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What does the evidence say about Online Physiotherapy / Telerehabilitation?

Estimated Read time:  10 minutes

Please note: Our articles are not designed to replace medical advice. If you have an injury we highly recommend seeing a qualified health professional. To book an appointment with Tim, or one of The Online Physiotherapy team, please visit our Physio clinic page. We have specialists for each major area of the body, ensuring you receive the best treatment for your injury.

Digital Leaders Conference 2022

This article is linked to the Digital Leaders Conference 2022- where we covered the topic ‘Reimagining Physiotherapy.’ 

If you have not yet seen it you can watch it below – or click here to see other Digital Leaders conversation topics.

💡 ‘The 30-second summary’

1️⃣ Online Physiotherapy started 20+ years ago, but in the last 5 years has rocketed in regards to convenience, accessibility and effectiveness. 

2️⃣ Various pieces of research done on Online Physiotherapy states that it is ‘a valid and effective alternative to in-person Physiotherapy’ – giving support for a wide array of injuries being treated remotely, including but not limited to muscle, bone, ligament, nerve, tendon and joint issues! See the many studies below for more information on this.

3️⃣ Evidence is largely in support of Online Physiotherapy even stating that in some areas it can be more effective when weighed in balance with the inconvenience attached to getting to a clinic, and everything involved in this, especially with travel increasing in cost and difficulty, and in the process inflaming the very issue you’re seeking to get better!

4️⃣ More research is required into the different fields of Physiotherapy to establish a more substantial view on Online Physiotherapy, but at present, the research is in support of Online Physiotherapy as an alternative method of rehab, and also point out the various advantages to Online Physiotherapy.

5️⃣ The Online Physiotherapist data over the last 3 years shows that our patients have recovered as quickly, if not up to 50% faster in many cases via Online Physiotherapy – and spending only half as much…

Introduction: "Online Physiotherapy? When did this begin, How does it work, and does it actually work?"

Online Physiotherapy has been around for over 20 years…. essentially since the internet has been around. It has taken on many different formats, from internet telephones, to MSN, to Skype, to WhatsApp, Zoom and now? Well, technology has given the world an amazing advantage of being able to access your Physiotherapist from wherever you are, and saving you a ton of time too. But does it really work?

Well, rather than relying on our data over the last 3 years alone (more of that in our conclusion), we want to remain in the evidence and see what others have to say – after all, we are an evidence-based profession!

I have also posted a video at the bottom of this article, on HOW Online Physio works, and WHY, from our clinical practice and opinion.

WHY would Online Physio even be considered?

Online Physiotherapy ignited with the introduction of the internet and it was considered for these main reasons;

1. Inability to travel

– due to various circumstances be that, childcare, looking after parents, work or travel commitments, or being house-bound due to injury.

2. Convenience

– Getting to a clinic could be up to an hour away

– Travelling after a Stroke, operation or painful condition negated any positive effects gained at the appointment, or put them in a worse state than prior to going.

3. Infection, or anxiety

– Those with a viral or bacterial infection, who needed rehab and struggled to get consistent or timely Physio.

4. No Physio in their region.

– For some either in the UK, or other countries, access to a Physiotherapist was difficult and so Online was their option!

why online physio works

5. Results of early inception were positive and for many these outweighed the early obstacles

– The benefits included, no travel hassle, no costs or time associated with travel, and obviously improved injury symptoms, function, pain levels and quality of life.

– The early obstacles were those such as dial-up, cost of internet or accessing a video device. The vast majority of which have now been largely eliminated.

Studies on Online Physiotherapy from 2009 to present day!

Accuracy of diagnosis, and validity and reliability of Online Physio assessments.

evidence based physio

A study completed in 2012 by Lade et al, compared Online Physiotherapy to traditional Physiotherapy for those with tennis elbow – a common musculoskeletal disorder. It concluded that “performing a telerehabilitation physical examination to determine a musculoskeletal diagnosis of the elbow joint complex is both valid and reliable.”

Another randomised control study completed in 2009 looked at the diagnostic accuracy of telerehabilitation for non-articular lower-limb musculoskeletal disorders

It concluded that ‘using telerehabilitation for musculoskeletal physical therapy assessment of non-articular lower limb conditions was found to be valid and reliable.

