Article Archive
September/October 2020

Therapy: Virtual Physical Therapy, Telehealth for Total Knee Replacement
By Kathy Hardy
Today’s Geriatric Medicine
Vol. 13 No. 5 P. 26

Whether it’s a need to practice social distancing in times of viral outbreaks, or a need to stretch limited staff and resources, virtual physical therapy (PT) and telerehabilitation are emerging as viable options to in-person rehabilitation. This is particularly true with total knee replacement patients, who are discharged with a series of at-home exercises as part of their recovery regimens.

The findings of a recently published study comparing the financial impact and clinical results of virtual PT with traditional in-person PT programs reveal that virtual PT with telerehabilitation could be a cost-effective option for patients, providers, and payers and does not sacrifice the positive results of traditional in-person PT.

The Long View
“Virtual PT is a paradigm shift,” says Janet Prvu Bettger, ScD, FAHA, an associate professor of orthopaedic surgery and director of health policy and implementation science research at Duke University. “We’re hoping that the new policy changes to expand telehealth during COVID-19 will stay. Virtual PT could be valuable in cases of flu or other infectious illnesses or when it could be challenging for a patient to leave home due to chronic disease or unavailability of transportation. Regardless, we want to continue to provide care to those who need it. Physical barriers should not block access to care.”

Study findings are of particular value in this time of COVID-19 “stay-at-home” orders by state and federal government leaders.

“Situations like the COVID-19 pandemic remind us about how we can expand access to physical therapy while patients are required to stay at home,” she says. “If we can provide guidance and clinical oversight while not being in the same physical location, then patients can perform their exercises at home. It’s an ideal scenario.”

Bettger was the primary investigator of a recent study published in The Journal of Bone and Joint Surgery entitled “Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared With Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial.” The study focused on total knee replacement and the effect of a virtual PT program on total costs in the 12 weeks after surgery. In addition to costs, researchers examined whether the clinical effectiveness and safety of virtual PT were not inferior to those of the usual care provided via traditional PT. This is considered the first clinical trial to compare virtual PT with in-person PT.

The study notes that rates of total knee arthroplasty (TKA) have doubled in recent years, with projections for increased numbers having “substantial implications for health care financing and postoperative clinical management.” The Agency for Healthcare Research and Quality notes that more than 790,000 knee replacements are performed each year in the United States.

In the study, investigators conducted a randomized trial of 306 patients with a mean age of 65, compared one-to-one traditional vs virtual PT. All participants were admitted to a hospital and underwent TKA surgery. Gait speed and knee flexion and extension were measured at the six-week examination. Results for patients who underwent virtual PT were not inferior in regard to knee extension, knee flexion, and gait speed at six weeks; hospital readmissions at 12 weeks were also not inferior among virtual PT patients. However, falls did increase among the virtual PT group compared with those in the traditional care group.

Findings showed that virtual PT was just as effective in patients recovering from total knee replacement surgery as in-person therapy, meeting the same recovery benchmarks as those following traditional PT programs outside their homes. In addition, virtual PT patients had fewer rehospitalizations following discharge than did those undergoing traditional PT.

The virtual PT program used in the study was Reflexion Health’s Virtual Exercise Rehabilitation Assistant (VERA), an FDA-cleared, cloud-based system that uses a digitally simulated coach to demonstrate and guide activity, including visual and audio instructions. The system guides patients through exercises and records them in 3D video; an avatar provides instruction and feedback in real time. The system is installed in the patients’ homes prior to surgery. Patients meet virtually with their telehealth physical therapist and must demonstrate their ability to use the system. The patients then receive recommended exercises to begin after returning home after surgery.

“As the patient exercises in front of the screen, the program measures every movement,” Bettger says, “providing feedback on the quality of the exercises performed. Some people need that. Others can recover with less guidance.”

The Next Level
The platform also enables virtual visits with a physical therapist, who can review progress from the week and videos of the patient performing the exercises. Videos are also available for therapists and surgeons to review the patients’ progress together, with the ability to adjust their rehabilitation regimens along the way to recovery. This collaborative telehealth approach can make a big difference in a patient’s successful recovery.

“The next level of e-health is coordinated telehealth,” she says. “Through telehealth, we can connect the patient with their therapist, their surgeon, nurses, and their entire care team.”

