Telehealth Clinical Practice Guide for Occupational Therapy,Physical Therapy,and Speech and Language Pathology: A Saudi and Middle Eastern Guide

Abstract

Telehealth refers to the application of telecommunications technology to deliver clinical services at a distance by linking clinician to patient, caregiver, or any person(s) involved in client care for assessment, intervention, consultation, and supervision. Telehealth for occupational therapy (OT), physical therapy (PT), and speech and language pathology (SLP) have produced service delivery venues that are of great benefit during the coronavirus disease 2019 pandemic. The concept of telehealth for rehabilitation services is relatively new in the Middle East, and no specialty-specific clinical practice standards or guidelines are published to guide the rehabilitation practitioners. Therefore, a specialty-specific telehealth practice guide for rehabilitation practitioners has been developed by an expert panel in the field of rehabilitation. This guide is documented in this article. Such a guide will be beneficial when providing tele-evaluation, teleintervention/telerehabilitation, teleconsultation, and telemonitoring through communication technologies. The purpose of this guide is to enable understanding of core telehealth clinical principles and aid the provision of OT, PT, and SLP telehealth services in Saudi Arabia. Also, the guide can potentially be implemented in other Middle Eastern countries. The guide is based on key telehealth guidelines involving the American Occupational Therapy Association telehealth resources, American Physical Therapy Association, American Speech and Hearing Association, telemedicine policies in Saudi Arabia by the national health information center at the Saudi Health Council, and a blueprint for telerehabilitation guidelines that are based on the American Telemedicine Association's Core Standards for Telemedicine Operations.

Scope

The following telehealth clinical practice guide offers crucial information to be considered when providing telehealth services for persons with disability. This guide applies to rehabilitation practitioners practicing in Saudi Arabia and the broader Middle East mainly occupational therapist (OT), physical therapist (PT), and speech and language pathologist (SLP). It is also applied to patients receiving telehealth services in the Middle East and their families or caregivers. When providing telehealth services, rehabilitation practitioners should also review existing general telehealth or telerehabilitation guidelines or standards and incorporate them into the clinical practice.

Definitions

For the purpose of this article, the following terms are defined to aid in understanding of this document:

Telehealth—is ‘the application of telecommunications technology to deliver clinical services at distance by linking clinician to client, caregiver, or any person(s) responsible for delivering care to the client, for the purposes of assessment, intervention, consultation, and/or supervision.’

Telemedicine—is often used interchangeably with telehealth as it describes delivery of clinical services.¹

Telerehabilitation—is considered as a branch of telehealth which is explained as “the application of telecommunication and information technologies for the delivery of rehabilitation services.”¹

Shall, Should, and May—Shall “indicates a required action whenever feasible and practical under local conditions,” whereas “Should indicates an optimal recommended action that is particularly suitable, without mentioning or excluding others,” and “May indicates additional points that can be considered to further optimize the healthcare process.”²

Rehabilitation practitioners—refers to OT, occupational therapy assistants, occupational therapy technicians, PT, physical therapy assistants, physical therapy technicians, SLP and SLP assistants.

Introduction

More than 330.63 million people are living in different Middle Eastern countries with Saudi Arabia being the largest country with a total population of >33 million.³ It has been estimated that the prevalence of disability in the Middle East is expected to be at least equal to that of Europe and the United States if not higher. This gives an indication that an extremely large number of people with disabilities live in this region. However, prevalence rates across the Middle Eastern countries have been unreliable for many years.⁴

Given the global health crisis due to coronavirus disease 2019, regular rehabilitation services targeting individuals with disability that are delivered by rehabilitation practitioners mainly OT, PT, and SLP have been interrupted in the Middle East, including Saudi Arabia.

