On arthritic knees and the hope of telerehabilitation

OK so there are days when I start wondering how many years I am going to spend crawling around on the floor with children.  Sometimes I just wonder how many miles are meant to be crawled in a lifetime.  This leads to thoughts about how appealing academia might be where I can spend a greater amount of my time sitting instead of running/hopping/crawling/etc.

The concept of telerehabilitation appeals to me - instead of/in addition to academia maybe a career in telerehabilitation is another option for my decrepit knees?  I have no inherent bias against telerehabilitation; in fact, I kind of think it would be great to find out that some types of OT treatment could be effectively delivered in a distance format.

Our regulatory system is miles behind the telerehabilitation movement.  I attended a well publicized telerehab 'continuing ed' seminar recently and hoped to have some questions about regulations answered, but they really didn't have any.  I have 'continuing ed' in quotes because I am not sure if it was continuing ed as much as it was a cheerleading session and maybe a marketing ploy.  I noticed that a press release announcing OT being added to the company's telerehab services came out the day after the webinar.  Apparently this company is providing 'online OT' within the context of 'online charter schools.'  That hardly represents a standard context so I don't really even think that there is a lot of 'telerehabilitation' happening in a pediatric school-based context.

Still, even if my knees are not so springy my hope springs eternal - I was happy to see an article published entitled School-Based Telerehabilitation in Occupational Therapy: Using Telerehabilitation Technologies to Promote Improvements in Student Performance.   Unfortunately, the article was a little disappointing. 

I expected a pilot study of some sort but as happens often, researchers overstate their results which is unfortunate because the cheerleading crew does not looks at these things with a discerning eye.  That makes us look like we aren't really very serious about producing high quality evidence.

In this particular study the researcher used The Print Tool which is a non-standardized tool that is used to assess handwriting.  This tool is probably fine to use on an informal basis in a clinical context for comparing a child's performance to themselves in a pre-test post-test fashion.  At the least it sets some moderately objective parameters and attempts to operationally define some parameters about writing.  However, it is not norm-referenced or even criterion-based, and so there are no associated standard errors of measurement that we can consider.  We have no real way of knowing how sensitive the tool is and if measurement differences have any meaning.  We also have no reported data on reliability.  These issues are important but forgivable if we are just using something for informal clinical use as a tool to look at progress, but this is definitely not a tool to be using in a research context.

That was just the beginning of the concerns.  No control group.  No blinding.  Small sample size.  Very short treatment duration (only 6 sessions).  The research design just does not provide any reason whatsoever to consider the results significant in any way.

This is not to say that future studies won't show that telerehab models are effective, but so far all we are seeing are cheerleading sessions from agencies that are already in the field trying to drum up support for the model and really poorly done research that doesn't begin to hold up under any kind of scrutiny.

Anyway, my poor broken down knees did not get any relief or hope that telerehabilitation in pediatrics is effective.  But I will still keep looking.


Criss, M. (2013). School-based telerehabilitation In occupational therapy: Using telerehabilitation technologies to promote improvements in student performance. International Journal of Telerehabilitation, Available at: <http://telerehab.pitt.edu/ojs/index.php/Telerehab/article/view/6115>. Date accessed: 13 Jun. 2013. 


Christopher, I am a pediatric occupational therapist with a clinic that specializes in the assessment and remediation of children's handwriting skills. I attended courses at the AOTA conference this year on telehealth experiences in various venues and have utilized some telehealth in my practice. I have to admit that the courses did "spark" me up and increased my feeling that telehealth is a valuable method for increasing reach for students that cannot come to my clinic. I was, as you were, disappointed that there were not enough concrete answers. I decided at that conference to become more involved in the evolution and development of telehealth practices in OT and am working to get involved with those in OT who are doing just that. I certainly hope that we get enough accomplished to give you knees a break! (I know completely how you feel!) I am currently a Cape Cod resident; however, I am originally from Rome, NY. Where in Western NY are you located? Would love to take a peek at your clinic! Have a great day!
Hi Katherine,
Thanks for your note - I enjoyed visiting your website and blog! I am glad you are able to invest some time to help with the evolution of this method; it is one of those things I am interested in but I am unfortunately unable to dedicate direct time to everything I am interested in! We have a lot of regulatory hurdles to overcome (from a licensing as well as a reimbursement standpoint) before telerehab interventions can work in NY State. To be honest, the hurdles are so large I am not even really sure where it has to start. However, I think we can help by producing high quality research that will support our lobbying. I was glad to see someone write an article, but I really want to see some rigor so that we don't get shot down just as we are leaving the gate. Thanks for your efforts!

BTW, I am near Buffalo - if you are ever in the area please feel free to call and stop by!
Christopher, I am in a different situation as I work entirely with cash or check payments. So, I only have to worry about licensing. But, we certainly have a long way to go considering the fact that the OT gurus at the telehealth sessions really didn't have any more answers than I did. But, plug along, I will. If I am in the Buffalo area...I'll be over to see you! Thanks for checking out my site and blog. I enjoy working on both. Thanks for your reply. Katherine

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