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Telerehabilitation and Pressure Ulcer Management

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Telerehabilitation has been defined as “the use of telecommunication technology to deliver rehabilitation services at a distance” (Vesmarovich et al. 1999; p 264). Telerehabilitation allows for visual and verbal interaction between an individual with SCI and a health care provider. Impaired mobility and great distances to specialized SCI centers often make follow-up care difficult for individuals with SCI (Mathewson et al. 2000; Galea et al. 2006). Telerehabilitation has the potential to deliver medical rehabilitation including education, nutritional and psychosocial elements of health care at a distance thereby facilitating continuity of care (Galea et al. 2006). Shorter lengths of stay have potentially increased the need for education post-discharge and technology can be used to continue education begun during inpatient rehabilitation including education on pressure ulcer prevention and care of ulcers if they occur. Continuation of pressure ulcer prevention education and early detection and intervention via technology may reduce the need for hospitalization related to pressure ulcers (Phillips et al. 2001). The use of a videophone capable of transmitting high resolution images, and verbal interactions between nurse, patient and caregiver could mean accurate and timely assessment and treatment of wounds and improved healing (Mathewson et al. 1999). In a study conducted at a mock home setting, Hill et al. (2009) found “video conferencing was better overall than the use of the telephone when assessing the detailed clinical characteristics of a pressure ulcer (p 200).” Both were found to be useful when assessing for the presence of a pressure ulcer.

The 2013 Canadian Best Practice Guideline for Prevention and Management of Pressure Ulcers in People with SCI provided a Level IV recommendation (based on studies of telerehabilitation for wounds of various etiologies including SCI) telerehabilitation as a promising approach for delivering pressure ulcer prevention ad management to people with SCI. A Canadian multisite pressure ulcer internet clinic feasibility study will assist to elucidate the specific utility of telerehabilitation for pressure ulcer management in people with SCI (Rick Hansen Institute, 2009).

Table: Telerehabilitation and Pressure Ulcer Management Post SCI

Discussion

Vesmarovich et al. (1999) described the use of telerehabilitation delivered via a videophone system that transmitted still images and audio to treat stage III and IV ulcers. While no statistical results were reported, 7 out of 12 ulcer sites healed. Using the same videophone system, Philips et al. (1999) divided SCI participants into 3 groups. The videophone group had the highest number of identified and/or reported ulcers. The annualized data for emergency room (ER) visits, hospitalizations and health care visits were similar for the video and telephone groups while hospitalizations and visits were less in the standard care group. No differences were significant at p<0.05. However a small non-randomized sample size and several other limitations were identified to inform future investigations.

Results of these two small studies fail to support the use of this form of telerehabilitation in delivery of cost effective prevention strategies and early pressure ulcer identification and treatment. However, Houlihan et al. (2013) did achieve some positive results by employing interactive voice response (IVR) telephony called “CareCall” to enable virtual health care to monitor and assess patients’ health with respect to pressure ulcers and depression and to increase appropriate use of health resources such as preventative outpatient clinics and to reduce ER visits. Participants (N=142) were randomized into either a control (i.e., usual care) or intervention (i.e., “CareCall”) group and received service over a 6 month period. Those receiving “CareCall” received weekly automated calls and could call into the service at any time to receive algorithm-based, branched-logic modules (scripts of content deemed relevant to their health concerns). The scripts were delivered by both clinicians and persons with spinal cord disease and were developed through consideration of health behavior change theory (i.e., Social Cognitive Theory and Transtheoretical Model) to promote healthy behaviours. Using this approach, women were found to have reduced pressure ulcer incidence over the study period (p<0.0001) for the “CareCall” group versus control, whereas men did not. There was no difference in healthcare utilization between the two groups although the intervention group did self-report perceived increases in health-care availability.

Despite these promising results, more research is needed to determine how and what telerehabilitation strategies can be used to deliver and monitor compliance with pressure ulcer prevention strategies as well as their use in identification and treatment of pressure ulcers post SCI.

Conclusion

There is level 1b evidence (from a randomized controlled trial; Houlihan et al. 2013) that telerehabilitation using an automated call-in system with built-in theory-based behavior change strategies may make a significant difference for women but not men in preventing pressure ulcers post SCI.

There is level 4 evidence (from one case series; Vesmarovich et al. 1999) that telerehabilitation via videophone to support clinical interactions and digital photography does not make a significant difference in the prevention and treatment of pressure ulcers post SCI.

More research is needed to determine what telerehabilitation strategies are effective in preventing pressure ulcers, improving healing and reducing costs.

  • The role of telerehabilitation in delivering prevention education and treatment to those individuals with SCI living in the community is not yet proven; more research is needed.