The Saudi Ministry of Health precautionary measures, such as avoiding gatherings and restricting traveling to contain the widespread of the virus, have created barriers to access rehabilitation services at the different facilities in the country. Many individuals with disability have had their rehabilitation sessions or appointments postponed or canceled. Such restrictions could have a significant impact on the person with disability, ranging from physical, social, economic, and psychological effects.^5,6 According to the World Health Organization, the impacts of interrupted rehabilitation services can be mitigated if stakeholders take simple actions and protective measures.⁶

During this pandemic, telehealth for OT, PT, and SLP has been used to increase access to health care, improve health care delivery, and client-centered care for individuals with disability. Research indicated that face-to-face model can be integrated with telerehabilitation and be used to provide access to specific disciplines or service providers that are not available in the community, yet more research is required.⁷ A more recent study reported that the implementation of telehealth proactively rather than reactively is more likely to produce higher gains in the long term, besides helping with every day as well as emergency challenges that could be encountered in health care.⁸

In addition to this, telehealth could assist in further enhancing rehabilitation practices for which it can be used with those living in rural areas or those having difficulty accessing health care facilities. A challenge would also be to maintain the wins and advancements in telehealth to continue postcrises and have protocols for implementing a wider version if other crises would reoccur.

In different parts of the world, such as the United States,⁷ Australia,⁹ or Canada,¹⁰ specific telehealth clinical guidelines for OT, PT, and SLP have been established to guide the clinical practice. In Saudi Arabia and the broader Middle East, telehealth is a relatively new suggested method of service delivery with available guidelines addressing general telerehabilitation principles; focusing on administrative, technical, and general clinical aspects.³ Yet, no published guidelines were designed to address specialty-specific telehealth clinical principles. Such specific guidelines would further assist rehabilitation practitioners in pursuing telehealth for people with disability. Therefore, this article aims to help rehabilitation practitioners to understand fundamental telehealth clinical practice principles. It is also proposed to aid the provision of specialized telehealth services in Saudi Arabia for persons with disability.

The development of this guide would help to overcome the existing limitation of not having a specialty-specific telehealth clinical guide for rehabilitation practitioners in Saudi Arabia. This guide can also be applied in the majority of Middle Eastern countries, given the similar social, cultural, and religious backgrounds between Saudi Arabia and other Middle Eastern countries. A recent systematic review of the literature published from 2010 to 2020 on the use and adoption of telehealth in Middle Eastern countries indicated that the slow implementation of telehealth in these countries is due to the complex and diverse nature of their social and cultural backgrounds. This review found that attitudes toward adopting and accepting a new health care system by health care practitioners were found to be strongly influenced by cultural, social, and religious barriers.¹¹ Therefore, the guide documented in this article can be applied in the majority of Middle Eastern countries, with the exception of low-income countries such as Yemen and Syria, especially because organizational barriers, including poor infrastructure, were identified to be the main challenges to implement telehealth in these countries.^5,12

This guide has been developed by a panel of experts in the field of rehabilitation. It is based on crucial telehealth resources for rehabilitation practitioners involving the American Occupational Therapy Association, American Physical Therapy Association, and American Speech and Hearing Association, telemedicine policies in Saudi Arabia by the national health information center at the Saudi Health Council, a blueprint for telerehabilitation guidelines that are based on the American Telemedicine Association's Core Standards for Telemedicine Operations.^7,13

–16 As participant data was not collected for this clinical guide, IRB approval was not required.

Telehealth Clinical Practice Principles

Telehealth should be provided through specific means of communication, including video, audio, image, text, and data. Telehealth may include the use of robots or artificial intelligence. OT, PT, and SLP telehealth services can be delivered through asynchronous telehealth; the provider of the service and the individual receiving the service are not connected at the same time. Video clips, digital photographs, virtual technologies, and other forms of telecommunication are examples of asynchronous.^17,18 OT, PT, and SLP telehealth services can also be delivered through synchronous telehealth; indicates live interactive, “face-to-face” communications using different forms of technology, that is, mobile videoconferencing, telehealth network with commercial videoconferencing system, consumer high-definition television, voice over internet protocol software, land line, or virtual reality (VR) technologies with live-streaming data to remote practitioner.^7,19 Other forms of telehealth service delivery could include text-based technology such as e-mail or mobile phone text messaging, audio-based technology such as teleconferencing; VR such as video games; web-based technology such as real-time chat rooms, and wireless technology such as personal digital assistants.²⁰

Hybrid is also considered to deliver telehealth services; where both in-person and telehealth services are provided to the patient, and remote patient monitoring, which refers to the use of devices to remotely collect patient information, such as glucose and blood pressure monitoring.¹⁷ Then this information is sent to a home health agency or a remote diagnostic testing facility for interpretation, tracking, and monitoring of the patient. The newest model used by PT is m-health; this includes online services and mobile phone applications that are marketed directly to consumers.¹⁸ It enables patients to access health information, as well as online groups that provide peer-to-peer support.

