1. Brain Injury
  2. Guidelines
  3. Section 1
  4. Components of the Optimal TBI Rehabilitation System

B. Telehealth

The global impact of the COVID-19 pandemic resulted in the increased need for virtual care and telerehabilitation, to protect both patients and clinicians, while continuing the delivery of essential healthcare services. Telerehabilitation provides increased accessibility for individuals who may be less able to participate in-person rehabilitation services, due to limited financial resources, transportation challenges, distance, and mobility challenges (Toronto Rehabilitation Institute Telerehab Toolkit, 2022). This section aims to provide clinical best practice recommendations that aid effective tele-assessment and telerehabilitation, to promote the provision of timely and equitable access to care for individuals with a traumatic brain injury (TBI). The outcomes of telerehabilitation have been found to be comparable to those of in-person interventions, making virtual care an effective mode of care delivery. When appropriate, clinicians should consider a hybrid model, using telerehabilitation and in-person interventions. Special attention must be paid to organizational and provincial privacy and security policies, to ensure patient safety.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ across jurisdictions. 

Clinical Tools:

INCOG 2.0 Guidelines - Open Access Series: 

Rehabilitation is an integral part of the healthcare continuum, and access to early and intense rehabilitation has been found to reduce mortality, optimize recovery of function, and enhance quality of life (Toronto Rehabilitation Institute Telerehab Toolkit, 2022). There is a growing body of research on virtual care and telerehabilitation, indicating increased interest and application.

Telerehabilitation refers to the use of communication and information technologies to provide rehabilitation services from a distance (Salbach et al. 2022). Telerehabilitation can be used for purposes including assessment, supervision, education, counselling, treatment, and support (Salbach et al. 2022). Telerehabilitation is often delivered using video or telephone conferencing, but can also be delivered using other modalities, such as recorded videos, and asynchronous communications (Salbach et al. 2022).

Cognitive-Communication and Social Communication

Two cohort studies investigated the effects of in-person and telehealth delivery of a social communication skills program (Rietdijk et al., 2020). Both studies found no significant differences on communication skills outcomes, suggesting that telerehabilitation is equally efficacious, feasible, and acceptable as in-person programs, for improving social communication skills in individuals with traumatic brain injury (TBI).

See ERABI Module 20 for additional information.

Telehealth Interventions for Caregivers

Powell et al. (2016) reported that caregivers receiving a telehealth self-management intervention, comprised of education, and mentored problem-solving, showed improved coping ability and psychological well-being, when compared to usual care. In a follow-up to this study, Powell et al. (2017) reported that, 6 months post ABI, caregivers were able to increase their involvement in recreational and professional endeavours (see ERABI Module 13.5.3 for additional information).

An important factor to consider for clinical decision-making, however, is whether telehealth interventions are suitable for all caregivers/family members. Rietdijk et al. (2012) reported that although caregivers reported high satisfaction with telehealth interventions overall, when they were asked about their preferences, approximately a third of the sample reported a preference for in-person interventions, with a belief that these would be more helpful. These findings suggest that not all caregivers/family members will be receptive to a telehealth approach (Rietdijk et al., 2012). Preliminary evidence from other studies suggests that factors such as socio-economic status, age, gender, prior experience with technology, and/or attitudes towards computers may influence virtual care outcomes (Perle et al., 2011).

REFERENCES

Brain Injury Program and Mobility Innovations Centre. The Toronto Rehab Telerehabilitation Toolkit for Outpatient Rehabilitation Programs. 2nd ed. Toronto Rehabilitation Institute. (2022). https://kite-uhn.com/tools/tr-telerehab-toolkit

Dams-O'Connor, K., Sy, K. T. L., Landau, A., Bodien, Y., Dikmen, S., Felix, E. R., Giacino, J. T., Gibbons, L., Hammond, F. M., Hart, T., Johnson-Greene, D., Lengenfelder, J., Lequerica, A., Newman, J., Novack, T., O'Neil-Pirozzi, T. M., & Whiteneck, G. (2018). The Feasibility of Telephone-Administered Cognitive Testing in Individuals 1 and 2 Years after Inpatient Rehabilitation for Traumatic Brain Injury. J Neurotrauma, 35(10), 1138–1145. 

