September 2020Telehealth

Telehealth opens new doors—and video screens—to rehabilitation at home

Stroke recovery, wheelchair measurement, autism support now offered remotely

As Barry Evans waited to be discharged from hospital in mid-May, he couldn’t help but wonder whether the COVID-19 lockdown would keep him from getting his vital rehabilitation.

Barry Evans

Barry Evans

With his left arm at half-strength and his speech impaired by a stroke, Mr. Evans needed to start an exercise routine without delay—but without visiting a rehabilitation centre or letting a therapist into his Pierrefonds home.

He needn’t have worried.

The next day, Mr. Evans received a phone call from Ivy Gumboc, an Occupational Therapist in CIUSSS West-Central Montreal, who helped him set up his telehealth connection. And the day after that, he had his first rehabilitation session via Zoom.

Aiming an iPad’s lens at her husband, Wendy Evans showed Ms. Gumboc and her colleagues how he was responding to their instructions.

“Wendy became quite adept with the camera angles,” Mr. Evans recalls. “The therapists watched their screen and knew pretty quickly whether I needed to adjust my movements.”

His experience with rehab at a distance, rare before the pandemic, became the norm this past spring, as CIUSSS professionals rushed to deliver rehabilitation at a distance. If not for the crisis, it’s unlikely that tele-rehabilitation would have been introduced so quickly or so soon.

“In rehab, we often say we’re high-touch, not high-tech,” says Gary Stoopler, the CIUSSS’s Director of Rehabilitation and Multidisciplinary Services. “There’s only so much you can accomplish virtually, but we had to act promptly to provide whatever could be offered at home.”

Maxine Lithwick, Coordinator of Social Services and Professional Practice, says guidelines were also developed, so that professionals would have a framework to assist them as they embarked on telehealth.

This helped support staff in deploying the new technology and familiarizing them with the platforms, including tools for protecting the confidentiality and consent of healthcare users, as well as information on how to be certain that  professional standards were respected.

For Mr. Evans, the use of tele-rehab was essential for his recovery from the stroke he had suffered on May 4. While playing a video game, he noticed that his left hand was not responding properly, and although he suspected a stroke, it was only the next day, at his wife’s urging, that he finally sought help.

Maxine Lithwick

Maxine Lithwick

Treatment was provided at the Lakeshore General Hospital, followed by a transfer to the Montreal Neurological Institute for a five-day stay and then the start of tele-rehabilitation at home.

Upon discharge, Mr. Evans returned home and soon began four intensive weeks of therapy, followed by a less demanding four-week program that ended in late July.

Using tele-rehab via Zoom, he was shown how to regain dexterity in his left hand with the graded hand acitivities of stacking backgammon chips, flipping playing cards, picking up coins and squeezing a ball.

“We had to use whatever items I had at home, which wasn’t always easy,” Mr. Evans says, “but my therapists were very good at adapting my treatment on Zoom.”

Telehealth: “Our eyes and ears in the home”

The course of rehab that Mr. Evans experienced was the Early Supported Discharge program, which had been launched in 2017 to provide rehab services in the homes of patients recovering from a mild to moderate stroke. (The program is better known as CPA, or Congé précoce assisté.)

Ivy Gumboc, who coordinates the CPA program from the Constance-Lethbridge site of the Lethbridge-Layton-Mackay Rehabilitation Centre, says the service is available to everyone who lives on the island of Montreal. This has been made possible through a collaboration among the West-Central and South-Central CIUSSSs and the Villa Medica Rehabilitation Hospital.

Before COVID-19, Ms. Gumboc explains, each of the CPA sites was able to treat five clients at any one time in the program. However, during the pandemic’s springtime peak period, the services were extended to nine to eleven clients, who participated in their rehab via Zoom.

During the summer, the CPA program shifted to offer a combination of in-person and virtual tele-rehab visits.

“When we work as a team, the word ‘impossible’ becomes meaningless. We’re proud of our willingness to embrace the technology.”

When support is provided remotely, the professionals coordinate closely with caregivers, who becoming what Ms. Gumboc calls “our eyes and ears in the home.

“When we work as a team, the word ‘impossible’ becomes meaningless. As professionals, we’re proud of our willingness to learn something new and embrace the technology.”

Telehealth has also proved invaluable in enabling in-patients to maintain contact with their families, says Nancy Cox, Rehabilitation Coordinator for Adult Motor Disability Programs.

This is not just a matter of bolstering the patient’s morale, Ms. Cox explains, but giving relatives an opportunity to witness the patient’s progress—for instance, walking for the first time since suffering a stroke.

In planning to be discharged, the patient and therapist in the healthcare facility use an iPad to connect with a family member and occupational therapist in the patient’s home. Since the interior of the home is visible on-screen, the therapist can more easily determine what must be done to accommodate the patient.

“Before COVID-19, we tried to make preparations by simulating the home environment in the hospital setting,” Ms. Cox says. “That meant asking the patient or relative, for example, ‘What does the bathtub looks like? Which side of the bathroom is it on? Where is the tap? When you step in, where’s the toilet?’

“But with telehealth, the spouse holds the iPad and literally walks us around the home to help us more accurately plan how the patient will function in that environment.”

Wheelchairs measured via telehealth — unique to Quebec

Teamwork has been similarly crucial to a CIUSSS program that customizes wheelchairs to meet clients’ specific needs.

“It’s not just a matter of picking a certain model from a catalogue,” explains Filomena Novello, who coordinates Rehabilitation Services at the JGH and the Technical Aids Service Department at Lethbridge-Layton-Mackay.

Filomena Novello

Filomena Novello

“Everything is built to measure,” she says, “so you have to pay close attention to the positioning components, as well as the cushions, padding and moldings that help the patient sit safely, securely and comfortably.”

