The purpose of this study was to evaluate the pragmatic effectiveness of telerehabilitation for promoting RTW among injured workers using data from a workers’ compensation insurer. RTW outcomes were not statistically different across delivery formats, suggesting that telerehabilitation is a novel strategy that may improve equitable access and earlier engagement in occupational rehabilitation. All PROMs showed improvement between admission and discharge, with small differences across delivery formats that were not clinically important.
We found that RTW outcomes were not statistically different across delivery formats, highlighting that telerehabilitation is a potentially useful alternative to traditional in-person program delivery. Published literature supports this finding. In a systematic review and meta-analysis conducted pre-pandemic with 13 studies (n = 1,520 participants) evaluating the effectiveness of real-time telerehabilitation in comparison to in-person management of musculoskeletal conditions, Cottrell et al. (2017) found equivalent changes in pain and function across the two modes of treatment delivery (17). In another systematic review and meta-analysis post-pandemic of five randomized control trials (n = 402 participants) comparing telehealth to in-person consultations for patients with any musculoskeletal condition, Krzyzaniak et al. (2023) found that there were no significant differences between telerehabilitation and in-person consultations for adults after knee surgeries (18). In a randomized control trial studying the effectiveness of digital interventions for chronic low back pain (n = 140), Cui et al. (2020) found that digital interventions can promote the same levels of recovery as evidence-based in-person services (19). Taken together, these findings complement the current study’s results. However, they were conducted in pre- and post- pandemic contexts (compared to our study, which analyzed data collected during the pandemic) suggesting that telerehabilitation may be comparable to in-person treatment methods irrespective of context.
Although we found that telerehabilitation is a comparable alternative to in-person service delivery in terms of RTW outcomes, we also need to consider populations in which it may be a better alternative to in-person service delivery (e.g., rural dwelling, immunocompromised individuals, or those with limited mobility or transportation options). We observed some differences in who received telerehabilitation versus in-person delivery. Men were more likely to have their programs delivered in-person and women were more likely to have their programs delivered via telerehabilitation or hybrid formats. More workers in Edmonton zone received telerehabilitation whereas workers in Calgary zone were more likely to receive in-person treatment. These gender-based and geographical differences in delivery format likely reflect a combination of administrative choices by the insurer, clinical decisions of the healthcare providers delivering services, worker preference, and zonal differences in when in-person services were offered again during the pandemic. Alternatively, literature indicates that women may prefer or require alternatives to traditional in-person service delivery. In a survey study (n = 551), Ebbert et al. (2023) found that men had lower odds of preferring telehealth services compared to women (20). This was due to gender-related differences such as women having childcare responsibilities as well as spousal and elderly caregiving duties (20). Similarly, in a cross-sectional satisfaction survey study (n = 1,734), Polinski et al. (2015) found that 70% of the telehealth participants were women who the authors noted were most likely managing childcare, work, and other responsibilities at the same time and thus found telehealth more convenient (21). Research has also demonstrated that in rural settings, where limited in-person clinics are available, telerehabilitation could be a more useful and efficient alternative to in-person services (22). Taken together, these findings complement the current study’s findings and suggest that factors such as gender and geographical location should be considered when deciding on mode of delivery.
While the benefits of telerehabilitation have been established here and elsewhere, it cannot completely supplant in-person service delivery and thus, hybrid programs are necessary. Research supports hybrid service delivery as it combines the positive elements of both in-person and virtual delivery formats (23, 24). Hybrid services have gained popularity across various domains due to the potential to enhance user experiences, overcome traditional limitations associated with solely in-person delivery, and provide care within the comfort of peoples’ homes (25). While our findings did not show that hybrid programs were better or worse in terms of RTW outcomes, we did find that receiving more than six in-person sessions in hybrid programs was significantly associated with a slower RTW. It may be that those with more in-person sessions in hybrid programs had workplace injuries requiring more intensive or hands-on care, such as more severe musculoskeletal injuries. While no studies could be found evaluating the impact of number of in-person sessions in hybrid rehabilitation programs on RTW, Cottrell and Russell (2020) concluded that more complex patients requiring musculoskeletal physiotherapy may be managed more successfully with in-person components to their program as there are some methods of diagnosis and treatment that require in-person (26). However, a mixed-methods study (n = 96) found that treatment and exercise programs after proper diagnosis appeared beneficial via telerehabilitation (27). Taken together, these studies suggest that there are positives to both modes of delivery supporting the idea that hybrid programs may result in timelier, more efficient management of musculoskeletal conditions. Further research is needed to explore the relationship between the value of in-person components, number of in-person sessions in hybrid rehabilitation programs, severity and type of condition being treated, and RTW outcomes (such as days receiving wage replacement benefits) before firm conclusions about hybrid modes of delivery can be drawn.
Limitations
Limitations of the current study are two-fold. First, while analysis of PROMs in the current study showed improvements across all measures with significant improvements on the physical functioning and vitality domains of the SF-36 as well as the PDI, these results should be interpreted with caution. PROMs rely heavily on self-report and completion is voluntary, which often translates to high levels of missing data on these measures. Our study was not immune to these challenges. More importantly, it is unlikely that the change scores we observed reached thresholds of clinical importance. The large amounts of missing data on the PROMs may have impacted study findings as improvement of program outcomes across the various program delivery formats cannot be truly represented. This limitation stemmed directly from our use of retrospective WCB-Alberta data and therefore could not be avoided. Second, the reliance on archived data from the WCB-Alberta may have limited findings. Reliance on retrospective WCB-Alberta data meant that we could only analyze the variables thy regularly collected for program monitoring versus any additional variables that may be influencing RTW outcomes. However, we chose not to collect any data prospectively for feasibility purposes. Further research with a greater variety of variables and more complete datasets is needed to fully understand how patient-reported outcomes are impacted by delivery format as well as to understand what other variables may be predictive of RTW outcomes.