DiBlasio, C. A., Novack, T. A., Cook, E. W., 3rd, Dams-O'Connor, K., & Kennedy, R. E. (2021). Convergent Validity of In-Person Assessment of Inpatients with Traumatic Brain Injury Using the Brief Test of Adult Cognition by Telephone (BTACT). J Head Trauma Rehabil, 36(4), E226–E232. 

Evidence-Based Review of Moderate to Severe Acquired Brain Injury (ERABI). (2021). https://erabi.ca/

Ownsworth, T., Arnautovska, U., Beadle, E., Shum, D. H. K., & Moyle, W. (2018). Efficacy of Telerehabilitation for Adults with Traumatic Brain Injury: A Systematic Review. J Head Trauma Rehabil, 33(4), E33–E46.  

Perle, J. G., Langsam, L. C., & Nierenberg, B. (2011). Controversy clarified: an updated review of clinical psychology and tele-health. Clin Psychol Rev, 31(8), 1247–1258. 

Pettigrew, L. E., Wilson, J. T., & Teasdale, G. M. (2003). Reliability of ratings on the Glasgow Outcome Scales from in-person and telephone structured interviews. J Head Trauma Rehabil, 18(3), 252–258. 

Powell, J. M., Fraser, R., Brockway, J. A., Temkin, N., & Bell, K. R. (2016). A Telehealth Approach to Caregiver Self-Management Following Traumatic Brain Injury: A Randomized Controlled Trial. J Head Trauma Rehabil, 31(3), 180–190. 

Rietdijk, R., Togher, L., & Power, E. (2012). Supporting family members of people with traumatic brain injury using telehealth: a systematic review. J Rehab Med, 44(11), 913–921.  

Rietdijk R, Power E, Attard M, Heard R, Togher L. (2020). Improved Conversation Outcomes After Social Communication Skills Training for People with Traumatic Brain Injury and Their Communication Partners: A Clinical Trial Investigating In-Person and Telehealth Delivery. J Speech Lang Hear Res, 63(2), 615–632.

Rietdijk, R., Power, E., Attard, M., Heard, R., & Togher, L. (2020). A Clinical Trial Investigating Telehealth and In-Person Social Communication Skills Training for People with Traumatic Brain Injury: Participant-Reported Communication Outcomes. J Head Trauma Rehabil, 35(4), 241–253.

Salbach, N. M., Mountain, A., Lindsay, M. P., Blacquiere, D., McGuff, R., Foley, N., Corriveau, H., Fung, J., Gierman, N., Inness, E., Linkewich, E., O'Connell, C., Sakakibara, B., Smith, E. E., Tang, A., Timpson, D., Vallentin, T., White, K., Yao, J., & Canadian Stroke Best Practice Recommendations Advisory Committee, in collaboration with the Canadian Stroke Consortium and the Canadian Partnership for Stroke Recovery (2022). Canadian Stroke Best Practice Recommendations: Virtual Stroke Rehabilitation Interim Consensus Statement 2022. Am J Phys Med Rehabil, 101(11), 1076–1082.

Tran, V., Lam, M. K., Amon, K. L., Brunner, M., Hines, M., Penman, M., Lowe, R., & Togher, L. (2017). Interdisciplinary eHealth for the care of people living with traumatic brain injury: A systematic review. Brain Inj, 31(13-14), 1701–1710. 

P

Priority

F

Fundamental

N

New Level of Evidence

A

B

C


B.1.1

N

C

Clinicians should assess suitability of virtual care/telerehabilitation on an individual basis, taking into consideration: 

  • The patient’s abilities, goals, preference, and capacity and experience with telerehabilitation 
  • Feasibility of access to in-person rehabilitation therapy 
  • Risk and benefits based on the patient profile (i.e., chance of adverse events) 
  • Availability of caregiver/close other to offer support 
  • Inventory of equipment available to patient  
  • Familiarity with that technology and WIFI capabilities

(INCOG, 2022)

Last Updated June 2023

B.1.2

N

C

Prior to commencing telerehabilitation, clinicians should obtain informed consent from the person with TBI, and be aware of the policies of their local organization and accrediting organizations including security and privacy considerations. The designated healthcare team member in-person, or over the phone, should ensure that the contact information of the patient (where telerehabilitation is occurring); the first responder or local non-emergency phone number; the emergency contacts (e.g., family member); and the physician and other relevant HCP are all identified and documented. 