Alice Bell, PT, DPT, a spokesperson for the American Physical Therapy Association (APTA), says it’s important to implement an integrated program of technology-based care and telehealth, and sees this movement as a valuable adjunct to in-person PT. The term “virtual PT” is not one the APTA uses to describe physical therapists’ services. The technology-based applications and tools that can serve to supplement a patient’s rehabilitative experience are not PT. PT is an expansive discipline that is not defined or described by procedures. There is PT that’s delivered either in real time with an interactive audio and visual connection between the patient and physical therapist or via store and forward systems where data are sent to the physical therapist to review and evaluate in order to make clinical decisions regarding a patient’s condition, program, and/or progress. The term virtual PT in this case is being used to describe a combination of these services.

“Sometimes the term virtual PT is being used to describe just an app that is not physical therapy,” she says. “Along with the technology, you should have the instructional aspect that comes with a telehealth visit from a physical therapist. It’s valuable to have the two aspects working together.”

This is especially true, Bell says, if the patient appears to need additional assistance.

“Physical therapists do more than just execute on certain procedures,” she says. “They provide support, educate the patient, and evaluate their progress, all with the goal of promoting self-efficacy.”

Bell says that a joint virtual PT/telehealth program is valuable for many patients, including those who have undergone a total knee replacement, where the goal is to help patients get back their mobility, range of motion, and muscle strength for walking, lifting, and bending.

“With telehealth, we can follow a patient’s progression, analyze their gait, and recommend modifications to their exercises,” she says. “Having video of them functioning in their home environment also helps determine if modifications need to be made to a kitchen or bathroom to accommodate any new physical needs.”

When it comes to care management, some patients may want or need some human interaction or may even work better in a group environment. Bettger says that’s not a problem. A human aspect can be incorporated into an individual’s PT program.

“Some people still want in-person interaction during their rehabilitation,” Bettger says. “You can design a hybrid PT program for in-office and at-home PT, as some people may need in-person instruction.”

The clinical needs of the patient are an important factor in determining whether virtual PT is the right solution, according to Anang Chokshi, PT, DPT, OCS, SCS, an investigator on the VERITAS study.

“Total knee replacement recovery lends itself well to an at-home recovery program,” Chokshi says. “Traditional rehab programs involve exercises that patients are instructed to complete at home daily. Having VERA in the picture gives patients virtual supervision and oversight of their rehabilitation and progress by a licensed physical therapist.”

He adds that a virtual and telehealth program also has benefits for physical therapists.

“We’re not just putting technology with an avatar in front of the patient,” he says. “VERA gives [physical therapists] another avenue to work with their patients. It’s not meant to be a PT replacement, but a way to provide patients with guided help. A program like this can augment the care delivered by a [physical therapist] and triage which patients require in-person attention. This will free up staff in a setting where there aren’t many [physical therapists] on site.”

Dollars and Cents
Along with the physical patient recovery impact, the study found that the use of a virtual PT program such as VERA also resulted in an average cost savings of $2,745 per patient receiving virtual therapy. Chokshi notes that technology solutions such as VERA fit with the health care industry’s transition from bundled payments to value-based care models.

However, Chokshi says, a lack of reimbursement can be a deterrent to use. According to the APTA website, physical therapists are not statutorily authorized Medicare providers of telehealth, and PT services delivered via telehealth are not payable under the physician fee schedule. That said, in response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services agreed to ease Medicare telehealth restrictions in ways that could allow physical therapists to provide “e-visits,” a limited type of service that must be initiated by the patient. Prior to this change, the Centers for Medicare & Medicaid Service did not recognize physical therapists as health care professionals who can bill codes associated with visits.

“Although COVID-19 sheds light on this issue, it’s not a new topic,” Bell says. “We have to look at better ways to serve this population. APTA has been advocating for policies that provide payment for services delivered by physical therapists via telehealth and for the use of remote physiologic monitoring as described by virtual PT in this article for several years. The use of these tools and delivery models can serve to better support patients and save costs by providing patients with real-time access to resources that support their rehabilitation.”

In addition, there can be high co-pays for PT or limits on the number of visits, each resulting in deterrents for patients. These deterrents lead to patients opting not to participate in PT programs to or drop out, convincing themselves they can and will perform the exercises on their own. However, unsupervised PT can lead to injuries and discouraged patients.

“Only 7% of people who need physical therapy actually go,” Chokshi says. “If we could just make a dent in that number, that would be great.”

— Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania.