Feasibility and Safety of Telerehabilitation for Physiotherapy Interventions in Movement Disorders Patients

Several movement disorder patients were forced to stay in self‐quarantine due to the current coronavirus disease 2019 (COVID‐19) pandemic, interrupting their physiotherapy treatment.¹, ² To overcome the negative effects of this sudden stop, video call systems started being used to perform physiotherapy sessions remotely (telerehabilitation).

This letter reports the results of a pragmatic feasibility study that evaluates the feasibility and safety of telerehabilitation physiotherapy sessions in patients with movement disorders.

Participants were recruited from the CNS—Campus Neurológico, a specialized movement disorders center in Portugal. Eligible patients with a clinical diagnose of Parkinsonism and at least four telerehabilitation sessions between March and June 2020 were invited to participate. The sessions included amplitude‐based exercises, functional mobility as the basis for strength and endurance training, and balance training. Cognitive and motor multitask training were integrated using a graded approach, tailored to each patient's individual performance. Appendix S1 and the available videos (1, 2 and 3) described the type of the exercises carried out in telerehabilitation sessions in early and advance stage patients. The clinical evaluation was completed in person before the online program.

Video 1.

Standing exercises carried out in telerehabilitation sessions.

Video 2.

Sitting exercises carried out in telerehabilitation sessions.

Video 3.

Floor exercises carried out in telerehabilitation sessions.

The survey included questions about participants' satisfaction and usability with telerehabilitation sessions (Appendix S2). Additionally, data on patients' adherence and safety were collected. The primary outcome of the study was patients' satisfaction with physiotherapy telerehabilitation sessions. The study was undertaken with the approval from the CNS Ethics Committee (Ref. 07‐2020).

Twenty patients completed a total of 240 telerehabilitation sessions. Participants' demographic and clinical characteristics are summarized in Table 1. A total of 98% of the online sessions scheduled were completed. Missed appointments occurred as a result of schedule miscommunication, with one of the appointments being missed due to the patient's illness.

TABLE 1.

Summary of the survey findings

Demographic data (n = 20)
Age		73.55 (±8.4)
Male		68,40%
Bachelor's degree or higher education n (%)		15 (75%)
Daily use of technology	≥2 hrs per day n (%)	10 (50%)
	<2 hrs per day n (%)	6 (30%)
	Occasionally	4 (20%)
Clinical data (n = 20)
Diagnosis
Parkinson's Disease n (%)		14 (70%)
Lewy Body Dementia n (%)		2 (10%)
Functional Disorder n (%)		1 (5%)
Progressive Supranuclear Palsy n (%)		2 (10%)
Vascular Parkinsonism		1 (5%)
Years of disease		6.1 (±4.6)
Feasibility of telerehabilitation
Satisfaction of telerehabilitation	Duration of the sessions	4.5 (±0.6)
	Adequacy of content to problems	4.6 (±0.5)
	Overall care	4.7 (±0.4)
% of Sessions completed		98%
Facility of access		4.3 ± 0.8
Global utility		4.6 ± 0.5
Participants who need technological support from family members/caregiver		12 (60%)
Participants who need support to perform the sessions		3 (15%)
Patients' perspective of privacy		4.5 ± 0.8
Safety
Total number of adverse events		17
Adverse events reported during the sessions	Extreme fatigue	4
	Near‐fall	4
	Orthostatic hypotension	3
	Back pain	1
	Cervical pain	1
	Dizziness	1
	Fall	1
	Increased dystonia	1
	Shoulder pain	1

Participants scored 4.7 ± 0.4 in the Likert scale for the overall care received (5—Very satisfied), 4.5 ± 0.6 for the duration of the sessions (4—Satisfied), and 4.6 ± 0.5 on the adequacy of content to problems. Regarding the usability of the telerehabilitation sessions in physiotherapy, patients stated that they were very satisfied with the global utility (4.6 ± 0.5) and the privacy of the remote healthcare service (4.5 ± 0.8). In 7% (n = 17) of the total number of sessions done, there were adverse effects. None of the events were considered severe or required medical assistance (Table 1).