It is important to state that this was almost 15 years ago!  As we are aware technology has advanced rapidly since then increasing effectiveness, and quality of care.

DEFINITION:

Non-articular simply means muscles, tendons, ligaments, vs joints.

This therefore can include low back pain, shoulder injury, ankle sprains, knee pain, but these studies claims do not claim to include those such as, joint replacements of hip, knee, ankle, shoulder and arthoscopys and more – for this lets see the other research down below!

A systematic literature review completed by Mani et. al (2016) looked at studies between 2000-2015 to explore and summarise the validity and reliability of telerehabilitation (TR)-based physiotherapy assessment for musculoskeletal disorders.

It concluded that “online physiotherapy assessment was technically feasible with overall good concurrent validity and excellent reliability, except for lumbar spine posture, orthopaedic special tests, neurodynamic tests and scar assessment.”

Since 2015 when this was completed, there have been many advancements in Online Physiotherapy, accelerated by the Pandemic of Covid-19. 

For example;

  • Most orthopaedic special tests can be completed at home in a number of different ways. That being said, the evidence for these tests are fairly poor anyhow.
  • Neurodynamic tests – again, this does not necessitate a Physiotherapy and can be completed independently via watching a video, or through asking a family member or friend to assist over video call or via a pre-recorded video – very easily.
  • Scar assessment – this is necessary in most conditions, and for post-operative conditions, many see a district nurse who will review this.

A study completed by Palacin-Marin et al. (2013) was carried out to determine the level of agreement between an in-person assessment of somebody with chronic low back pain, and an online Physio assessment.

It concluded that online Physiotherapy had strong correlation coefficients i.e similar findings to that of an in-person assessment – and that it is a useful adjunct in assessing those with low back pain.

low back pain common injuries black young athlete female

Studies that compare Online Physiotherapy, vs traditional Physiotherapy?

A systematic review and meta-analysis carried out in 2017 (26), completed by Cottrell et al, scoured 6 databases(Medline, Embase, Cochrane CENTRAL, PEDro, psycINFO, CINAHL) which were searched from their inception to November 2015 for literature which reported on the outcomes of real-time telerehabilitation for musculoskeletal conditions. They found 5913 abstracts, of which 13 studies met the high standards of their eligibility criteria.

These studies looked at many various conditions, including but not limited to; many sporting injuries such as ankle sprains, shoulder dislocations, runners knee, shoulder-related injury (previously known as rotator cuff injury) – as well as post-operative conditions such as total knee replacements, total hip replacements and shoulder replacements, and finally some neurological conditions, such as stroke rehab among others.

evidence for online physio

Aggregate results of this study above states that telerehabilitation is effective in the improvement of physical function (SMD 1.63, 95%CI 0.92-2.33, I2=93%), whilst being slightly more favourable (SMD 0.44, 95%CI 0.19-0.69, I2=58%) than the control cohort following intervention. Sub-group analyses reveals that telerehabilitation in addition to usual care is more favourable (SMD 0.64, 95%CI 0.43-0.85, I2=10%) than usual care alone, whilst treatment delivered solely via telerehabilitation is equivalent to face-to-face intervention for the improvement of physical function(SMD MD 0.14, 95% CI -0.10-0.37, I2 = 0%). The improvement of pain was also seen to be comparable between cohorts (SMD 0.66, 95%CI -0.27-1.60, I2=96%) following intervention.

Online Physiotherapy, Traditional Physiotherapy + Knee Osteoarthritis?

A 2014 study by Obole and Ojo looked at the improvement of quality of life of patients who had Knee Osteoarthritis (OA) and how Online Physio, more specifically telephone Physiotherapy, compared to face-to-face Physiotherapy. They concluded that “telephone-based physiotherapy intervention is effective in management of patients with knee osteoarthritis and it produces a similar outcome in terms of quality of life to conventional clinic based physiotherapy as documented in this research.”

These results are no different to our experience, and that of other high-quality studies. This study can be found in the National Library of Medicine, and I have linked to it in the references at the bottom of this article (25).

How about other forms of Physiotherapy, such as Stroke rehab?

This systematic review and meta-analysis from 2018 aimed to investigate the efficacy of telerehabilitation in post-stroke patients. It used randomised control trials searching Medline, Cochrane Central and Web of Science to extract high-quality trials.