Rehabilitation practitioners share similar telehealth service delivery models. More specifically, OT, PT, and SLP consider tele-evaluation, teleintervention/telerehabilitation, teleconsultation, and telemonitoring.

The candidacy and appropriateness of OT, PT, and SLP telehealth service delivery model should be determined on a case-by-case basis using clinical judgment, taking into account the variability of client factors, activity demands, performance skills, performance patterns, and contexts and environments.⁷

1-Tele-Evaluation

When choosing tele-evaluation, rehabilitation practitioners shall consider the patient's health status, patient's preference, access to technology, and the ability to measure outcomes.⁷ Since most of the Middle Eastern countries such as Saudi Arabia, United Arab Emirates, and Oman are considered conservative, some patients may prefer to be evaluated, treated, or monitored by the same gender rehabilitation practitioner (i.e., female patients may prefer to be treated by female OT or SLP).

Rehabilitation practitioners shall consider the patient demographics and any potential barriers associated with those demographics, including, but not limited to, language and communication, cultural, and environmental, as well as access to and competence with technology. Rehabilitation practitioners ensure carrying out a risk analysis and development of contingencies to manage potential risks that might be encountered during tele-evaluation, such as incidents of falls.^21,22

The clinician's clinical reasoning guides the selection and application of appropriate information communication technology (ICT) required for the evaluation. Rehabilitation practitioners should review the latest research in telehealth or telerehabilitation to remain up to date with the proper use of technology for conducting evaluations.

OT practitioners may use tele-evaluation for wheelchair assessments, home assessment, activities of daily living (ADL) assessments, hand function assessments, mobility and adaptive equipment assessments, and more.¹⁹

When selecting an assessment tool for persons with disability, to be used for tele-evaluation, rehabilitation practitioners should consider the reliability and validity of the assessment.^7,23 Researchers have found the following assessments to be reliable when administered remotely through telehealth by OT and PT practitioners:

Numeric Rating Scale; Functional Independent Measure (FIM).²⁴

Functional Reach Test and European Stroke Scale²

Timed Up and Go Test²³

French version of the Disability of the Arm, Shoulder and Hand questionnaire (F-DASH)²⁵

Mini-Mental State Examination (MMSE)^26,27

Montreal Cognitive Assessment (MoCA)²⁸

European Stroke Scale²

Kohlman Evaluation of Living Skills

Canadian Occupational Performance Measure.²⁹

Few of the listed assessments were validated for their use with Arabic-speaking patients such as those from Saudi Arabia, involving MMSE and MoCA.^28,30 Adaptations of the regular examination and modifications of the special tests and other evaluation methods may be essential.³¹ When a modification is required for the assessment materials or the administration protocol, this should be documented and factored into the scoring and interpretation of the assessment.⁷ Furthermore, rehabilitation practitioners should consider the safety and effectiveness of the test administrated.

SLP tele-evaluation can be used in the assessment of a wide range of speech and language disorders. This includes aphasia, where standardized aphasia assessments such as the Boston Diagnostic Aphasia Examination, and the Western Aphasia Battery-Revised can be delivered through videoconferencing system with high validity and reliability.^32,33 These assessments, however, have not been adapted for use with Arabic speakers. Therefore, other formal aphasia assessments that has been specifically developed for use by Arabic speakers: the short aphasia test for Gulf Arabic speakers and the Arabic Object and Action Naming Battery should be considered during tele-evaluation for Arabic-speaking patients with aphasia.^34,35 Language and cognitive disorders can also be assessed through videoconferencing system.³⁶ SLP tele-evaluation delivered through videoconferencing systems or computer-based methods can also be used to assess articulation disorders, dysarthria and speech intelligibility, and voice disorders.^37
–39

2-Teleintervention/Telerehabilitation

Teleintervention may be used for the provision of preventative or rehabilitative interventions. When providing teleintervention, rehabilitation practitioners shall consider safety, effectiveness, and quality of interventions. Technology availability and options for the rehabilitation practitioners and patient shall also be considered. Choices of receiving interventions employing telehealth shall be made available to the patient or caregiver.

