Telerehabilitation in Low- and Middle-income Countries

Abstract

Telemedicine is the delivery of healthcare services using information and communication technologies (ICT) to its users. Mobile communications in telemedicine or Mobile health (mHealth) is the most commonly accepted mode of telemedicine in low- and middle-income countries (LMICs) due to its affordability and user-friendly features. Telemedicine may be used to treat, prevent and monitor health conditions; as well as to promote health and educate clients. Access to medical and rehabilitation services in LMICs may be limited due to the lack of expertise, geographical locations, and sociocultural issues. Telerehabilitation (TR) may be a practical solution to circumvent these barriers in LMICs. TR providers must possess the necessary knowledge, skills, and expertise to deliver quality TR services to clients while ensuring patient safety and adhering to medical ethics and regulations. Policymakers and administrators should ensure vulnerable groups are included when making policies on healthcare services. Changes must be made to existing policies on telemedicine, in order to include all stakeholders in TR and overcome human, organizational, and technical challenges in LMICs.

1. Introduction

Telemedicine, also known as telehealth, eHealth, telepractice, online medicine, virtual consultation [1], or distant medicine [2] is the delivery of healthcare services using information and communication technologies (ICT) to its users. The use of mobile communications is called Mobile health (mHealth), which is the most commonly accepted mode of telemedicine in low- and middle-income (LMIC) [3, 4]. In 2020, upper-middle income countries (UMIC) like Malaysia had 40.69 million mobile subscriptions and 27 million (83.1%) internet users [4].

Telemedicine may be used to treat, prevent and monitor health conditions, as well as to promote health and educate clients [5]. Although the list is not exhaustive, applications of telemedicine have expanded beyond teleconsultations to telerehabilitation, telesurgery, telerobotics, telereferrals, telepharmacy, teletherapy, telediagnostics (telepathology, teleradiology); teleassessments, telemonitoring, telementoring, teleeducation, and telecounseling [6, 7].

Telemedicine provides faster access and communication between healthcare providers (HCPs) and patients [8, 9]. The COVID-19 pandemic has accelerated the uptake of telemedicine as it avoids direct exposure to infections, reduces traveling time and cost [8, 9, 10], and reduces time away from work or caregiving. Sub-acute cases requiring rehabilitation and monitoring can no longer be managed in acute or rehabilitation hospitals due to competing health priorities and shortened length of stay (LOS). Telerehabilitation (TR) may be a key innovation to ensure continuity of care post-hospital discharge and reduce the global burden of disability [11, 12, 13].

The scope of TR services depends on 4Ps namely the patient, provider, policymaker, and payer. The needs of its people and healthcare system will steer the direction of telemedicine in LMIC [13]. The success or failure of TR will depend on the dynamic relationships between human, organizational, and technical factors [10, 11]. Vulnerable groups such as people with disabilities (PWDs) and the elderly in LMIC face additional challenges in accessing TR.

Sociocultural issues such as unemployment, homelessness, overcrowding, language barrier, cultural and religious beliefs; and literacy will influence the delivery and uptake of TR. Literacy does not only mean the basic ability to read and write, but also the ability to navigate ICT and contextualize information obtained from healthcare professionals (HCPs) and the media. Non-English speakers may face additional literacy disparity, as 63.2% of the information on the internet is in English [14]. TR services should be available in foreign languages so as not to exclude a significant proportion of people who are only proficient in their native language [13]. Policymakers and HCPs must ensure vulnerable groups are included when making policies on healthcare services. Existing policies and guidelines on telemedicine in LMIC are mostly physician-centric [15, 16, 17] and do not have clear policies on fee structure, insurance coverage, and financial incentives for allied health professionals (AHPs) [17]. Changes must be made to existing policies on telemedicine, in order to include all stakeholders in TR and overcome human, organizational and technical challenges in LMIC.

2. Telerehabilitation in low- and middle-income countries

2.1 Telerehabilitation requirements

TR services depend on the needs of its people and healthcare systems and are differentiated by their ecosystem and convenience. Low cost and technology, easy-to-use features, and quick responses are key to the adoption of TR in LMIC. Figure 1 shows a Hub-and-spoke model and illustrates the inter-relationships among TR stakeholders.