We included 15 studies (1339 patients) in our systematic review, while only 12 were included in the pooled analysis. The combined effect estimate showed no significant differences between the telerehabilitation and control groups in terms of the Barthel Index (SMD -0.05, 95% CI -0.18 to 0.08), Berg Balance Scale (SMD -0.04, 95% CI -0.34 to 0.26), Fugl-Meyer Upper Extremity (SMD 0.50, 95% CI -0.09 to 1.09), and Stroke Impact Scale (mobility subscale; SMD 0.18, 95% CI -0.13 to 0.48]) scores. Moreover, the majority of included studies showed that both groups were comparable in terms of health-related quality of life (of stroke survivors), Caregiver Strain Index, and patients’ satisfaction with care. One study showed that the cost of telerehabilitation was lower than usual care by $867.

online physo after stroke rehab

In conclusion:

Telerehabilitation can be a suitable alternative to usual rehabilitation care in post-stroke patients, especially in remote or underserved areas

Studies around Online Physio treating various conditions, including; chronic knee pain, low back pain, chronic obstructive pulmonary disease (COPD), heart disease, breast cancer, joint surgery and urinary incontinence, and women’s health.

A study completed by Anne Holland in 2017 reported that there are a large number of “high-quality randomised, controlled trials that support the benefits of telehealth interventions in many physiotherapy sub-disciplines, published over recent years.” She reports that “these have included tele-physiotherapy interventions for chronic knee pain, non-specific low back pain, chronic obstructive pulmonary disease (COPD), heart disease (4) breast cancer (5) joint arthroplasty, a.k.a. surgery (6) and urinary incontinence (7). Holland reports that “many of these studies have demonstrated significantly better clinical outcomes than usual care that did not include physiotherapy, including improved exercise capacity, better physical function, reduced symptoms and enhanced health-related quality of life.” Very encouraging, especially as these trials were completed 6 years ago!

The science that forms the foundation for telephysiotherapy is advancing fast! This offers physiotherapists new ways to deliver treatments of known effectiveness, in addition to new and innovative treatment strategies that are supported by the science and advancing technology.

Holland also states that “many people are digitally connected and ready to adopt telephysiotherapy”. She says that “the increasing number of senior people in developed societies, many of whom are living with one or more chronic diseases, means there will be a growing demand for physiotherapy services, along with the expectation that it is delivered in a flexible and patient-centred manner. Telephysiotherapy provides opportunities to improve access to effective care, reduce disability and enhance wellness. We now need modern funding models that can realise this potential.”

This final suggestion speaks to national health services and private health care as well as health insurance companies to enable funding to kickstart this ground-breaking advancement of healthtech that is more convenient, as or more effective than traditional Physiotherapy means and ultimately gives more opportunities for access.

Does Online Physio work for patients who have had surgery?

This systematic and meta-analysis review completed in 2018 was completed because “over the last 5-10 years, telerehabilitation services have developed rapidly, and patients value benefits such as reduced travelling barriers, flexible exercise hours, and the possibility to better integrate skills into daily life. However, the effects of physiotherapy with telerehabilitation on postoperative functional outcomes compared with usual care in surgical populations are still inconclusive.

 

Randomised controlled trials, controlled clinical trials, quasi-randomised studies and quasi-experimental studies with comparative controls were included with no restrictions in terms of language or date of publication.

Methodological quality was assessed using the Cochrane risk of bias tool. Twenty-three records were included for qualitative synthesis. Seven studies were eligible for quantitative synthesis on quality of life, and the overall pooled standardised mean difference was 1.01 (95% confidence interval 0.18 to 1.84), indicating an increase in favour of telerehabilitation in surgical patients.

online physio for patients after operation

 

The study concluded that ” Physiotherapy with telerehabilitation has the potential to increase quality of life, is feasible, and is at least equally effective as usual care in surgical populations. This may be sufficient reason to choose physiotherapy with telerehabilitation for surgical populations, although the overall effectiveness on physical outcomes remains unclear.”

We would therefore encourage more research to be completed, and we will certainly be a part of this, but as a result need large quantities of surgical patients to come through our virtual doors to complete a high–quality study that we can draw conclusions from.

