Establishing the efficacy of telemedicine as a clinical tool for physiotherapists: From systems design to a randomised controlled trial

High quality health services are often difficult to access in rural and remote areas of Australia. This is due to a shortage of health care professionals and specialists, inadequate and poorly distributed resources, and the tyranny of distance. The result is a reduced level of health and a higher mortality rate than seen in urban communities. Telemedicine, which is the use of various technologies to deliver a range of health care services over a distance, has the potential to increase equity and access to health care in rural and remote areas. To date there has been a poor uptake of telemedicine technology within the profession of physiotherapy. This undoubtedly stems from the perceived, and indeed, real difficulty of performing what is traditionally hands on therapy, via an electronic medium. Added to this is a paucity of rigorous clinical outcome studies to demonstrate the efficacy of performing successful treatment via this delivery method. The aim of this thesis was to establish the efficacy of telemedicine as a clinical tool for physiotherapists. To achieve this, the first major undertaking was the development of a telemedicine system to meet the unique needs of clinical physiotherapists and their patients. A series of studies was then performed to calibrate the system and establish its validity and reliability as a clinical assessment tool. Finally, a randomised controlled trial was conducted to assess the treatment efficacy of the telemedicine system. The telemedicine system was constructed using a human systems development approach, with close consultation with senior clinical physiotherapists and potential users of the system. The personal computer-based system was designed to connect patients in their home with physiotherapists in the hospital, via low-speed and low-cost communications. The system incorporated real-time videoconferencing and physical measurement tools to enable the remote assessment of patients. The validity and reliability of the telemedicine physical measurement tools were established through a series of five studies. The results demonstrated these measurements to be accurate and reliable, under various measurement conditions, when compared to reference instruments. A prospective randomised controlled trial was conducted to assess the treatment efficacy of the telemedicine system. The research model chosen for this study was the rehabilitation of subjects who had undergone total knee replacement surgery. Block randomisation was used to assign 65 participants to either a traditional face-to-face therapy group or a telemedicine rehabilitation group. Participants in both groups received treatment over a six week period. Data analysis focussed on comparing physical and functional rehabilitation outcomes achieved in each treatment group. The results of this study demonstrated that the rehabilitation outcomes produced via the telemedicine system were similar to those achieved in the traditional manner. Additionally, the telemedicine therapy was found to produce greater improvements in a number of functional outcome measurements. A high level of satisfaction was expressed by participants who received treatment via the telemedicine method. This thesis provides evidence of the efficacy of telemedicine as a clinical tool for physiotherapists. Furthermore, the work detailed in this thesis represents one of the first randomised control trials in telerehabilitation and makes a significant contribution towards the knowledge of low-bandwidth telemedicine in general. This thesis provides a framework upon which further research and telemedicine applications may be developed, with the ultimate goal of improving equity and access to high quality health services in rural and remote areas.