Figure 1.

Hub-and-spoke model on telerehabilitation stakeholders. (Source: Adapted from Malaysian Telemedicine Flagship Application, 2013; page 12) [7].

TR requirements can be categorized into:

• Providers

• Clients

• Information and communication technologies (ICT)

• Training

• Policies and guidelines

• Outcome measures

2.1.1 Telerehabilitation providers

Although the list is not exhaustive, TR providers may include:

• Healthcare Professionals (HCPs)

  Treat patients, instead of going to health centers, these services can be accessed through ICT they give consultation, examine patients and devise a treatment plan which includes prescribing medications, therapies, and rehabilitation equipment for patients. HCP also requests laboratory tests.

• Policymakers

  Write regulations for health care providers to protect patient’s rights and safety,

• Organizations, hospitals, or health centers

  Look into the runnings of TR

• Laboratories

  Process patient’s samples for health care providers to access, but this can also be accessed by the patients themselves without the health care providers.

• Pharmacies

  Dispense medicine prescribed by HCPs

• Researchers

  Conduct research and studies of evidence-based practice and review policies

• Data analyzer

  Analyze data, from all of the above, such as policies, laboratories, and the information stored and transmitted in the TR process

• Hardware or software developers

  Develop technology to be used in the TR process

• Telecommunication and internet providers

  Provide connectivity between TR providers and the clients

• Artificial intelligence (AI)

The three major components of TR are clinicians, IT, and TR services. A clinical provider’s role is to deliver TR services [18]. They may either be physicians, AHPs [17] such as nurses, therapists, counselors, social workers, dietitians, pharmacists or traditional and complementary practitioners, or even caregivers [11]. TR providers may be stationed at hospitals, clinics, health centers, homes [5], or online.

There should be good leadership in TR. TR providers are regarded as leaders or brand ambassadors in telemedicine; promoting and building relationships among stakeholders such as HCPs, policymakers, and hardware or software developers [18]. TR providers need to embrace new technologies such as AI (Chatbot or robots) to meet clients’ exponential demand for an immediate and constant response beyond office hours. The high cost and lack of human resources to deliver TR may be substituted with pre-programmed Chatbot responses, and prerecorded audio or text messaging systems.

2.2 Telerehabilitation clients

Telerehabilitation clients may include:

• Patients

• General public

• Paid caregivers

• Family members

• Healthcare providers

PWDs and those with chronic diseases in LMIC often undergo a vicious cycle of disability, unemployment, and poverty. Family members usually become informal caregivers, since paid caregivers are costly and not sustainable. Caregivers in LMIC often have to work several jobs to support PWD in the family or give up their jobs to be full-time caregivers. Family-based rehabilitation (FBR) and community-based rehabilitation (CBR) may be realistic models of care in LMIC [11, 12]. TR facilitates FBR and CBR by empowering caregivers and HCPs in the community.

Not all PWDs can be TR clients. Patients with acute emergencies, with severe communicative disorders and no access to ICT, may need additional considerations and in-person assistance [11, 19]. TR providers must adhere to the Code of Ethics and have a duty of care to ensure patient safety prior to selecting patients as TR clients [1, 10] (see case history 1).

2.3 Case history 1

Mrs. Y is an elderly lady who lives with her elderly husband, Mr. Y who has hearing impairment, in a village with no internet access. She has sudden left knee pain and cannot travel to the hospital on her own. Mr. Y informed Nurse LN to assess Mrs. Y. Nurse LN made a diagnosis of acute septic arthritis and called for an ambulance to transfer Mrs. Y to the local hospital. Dr. HQ (TR provider) discharged Mrs. Y a week later with a home exercise program, to be supervised by Nurse LN. Nurse LN (TR client) visited Mrs. Y weekly and taught Mr. and Mrs Y the prescribed exercises. Two months later, Miss SN (TR client) sent pictures and videos of Mrs. Y cooking and walking to Dr. HQ and the rehabilitation team at the hospital (TR providers) via WhatsApp.