OT practitioners may use teleintervention to help patients develop skills, create health-promoting habits and routines, incorporate assistive technology and adaptive techniques, and modifying work, home, or school environments.⁷

Research suggests that PT telehealth is effective with many disorders, including chronic joint pain or osteoarthritis (knee osteoarthritis and arthritis of other joints), shoulder hemiarthroplasty, total hip replacement, and nonspecific low back pain that is subacute; chronic nonspecific neck pain, total knee arthroplasty, and lumbar spine stenosis that is degenerative.⁴⁰ There is an acceptance of telehealth and rehabilitation service in chronic musculoskeletal conditions.⁴¹ However, many studies suggested that PT teleintervention is not suited for interventions such as manual therapy, soft tissue techniques, or any technique that requires a hands-on approach by the therapist to the client.⁴²

SLP teleintervention or telerehabilitation may be considered when face-to-face treatment is impossible or unsuitable if it is difficult for the patient to get access to health care facilities. Different telerehabilitation platforms and software can be used to deliver speech and language therapy with different speech and language disorders, including aphasia, articulation disorders, fluency disorders, motor-speech, voice disorders, and swallowing disorders.^{37
–39,43

–46} This includes live interactive videoconferencing with direct communication between the patient and the SLP to deliver regular therapy sessions. Another telerehabilitation option that should be considered to improve speech and language skills is computer- or application-based teletherapy programs.⁴⁷ The training is done by the patients themselves and their caregivers at home under the guidance of the SLP clinician who will determine the therapy goals. These applications and programs can also be used to aid face-to-face therapy sessions in which additional intensive training is done at home. Since the provision of education is a vital part of teleintervention, educational materials such as booklets or videos targeting persons with disabilities and their families or caregivers shall be made available in Arabic language.

3-Teleconsultation

Teleconsultation is a virtual consultation that uses ICT to get advice or medical information. Studies found that teleconsultation may be used to deliver different OT services such as preadmission consultation for home safety and home modification evaluations, ergonomic consultation, prevention and wellness services, and to facilitate support groups for people with chronic conditions. Positive outcomes associated with teleconsultation and remote wheelchair prescriptions were found.^47

–50

PT teleconsultation is done through interactive video with the patient and health practitioner present at the same time. It is used to consult with, diagnose, and treat patients.¹⁷ Consultation through telehealth means the rendering of a professional opinion, expert opinion, or advice by a PT to another PT or health care provider through telecommunication technology. Also, teleconsultation includes the review or transfer of patient records or related information through telecommunication technology.⁵¹

SLP synchronous teleconsultation can be delivered through interactive videoconferencing or audioconferencing systems between the patient or their caregiver and the SLP clinician to provide initial consultation on the need for SLP services, including evaluation and intervention/rehabilitation.

4-Telemonitoring

Telemonitoring, also known as remote patient monitoring, is commonly used with patients with chronic disease. Patient's data involving vital signs (i.e., blood pressure or oxygen levels) and other health data (i.e., ADL performance, fall events, or blood sugar levels) are transmitted for review by practitioners to assure more timely monitoring. Adherence to an intervention program, cognitive changes, ADLs, and fall risk may be monitored by OT practitioners using ICT.^22,52,53

As in the tele-evaluation phase, PT may also consider standardized functional outcomes to monitor improvement in patient's status. PTs should take into account the minimal detectable change and minimal clinical important differences of the measures.⁵⁴ In addition to the validity and reliability of the tested outcome measures.