Before COVID-19, measurements were taken in person at various CIUSSS sites—such as Richardson, Catherine Booth Hospital, Donald Berman Maimonides Geriatric Centre and the Father Dowd Residential Centre—where users resided or were receiving treatment as in‑patients.

However, once the pandemic arrived, “we had to start from scratch to develop a way of measuring a client for a wheelchair from a distance,” says Ms. Novello.

The solution was a virtual wheelchair clinic, developed by Sébastien Thibeault, an Occupational Therapist and Clinical Coordinator in the Technical Aids Service Department. An occupational therapist and technician were assigned to a room in Constance-Lethbridge, containing a large screen, telehealth software and the equipment to measure clients.

Located in another CIUSSS healthcare facility are the client (sitting in a general-purpose wheelchair) and an occupational therapist (in protective equipment). Using Zoom, the professionals relay data to one another, while watching the screen to gain a clear understanding of the client’s requirements.

This system has allowed clients to receive their wheelchairs about a month after they’ve been measured, compared to the two-to-three-month wait before the pandemic.

“Many people are following our lead and benchmarking with us, because we’ve accomplished something that no one else has thought of.”

“This was one of our biggest successes, achieved by none of Quebec’s other technical aids service departments,” says Ms. Novello. “Many of those other departments are following our lead and benchmarking with us, because we’ve accomplished something that no one else has thought of.”

In fact, she adds, no similar service exists anywhere in Canada. But she notes that a true comparison can’t be made, because Quebec is the only provice  where the customization of wheelchairs is handled by the public healthcare system, rather than the private sector.

A fresh approach was also required for individuals recovering from musculoskeletal injuries, says Ms. Novello. During the pandemic, patients who needed physiotherapy on an out-patient basis at the JGH were initially interviewed by phone or Zoom. Those with urgent cases received an in-person appointment with a physiotherapist (wearing protective gear).

The rest forged ahead with Zoom sessions at home, as professionals watched them on‑screen to determine, for example, whether they were walking properly or able to bend their knee past a certain point.

According to Ms. Novello, tele-rehab was also introduced by her teams in a wide range of other areas, including cardiac rehabilitation at the Richardson Hospital; occupational therapy for oncology patients and post-ICU admissions; speech and language pathology evaluations after radiation therapy; and clinical nutrition services in CIUSSS clinics.

“There’s a preconceived notion that certain things have to be done in person,” says Ms. Novello, “but that’s not necessarily so. We even made believers out of some of our own therapists, who were a bit hesitant at first about trying something like this.”

Interventions for autism—at a distance

The pandemic-related limitations were especially challenging at Miriam Home and Services where, under normal circumstances, in-person support is provided to clients with autism and/or intellectual disabilities.

Before COVID-19, family members were on hand in person to watch the therapist work with the client, says Dr. Shari Joseph, Psychologist Coordinator of Rehabilitation Services for Miriam Home. Then these family members performed the same intervention, while the therapist observed and made sure they were doing it correctly.

When crisis hit, staff at Miriam Home placed weekly calls to every client, whether living with family members or in a group home. They also phoned every client on the waiting list to determine if their rehab needs had become more urgent.

In addition, the Miriam Foundation quickly provided funding for approximately 40 iPads that enabled therapists to maintain visual contact with clients and families.

“We can see them in their natural environment and understand more clearly what they’re experiencing on a daily basis.”

What makes telehealth so pivotal, Dr. Joseph explains, is the continuity it provides, even if the amount of therapy is below pre‑COVID-19 levels.

For example, a program known as Intensive Behavioural Intervention (IBI) usually involves 20 hours of therapy per week for a child with autism under the age of 6. Once the IBI tele-rehabilitation program rolled out, most children were able to receive about three hours of support per week, with the therapist coaching the parents, while watching as the child learned new skills. With the easing of the pandemic, the number of hours of therapy has now returned to previous levels.

“The feedback has been really positive,” says Dr. Joseph, “especially from families who are relieved at not having to do a lot of travelling with a child who has a disability. They also like the fact that we can see them in their natural environment and understand more clearly what they’re experiencing on a daily basis.”

So encouraging is the response to tele-rehab that Miriam Home has expanded its kinesiology program to include a wide range of Miriam Home users. Before the pandemic, the kinesiologist provided clients with in-person sessions to improve their stability, balance and other motor skills.

Once COVID 19 hit, she began offering weekly Zoom sessions, and has since raised the number from one virtual group to seven.

“In many cases, these are clients the kinesiologist might not otherwise have seen,” adds Dr. Joseph. “Because they were under-stimulated, they really seized on this opportunity for supervised physical activity.”

Planning for the post-COVID era

Once the COVID-19 threat has passed, Dr. Joseph foresees using telehealth’s flexibility to increase options for Miriam Home’s clients—for instance, with Zoom and in‑person sessions on alternating weeks.

Gary Stoopler

Gary Stoopler

At Lethbridge-Layton-Mackay, consideration is being given to an expansion of the chronic pain program, which was available only in face-to-face sessions before the pandemic.

“As allied health professionals, we have to look at what makes sense for our type of practice,” says Maxine Lithwick. “Now that we have more experience, we’re surveying our staff to identify what we feel are the best practices for telehealth.”

“These initiatives are here to stay,” agrees Gary Stoopler. “They were developed to cope with COVID-19, but they’ll be with us for the long term.

“Even when a vaccine is developed, we don’t how many doses will be needed to provide immunity or how long it will take to vaccinate everyone. So we have to plan for a worst-case scenario, which means taking full advantage of telehealth to deliver as many essential services as possible.”

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