Are patients satisfied with the results of Online Physiotherapy?

In 2020, a study was  completed by Ascenti, looking at Virtual Physiotherapy vs Traditional Physiotherapy across 29,000 people! (27)

One of the key findings extracted from the data found that patients who access virtual physiotherapy services are happy with the results. Survey data showed that 92% of patients who were treated virtually were satisfied with its effectiveness and 77% would be ‘extremely likely’ to recommend the service to friends and family. Although this is very slightly lower than the results for face-to-face treatment, (which were 97% and 81% respectively), it is likely that the gap will close further as trust in virtual physiotherapy increases! Promising results indeed.

 

Furthermore, a study completed by Clemens et al. in 2017, published in the British Medical Journal explored the association of telehealth and patient satisfaction in regards to effectiveness and efficiency, and the reasons was to why they found it satisfied. (28)

It looked at 2193 articles which were filtered and assessed for suitability (44 matched the criteria). The factors listed most often as reasons for satisfaction were; improved outcomes (20%), preferred modality (10%), ease of use (9%), low cost 8%), improved communication (8%) and decreased travel time (7%), which in total accounted for 61% of occurrences.

 

Is Online Physio worth investing in for organisations and even the NHS? What does the evidence and experience say?

Here is a paper from the British Medical Journal published in 2017.

It summarises a series of presentations on telemedicine given at a UK eHealth Week conference session in 2016. The formal evidence base for telemedicine is equivocal, but practical experience suggests that implementations of technology that support telemedicine initiatives can result in improved patient outcomes, better patient and carer experience and reduced expenditure.

It “recommended that local organisations should consider deployment of telemedicine initiatives” and employ the technological advancements it brings to harness the best results.  It also “recommended that the National Health Service, takes a greater role in the collation and dissemination of best practice to support successful implementations of telemedicine and other health informatics initiatives.”

 

All that to say, the study found that Online Physiotherapy was a wise use of time, wider resources, and spoke of it’s effectiveness.

online physio for organisations

Could Online Physiotherapy be even better than traditional Physiotherapy?

In our opinion, having weighed the pros, the cons and everything in between, we believe that in the majority of cases, Online Physiotherapy is superior to in-person Physiotherapy.

Without rehashing the 25+ benefits of Online Physiotherapy, WHY Physiotherapy works so powerfully, or if Online Physiotherapy can be done online, or even what injuries the Online Physiotherapy can treat – I will simply stick to the evidence above, and reflect upon this!

 

The studies are pretty clear that Online Physiotherapy works – the real question is, are people willing to change their view on that? For us, this is when the real superpower of Online Physio is released. The realisation that the power of recovery lies in the expert advice, evidence-rich treatment programme that moves you into action, and holds you accountable…. that REALLY moves the needle and we would say, YES, Online Physiotherapy can be even better than traditional Physiotherapy. The decision lies with you, and if you are willing to move past tradition, and move into the light of the future of Physiotherapy.

is Online Physio better than in-person Physio?

What are the disadvantages of Online Physiotherapy, and of traditional Physiotherapy?

As ever, there is almost always drawbacks to everything! Here they are for the two respectively.

For traditional Physiotherapy the drawbacks include;

  1. Car, vehicle, mode of transport or legs required.
  2. Time traveling to clinic away from family, work and other activities.
  3. Risk of traffic jams, and car incidences.
  4. Impact on the environment through driving, and clinic consumables.
  5. Risk of infection.
  6. Dependent upon being in the same physical location – difficulty when travelling.
  7. Risk of physical harm from treatment methods.
  8. More expensive appointments, and course of treatments. See this evidenced blog on ‘Cost of Traditional Physiotherapy treatment compared to Online Physiotherapy’ for the full picture.
  9. Reliance more generally on the Physiotherapist/ passive treatment for recovery, than being fully empowered to know how to treat and improve your injury.

For Online Physiotherapy the drawbacks include;

  1. Potential lower relational element
  2. Potential for lower confidence in assessment and diagnosis – which in turn impacts recovery.
  3. Access to internet, and video device required.
  4. In many cases, we are seeing faster recovery via Online Physio, BUT it is important to be transparent, current published evidence reports a 5% margin of improvement in favour of traditional Physiotherapy (27).

As you can see for yourself … there are found to be far more disadvantages to traditional Physiotherapy than  Online Physiotherapy. You can also see I don’t stick to consultant approved 3, 5 or 10 bullet points!

Finally, you can watch this video for the benefits of Online Physiotherapy over here.

More information on how, what and why of Online Physio?

Our complete library of FAQ questions with answers in video format are right here! So check those out if you want to find out more before booking in.

Alternatively we are currently running a FREE intro call too if those answers don’t answer your specific question. Book in here. 

💡 In Conclusion

From all of the studies we have looked at….and we have looked at 150+ studies, we would say that the following is true;

  1.  Online Physiotherapy is a highly effective alternative to in-person Physiotherapy providing a whole host of additional benefits. See this video for more on the benefits of Online Physiotherapy.
  2. Online Physiotherapy is breaking ground and pushing boundaries, calling for us to Reimagine what we know to be Physiotherapy, and to reposition it in line with the evidence. See this video for WHY Online Physiotherapy is so powerful.
  3. Online Physiotherapy (like every scientific area) needs continuous study and research – but it is suffice to say, that the research thus far is extremely promising of its effectiveness across  a  wide array of injuries, conditions and syndromes. To hear more about what injuries we treat, watch this short video here.
 

Now, it is very difficult to provide convincing evidence that we haven’t cherry picked articles around this topic, but we have done this with high integrity (being one of our values as a company!) If you feel that it is not accurate, or there are other strong studies suggesting otherwise, please do let us know. Our goal is to merely provide information without bias.

We hope you enjoy the questions and evidence in this article.

 

Finally, if you are unsure if you need Physiotherapy, or if Online Physiotherapy can assist you, then we are currently offering a free 15-minute screening call, in which you can book in on the link.  Or, if you need urgent Physio advice and attention then book in below.

Any questions, or thoughts on this blog, we would LOVE to hear from you. Send us a message here.

If you are in pain, or have an injury book yourself in below to start your recovery today!

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References

1. https://www.researchgate.net/publication/319945938_Telephysiotherapy_Time_to_get_online

2. Bennell KL, et al. Ann Intern Med. 2017;166:453–462.2.

3. Tsai LL, et al. Respirology. 2017;22:699–707.

4. Varnfield M, et al. Heart. 2014;100:1770–1779.
5. Galiano-Castillo N, et al. Cancer. 2016;122:3166–3174.
6. Moffet H, et al. J Bone Joint Surg Am. 2015;97:1129–1141.
7. Sjostrom M, et al. BJU Int. 2015;116:955–964.
8. Chumbler NR, et al. J Telemed Telecare. 2015;21:139–143.
9. Asklund I, et al. Neurourol Urodyn. 2017;36:1369–1376.
10. Piotrowicz E, et al. Eur J Heart Fail. 2010;12:164–171.
11. Piqueras M, et al. J Rehabil Med. 2013;45:392–396.
12. Tabak M, et al. Clin Rehabil. 2013;28:582–591.
13. Seco J, et al. Spine J. 2011;11:966–977.
14. Koes BW, et al. Eur Spine J. 2010;19:2075–2094.
15. Lee IM, et al. Lancet. 2012;380(9838):219–229.
16. Chaudhry SI, et al. N Engl J Med. 2010;363:2301–2309.
17. Cartwright M, et al. BMJ. 2013;346:f653.
18. Ong MK, et al. JAMA Intern Med. 2016;176:310–318.
19. Hwang R, et al. J Physiother. 2017;63:101–107.
20. Piotrowicz E, et al. Eur J Prev Cardiol. 2015;22:1368–1377.
21. Sjostrom M, et al. J Med Internet Res. 2017;19:e154.
22. Tousignant M, et al. J Med Internet Res. 2015;17:e83.
23. Nguyen A, et al. Int J Med Inform. 2017;103:49–54
24. Krein SL, et al. J Med Internet Res. 2013;15:e181
25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3980780d 
26. Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil. 2017;31(5):625–38.
27. https://www.ascenti.co.uk/news-article/virtual-physiotherapy-report
28.Telehealth and patient satisfaction: a systematic review and narrative analysis, Kruse et al. (2017) bmj open 2017-016242.

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