SLP synchronous telemonitoring delivered through interactive videoconferencing systems or telephone calls between the patient or their caregiver and the SLP clinician can also be done to monitor therapy progress and treatment compliance, and to provide updated home-training exercises. Asynchronous telemonitoring delivered through text, audio, or video data allow independent practice and can be used to monitor therapy progress, including information on number, duration, and type of practice.^46,55 These practice logs allow the SLP to asynchronously monitor therapy progress without requiring costly in-person visits.

Telehealth Ethical Considerations

Despite the nature of practice, the code of ethics forms the foundation for OT, PT, and SLP practice. Rehabilitation practitioners delivering telehealth should comply with autonomy, beneficence, nonmaleficence, justice, integrity, fidelity, and privacy.⁵⁶ Rehabilitation practitioners should maintain patient's confidentiality, protect personal health information, and should inform patients about their rights. Possible threats to privacy or confidentiality of medical information should be clearly discussed. Furthermore, professional boundaries during the provision of telehealth services should be established and maintained by rehabilitation practitioners.

Informed Consent

Informed consent for OT, PT, and SLP telehealth services (tele-evaluation, teleintervention/telerehabilitation, teleconsultation, or telementoring) should be obtained before the start of telehealth. According to the Saudi Guidelines for Informed Consent, consent should also be obtained for the collection, use, and disclosure of personal health information. If the patient is unable to provide consent due to age, communication, or cognitive difficulties, informed consent has to be obtained from the legal guardian.

Mode of communication used, that is, video, e-mail, or phone, should be communicated clearly to the patient, and informed consent should be obtained. When using an audiovisual recording, the clinician and patient or caregiver should be made aware of any recording, and informed consent should be obtained before that.^57,58

Patient's Right

Patients involved in telehealth should sign and submit an approval form. The patient has the right to refuse or discontinue OT, PT, and SLP telehealth services at any time without the need to provide justification. The patient also has the right to complain about the service provided. If necessary, telehealth-related education should be provided to patients, family, or caregivers by the OT, PT, or SLP practitioners.¹³ Besides, rehabilitation practitioners should explain the purpose of telehealth and other related information, including benefits, limitations, risks, continuity of care options, and differences to face-to-face appointments at the organization.¹⁰

Potential Challenges/Barriers of Applying Telehealth in the Middle East

Owing to the variations in regulations, infrastructure, technology, and economy, across the Middle Eastern countries, some of these countries might face challenges when applying telehealth services. For instance, Iraq and Syria suffer from poor power supply and internet connection, which are fundamental to the application of telehealth services. In addition, economic status in countries such as Jordan, Syria, Iran, and Yemen have limited the growth of telerehabilitation.^5,59

Challenges also reach countries with high-economic status such as Saudi Arabia. The health care system in the Middle Eastern countries, including Saudi Arabia is publicly available. Individuals with disability can mainly access rehabilitation services when referred by doctors from their local hospital, indicating that other health care practitioners have no authority to refer those in need. Furthermore, the rehabilitation services in Saudi Arabia are only provided in secondary and tertiary care that have limited space and capacity allocated for rehabilitation.⁶⁰

Not having enough OT practitioners working in the rehabilitation facilities across the different Saudi cities is another addressed challenge. OT is a relatively new specialty in Arab countries, particularly in Saudi Arabia.⁶¹

Despite the barriers that might be faced when providing rehabilitation services in some Middle Eastern countries, there have been signs of improvement in health care system due to new legislation, preventive measures, increased medical care and rehabilitative resources.⁴ Accordingly, rehabilitation services could benefit from the application of telehealth, especially for those living in rural areas or those having difficulty accessing health care facilities due to restrictions such as in crisis.

Conclusion

This guide is hoped to offer practical solutions and clinical guide for the implementation of rehabilitation services, including evaluation, intervention/rehabilitation, consultation, and mentoring through telehealth in Saudi Arabia and potentially other Middle Eastern countries.

Footnotes

Acknowledgment

We thank Dr. Hadeel R. Bakhsh, assistant professor of occupational therapy at Princess Nourah bint Abdulrahman University (Riyadh, Saudi Arabia), for her valuable assistance and review of this article.

Disclosure Statement

There is no conflict of interest with any financial organization regarding the material discussed in the article.

Funding Information

No funding was received for this article.

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