2.3.1 Information and communication technologies

ICT is a major component of TR as it links TR providers to its users (Figure 1). ICT may be broadly classified into:

• Technology

• Equipment

• Combination of both (hybrid)

Information can be transmitted through the following methods:

• Synchronous

• Asynchronous

• Hybrid

2.3.1.1 Synchronous telerehabilitation

Synchronous communication is also known as sync, real-time, face-to-face (F2F) or live interaction between TR provide and its users. Synchronous TR provides immediate responses and exchange of information between two or more parties. Body language, tone of voice and better rapport can be established via live video. Illiterate and visually impaired TR clients can interact with TR providers without having to read written information, as in asynchronous TR. Any doubts, misunderstanding, and feedback can be obtained immediately via verbal communication.

Fast internet speed, adequate data capacity, and technical expertise are required in order to provide synchronous TR. The minimum broadband speed for satisfactory synchronous teleconsultation or teleeducation in Vietnam (LMIC) is 2 Mbps, whereas diagnostic images such as those transmitted in teleradiology would require a minimum of 4 Mbps2. Upper middle-income countries (UMIC) such as Malaysia, have an average download speed of wireless broadband of 15.6 Mbps to 27.6 Mbps20; which is slow compared with the average fixed internet connection speed worldwide (78.0 Mbps).

A survey conducted in 2020 revealed internet users in Malaysia used smartphones (96%), laptops/notebook/netbook (41%), and tablets (18%) for Chat Apps (97%), social networking Apps (70%), and entertainment or video Apps (55%) [4]. Some examples of apps which can be downloaded for free and have synchronous features are WhatsApp, Facebook live, FB messenger, Instagram, WeChat, GoogleMeet, Zoom, and Skype. Video conferencing and live chats can also be conducted on Chatbots and telephone. ICT user habits and trend may project how synchronous TR can be delivered in LMIC and UMIC [4, 23, 24, 25].

2.3.1.2 Asynchronous telerehabilitation

Asynchronous communication is also known as async or store-and-forward communication [7]. Information can be exchanged between two or more parties without the involvement of live or immediate responses. Asynchronous information can be stored and edited beforehand and viewed later. There is no time-pressure and it does not require everyone to be present at the same time. Caregivers in LMIC often have to juggle between work commitments and providing care for PWDs. Asynchronous TR may be more acceptable to caregivers and patients who cannot commit to appointment scheduled within office hours or when there are ICT limitations for synchronous TR. Clients who are introverts, shy or not well-versed in F2F communication may also find asynchronous TR more appealing.

Some examples of asynchronous communication are SMS, email, and voice or video recordings. Prerecorded lectures, webinars, and YouTube videos are popular modes of asynchronous information, which can be useful in LMIC.

2.3.1.3 Hybrid telerehabilitation

At times, TR clients may require a hybrid of synchronous and asynchronous telerehabilitation in order to fulfil their needs. Most smartphones contain apps with hybrid features, such as WhatsApp, Facebook live, FB messenger, Instagram, WeChat, Google Meet, Zoom, and Skype [4]. These apps are popular in LMIC as they can be downloaded for free, easy to use, and can be accessed on multiple ICT devices such as smartphones, desktops, laptops, and tablets.

2.3.1.4 Mobile health

Mobile health (mHealth) is the most commonly accepted telemedicine method among patients with chronic diseases in LMIC [3], because of its affordability and easy access in rural and poor communities [2, 8, 9, 10, 11, 12, 13, 20, 21, 27]. Systematic reviews on mHealth interventions in rehabilitation [23, 24] showed positive outcomes in the following domains:

• Exercise training

• Gait training

• Self-management systems

• Measurement tools

TR clients can receive reminders via SMS, access information and services; monitor biochemical markers, physiological readings, and behaviors from their mobile phones [23, 24]. The most commonly used mobile phone Apps in LMIC are Facebook, WhatsApp, Viber, Skype, Zoom, and GoogleMeet [4, 22, 23, 24, 25], mainly due to its free and user-friendly features.