According to our findings, patients reported a high level of satisfaction with telerehabilitation, implying that this could be an effective way to provide specialized care to patients who have difficulty accessing it. It also enables therapists to better monitor patients after they have been discharged or to increase the intensity of outpatient rehabilitation programs.³, ⁴

Physiotherapy, like pharmacological interventions, has a limited duration and must be continued over time in order to preserve the positive outcomes. Based on our clinical experience gathered during the lockout, telerehabilitation appears to be a useful strategy to maintain the benefits over time.

Seventy‐five percent of the patients (n = 15) required caregiver assistance, however only three need it to perform the sessions. Despite the fact that 60% of the patients (n = 12) required assistance to attend the session, they were satisfied (4.3/5) with accessibility, implying that the need for assistance was not a concern. Because of the increased risk of falling and the presence of dementia, patients' safety may be jeopardized during dynamic exercises, requiring the involvement of a caregiver.

Telerehabilitation appears to be a safe option based on the number and severity of adverse events reported. Nonetheless, some risk minimization strategies should be considered, such as not performing physiotherapy sessions at home alone and having a chair or a place to sit nearby if necessary. A supervised baseline assessment should also be performed to accurately understand patients' limitations and the most suitable intervention plan (type of exercises, intensity, repetitions, and duration).

This study presents some limitations. The small sample size, the predominance of well‐educated patients familiar with technology and receiving in‐person physiotherapy interventions may hinder the external validity of the results. We believe that although these aspects need to be clarified in a larger study, under non‐pandemic conditions, our results are important to inform clinicians that physiotherapy sessions at a distance can be feasible and safe.

Telerehabilitation physiotherapy sessions have created opportunities for enhanced care, better self‐management options for movement disorder patients, and overall improved healthcare. Future studies are needed to explore other aspects such as: the feasibility of telerehabilitation in patients unfamiliar with in‐person physiotherapy sessions, the efficacy of an online intervention protocol, and the long‐term adherence of patients to this type of care delivery.

Author Roles

(1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the first draft, B. Review and Critique.

V.C.: 1A, 1B, 1C, 2A, 2B, 3A

R.B.‐M.: 1A, 1B, 2A, 2B, 2C, 3B

J.J.F.: 1A, 1B, 2A, 2C, 3B

CNS Collaborators: 1C, 3B

Disclosures

Ethical Compliance Statement

The studies involving human participants were reviewed and approved by the CNS Ethics Committee (Ref. 07‐2020). The patients/participants provided their written informed consent to participate in this study. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.

Funding Sources and Conflicts of Interest

The authors declare that there are no financial disclosures or conflicts of interest relevant to this work.

Financial Disclosures for the Previous 12 Months

Verónica Caniça reports no additional disclosures. Raquel Bouça‐Machado reports no additional disclosures. Prof. Joaquim J. Ferreira: no conflict of interest to report. Stock Ownership in medically‐related fields: none; Consultancies: Ipsen, GlaxoSmithKline, Novartis, Teva, Lundbeck, Solvay, Abbott, BIAL, Merck‐Serono and Merz; Advisory Boards: none; Partnership: none; Honoraria to speak: none; Grants: GlaxoSmithKline, Grunenthal, Teva and Fundação MSD; Intellectual Property Rights: none; Expert Testimony: none; Employment: Laboratory of Clinical Pharmacology and Therapeutics of Lisbon; Contracts: none; Royalties: none; Other: none. CNS Physiotherapy Study Group report no additional disclosures.

Supporting information

Appendix S1. Physiotherapy core areas addressed during telerehabilitation sessions in early and advance stage patients

Appendix S2. Survey to assess the Feasibility and safety of telerehabilitation for physiotherapy interventions in Movement Disorders patients