(Adapted from Toronto Rehabilitation Institute) 

Last Updated June 2023

B.1.3

C

Prior to a virtual care appointment, clinicians should ensure that:  

  • All resources required, are prepared for the session (e.g., digital documents and web pages) so they can be easily retrieved and shared 
  • The room set-up promotes safety, privacy and confidentiality, as well as focus and attention by reducing visual stimuli on the walls and in the space  
  • Cameras are positioned appropriately. For example, if the provider needs to demonstrate an exercise or activity, is the camera positioned for a full body view  
  • The patient/close other has contact information for the provider if they experience any set-up or administration difficulties/technological challenges  
  • You are selecting the most user-friendly option of equipment possible 
  • The patient has had the opportunity to trial and troubleshoot any of the technology being used 
  • The roles and expectations of caregiver involvement have been discussed. 

(Adapted from Toronto Rehabilitation Institute)

Last Updated June 2023

B.1.4

N

C

Videoconference assessment is preferred over telephone because it allows direct observation of performance, non-verbal behaviour and effort level.  

(INCOG, 2022)

Last Updated June 2023

B.1.5

N

B

Clinicians should consider utilizing assessment tools for cognitive and communication functions that have been evaluated for their feasibility, reliability and validity using telehealth. Some assessments that have been evaluated for use in telephone include the assessment of discourse ability, the Brief Test of Adult Cognition by Telephone and the Glasgow Outcome Scale. 

(INCOG, 2022)

REFERENCES:

  • Dams-O'Connor et al. (2018) 
  • DiBlasio et al. (2018) 
  • Pettigrew et al. (2003) 

Last Updated June 2023



B.2.1

N

B

Clinicians should consider the use of telerehabilitation, in addition to in-person visits to provide timely and equitable access to care for individuals with a TBI. 

(Adapted from INCOG 2022) 

REFERENCES:

  • Ownsworth et al. (2018)
  • Rietdijk et al. (2020)
  • Tran et al. (2017)

Last Updated June 2023

B.2.2

N

C

The characteristics of the person with TBI who would be ideal for cognitive rehab interventions that have been proven in-person but not in the virtual environment are:

  • Their goals are well aligned and can be developed in concert with the person with TBI virtually
  • Patient has history of following instructions well 
  • Person has reasonable ability to self-monitor and is self-aware
  • Family support is available. 

(INCOG, 2022)

Last Updated June 2023

B.2.3

N

C

Hybrid models may be required if the person requires training in the use of technology or if there are concerns about safety. 

(INCOG, 2022)

Last Updated June 2023

B.2.4

N

C

To facilitate participation in each session, clinicians should: 

  • Maintain eye-contact by looking at the webcam and not the screen
  • Speak at a reasonable pace and pause frequently to allow patients to process information
  • Clarify the patient’s understanding of the material using several strategies, such as teach-back strategies
  • Ask clarifying questions
  • Offer/inquire about need for pauses to allow for cognitive fatigue induced by video screens. 

(Adapted from Toronto Rehabilitation Institute)

Last Updated June 2023

B.2.5

N

C

Group interventions provided by telehealth technology are recommended if there is evidence supporting that intervention using an in-person format and they are feasible in the telerehabilitation environment. 

(INCOG, 2022)

Last Updated June 2023

B.2.6

N

C

The use of telerehabilitation should be monitored and evaluated frequently, and adapted as necessary, for each patient. Patient’s level of engagement should be monitored closely.

(INCOG, 2022)

Last Updated June 2023



B.3.1

N

C

Telerehabilitation Delivered Metacognitive Strategy Training

One-to-one remotely delivered interventions (e.g., for goal management training), set up according to established telerehabilitation guidelines, is recommended if remote delivery is the most convenient or the only mode of reaching the person.

(INCOG, 2022)

Last Updated June 2023

B.3.2

N

C

Telerehabilitation-Delivered Group Based Treatment

Telerehabilitation-delivered group-based treatments of executive function may not achieve the same outcomes as in person and requires further evaluation. Therefore, they are not recommended at this time.

(INCOG, 2022)

Last Updated June 2023

B.3.3

N

B

Telerehabilitation is as efficacious, feasible and acceptable for communication partner training compared to in-person intervention.

(INCOG, 2022)

REFERENCE:

  • Rietdijk et al. (2020)

Last Updated June 2023