Rehab at the ready

19 July 2022 by Wendy Haaf

When COVID-19 hit, KITE launched a comprehensive tele-rehab program within weeks. It's now helping other institutions connect with their own patients virtually.

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“Could you order 25 webcams today?” Dr. Mark Bayley remembers asking one of his staff almost immediately after the pandemic began. Dr. Bayley, who is the Medical Director of Toronto Rehab and UHN's Physiatrist-in-Chief, had immediately grasped the potentially dire implications that the COVID-19 crisis could have on patients like his – people who had recently experienced a stroke or brain injury and required in-person rehab as part of their recovery.

After these potentially devastating events, there's a narrow window during which the brain is primed to rewire itself, particularly with the recovery of motor functions. But rehab is a must. “Failure to do rehabilitation activities during that period may ultimately lead to a worse recovery,” explains Dr. Bayley, who is also a senior scientist at KITE.

Back then video platforms were rarely used for rehab, but he knew to urgently order cameras. How? Because since 2005 he has been offering rehab online to patients in distant communities via Ontario Telehealth. “It was pretty clear right away that the only thing that was going to work was virtual rehab,” says Dr. Bayley, who is widely recognized as a tele-rehab pioneer.

The team jumped out of the gate instantly, arranging to deliver video-based rehab before many other institutions recognized the sound of the starter's pistol. He was in a unique position: he had been advocating for the creation of a virtual rehab program for two years prior to the pandemic, so “we were primed to do it, even though we were at the stage of minimal adoption,” he explains. Suddenly, COVID-19 had changed the game.

Still, despite his experience in this area, Dr. Bayley and his colleagues had to learn a lot on the fly, as the demands of a virtual rehab session are very different from those of most virtual doctor visits. For instance, “you're assessing people doing physical things – you're having them walk, talk and prepare a meal,” he explains. Consequently, for example, “you need to make sure the participant has the technology and can use it, and that they have a caregiver present who can supervise therapy,” he explains.

And, since many of the patients involved have physical weakness, poor balance or other limitations, compared to other types of tele-health visits, a virtual rehab session, “is inherently a little more dangerous, and requires a bit more creativity,” Dr. Bayley notes.

Tele-rehab can also present possible privacy issues. For instance, say someone Zoom-bombed a session with a CEO who was quietly undergoing rehab after a mild stroke, then revealed that fact to others. A potential leak, “of such sensitive information, regardless of stigma, was a real concern,” he says. Using Microsoft Teams, which is more secure than other platforms, helped alleviate those fears.

Dr. Bayley and the team regularly solicited feedback from therapists and patients to help them get a better sense of what everyone needed to make rehab successful. “We have a very capable project manager who set up surveys online,” Bayley says, “so we got real-time information about what the barriers were.” In response, Dr. Bayley and the team did everything from tweak the technology to develop step-by-step guidance on how to do different exercises.

At the time, Dr. Bayley assumed other hospitals were also rolling out tele-rehab programs, only to discover otherwise. “During informal conversations with my colleagues, I would say, ‘What are you guys doing in tele-rehab?' and they'd say, ‘Our hospital hasn't figured out the privacy issues yet,' or ‘We are not offering outpatients anything because our hospital has moved all of our staff to in-patients.' That's when I started to realize we needed to help other centres learn from our experience of rolling it out.”

Creating the Telerehab Toolkit

A few weeks later, Dr. Bayley and the team began helping health professionals at other institutions navigate the uncharted waters of virtual rehab. As those participants were looped into the feedback process, other issues emerged. For instance, therapists and clinicians with no prior experience needed guidance around what to do if they couldn't get a connection, while many feared a lawsuit or loss of their professional licence if, say, a patient fell during walking practice. Many organizations didn't have policies for dealing with remote care, or knowledge about whether patient privacy could be adequately protected, too.

With KITE's experts having expertise in a variety of areas, ranging from project management and quality improvement to research and knowledge translation, Dr. Bayley and the team were able to create an online resource for other centres – which included everything they needed to set up and deliver tele-rehab – within three months. In change management terms, that's something of a miracle. “We accomplished what otherwise would have taken a year to do,” he says.

In its first iteration, the free tool kit – which has since been downloaded more than 500 times – laid out basic instructions on such topics as how to obtain a patient's consent to attend a virtual visit, and troubleshooting technical issues. Version 2.0, which is in the works, will also include how to curate lists of videos demonstrating various exercises.

Unexpected advantages

Prior to the pandemic, Stacey Marshall, an occupational therapist with the Multiple Sclerosis Outpatient Services Program within Toronto Rehab's Brain and Spinal Cord Rehabilitation Program at the Rumsey Centre, knew little about virtual care. “Our services were fully in person,” she says. With the help of the tool kit, clinicians in her program quickly transitioned to seeing clients online using the Ontario Telehealth Network and Microsoft Teams, both of which meet UHN's confidentiality criteria, and enable therapists to share materials such as brochures.

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