potentially stimulate recovery and adaptations.^28,49

Limitations

One of our main limitations was the small sample size for the tele-rehabilitation group. We were limited to enrolling subjects into tele-rehabilitation over 5 months. During these 5 months, our research facilities were closed for in-person research and once we were given the capability to resume in-person research, we discontinued enrolling participants into tele-rehabilitation, per our funder’s request. However, this period provided the opportunity to pilot this rehabilitation program through virtual means. Also, the tele-rehabilitation group had significantly more males than females compared to the in-person group at enrollment and there are known sex/gender differences in symptom presentation and recovery.^50,51 Studies with a larger sample size would be needed to investigate the influence of sex on tele-rehabilitation outcomes. This study was not randomized and did not have a control group. A larger randomized controlled trial would be helpful to determine the efficacy of tele-rehabilitation after mTBI. It could be considered a limitation that our intervention included a set plan of all 4 subcategories rather than individualized treatment, as one would see in clinical care. We chose this design to best standardize the intervention and to set up this randomized controlled trial to be able to understand the effects of timing of rehabilitation after mTBI (the larger goal of this randomized controlled trial).³⁰ Therefore, our approach does not reflect clinical practice of using a personalized treatment plan. For example, the Clinical Practice Guideline (CPG) for physical therapists treating mTBI recommends that physical therapists design a personalized intervention plan for patients that aligns interventions with the patient’s identified impairments, functional limitations, participation limitations, self-management capabilities, and levels of irritability.¹⁸ Our study, however, can provide information on how a physical therapist could implement treatment methods for mTBI on commonly impaired domains through teleconference or virtual methods. Another limitation was the lack of objective measures for quantifying balance and gait recovery in the tele-rehabilitation group due to equipment limitations, space constraints, and the lack of published data on performing balance and gait assessments virtually. It is unknown if differences in objective measures of gait and balance would have existed between in-person and tele-rehabilitation care. This is a potential future direction for studies that determine tele-rehabilitation for mTBI efficacy.

CONCLUSIONS

This study demonstrated that evidence-based, multimodal, rehabilitation programs for sub-acute mTBI can be partially adapted and administered through virtual means. People using tele-rehabilitation can attend sessions regularly with no adverse events. Additionally, those using tele-rehabilitation for mTBI were able to successfully use the technology and found that it helped with their recovery. Tele-rehabilitation can improve post-mTBI symptoms. However, persons in the tele-rehabilitation did not receive the same treatment as in-person rehabilitation due to a diluted rehabilitation program, without hands-on cervical treatments, monitored aerobic exercise, and highly challenging balance exercises. Tele-rehabilitation may still be an appropriate intervention for those with limited access to in-person care such as those in rural or remote settings without access to specialized clinicians. Future studies could improve on the tele-rehabilitation program detailed in the current study to overcome equipment limitations and safety concerns to deliver a feasible and effective rehabilitation program for the recovery from mTBI.