Some examples of free mHealth Apps in South East Asia are MySejahtera, MorChana, Vietnam Health Declaration, PeduliLindungi, and StaySafe PH26. These apps are used to monitor public health, disseminate information and provide health education to the public. Mobile Apps such as Doc2us and Halodoc from Malaysia and Indonesia respectively, provide teleconsultation, teleprescription, and medication delivery to its user at an affordable fee. Such telemedicine services are not only timely during the COVID-19 pandemic but also help reduce the workload on government-funded health centers [26].

A critical factor that must be considered in LMIC is data affordability. In Malaysia, a prepaid mobile phone plan of 2.5 Gb data costs RM 26 (USD 6.22) per month, while a postpaid Plan with unlimited data costs RM68 (USD 16.28) per month [27]. The main difference between a Pre-paid and a postpaid mobile plan is the payment schedule. The former only provides mobile service based on the load of the purchase (pay-as-you-use), while the latter is billed at the end of the monthly subscription and is based on data consumption. Prepaid plans are more affordable for users in the lower economic group (B40) such as in Malaysia, a country where the minimum wage is RM 1200 per month or USD 9.57 per day. Similar observations have been reported in other LMIC [11, 12, 13, 25, 28, 37, 38, 39, 40, 41, 42, 43, 44].

2.3.1.5 Assistive technology

Assistive technology (AT) is any item, place of equipment, software program, or product system that may be used in rehabilitation to increase, maintain, or improve the functional capabilities of persons with disabilities (PWDs) [23, 24]. AT features may be built into smartphones such as switch and voice controls for PWDs with limited limb and verbal functions. Other accessibility features include magnifying or bolding fonts and texts for visually impaired people.

Some wearable devices have AT features that use wireless or Bluetooth technologies. PWDs with limited limb functions such as tetraplegics or amputees may use a wearable device such as the GlassOuse and Bite Switch (mouse) to connect and operate their mobile phones, computers, tablets, and smart television using Bluetooth technology [29] (Figure 2). TR providers in LMIC require training and funding for AT to be useful in their practice.

Figure 2.

GlassOuse is worn like a pair of glasses and connects to mobile phones, computers, tablets, and smart TVs via Bluetooth. The user moves her head from side to side to navigate the cursor on the screen and bites on the Bite Switch (in cyan) to click items on the computer similar to a computer mouse. (Photo by Intan Sabrina).

2.3.1.6 Robotic technologies

Although robotic technologies may be useful in rehabilitation, their affordability makes them neither feasible nor sustainable in low-resource settings. Evidence-based reviews comparing robotic technologies with standard care interventions did not show long-term significant differences in locomotor training for walking after spinal cord injury and stroke or upper limb function after stroke [30]. TR providers in LMIC may have to consider other affordable alternatives to robotic technologies.

2.3.2 Training

Delivering TR services requires specific competencies, which may not necessarily be taught to HCPs in their profession [11]. In addition, there is a big shortage of AHPs such as physiotherapists (PTs), occupational therapists (OTs), speech and language pathologists (SLPs) and audiologists in LMIC, especially in rural areas [11, 12]. There should be a TR coordinator for every TR activity in order for TR program(s) to succeed and be sustainable.

Guidelines on telepractice by AHPs are few [5, 11, 17, 30]. For example, only 10–20% of SLPs tend to use telepractice in India and only 3% of SLPs in Croatia had completed formal training related to telepractice in SLP services [11]. Organizations in LMIC should provide training and credentialing procedures for TR providers on a regular basis to suit the evolving needs of TR clients [31]. The IFNR Task Force (2021) cautioned that not everyone with a smartphone can deliver teleneurorehabilitation (TNR). They also noted that standardizing functional assessments through teleassessments may prove to be a challenge.

Training in TR can be divided into three main groups:

• HCPs

• Patients/caregivers

• IT support/technical assistant

HCPs must be trained to obtain informed consent from patients and caregivers and how to document TR activities [6]. Telemedicine service is voluntary and should allow clients to opt out at any point of the telemedicine service. Patients and caregivers in LMIC and rural areas usually require guidance, training, and on-site assistance before TR services can be delivered. The level of assistance should be determined beforehand, such as the need for interpreting language(s) or dialects, setting up ICT devices such as keeping their mobile phones charged [28] and ensuring clients have adequate mobile data and network coverage. TR clients in LMIC need to be briefed on the prerequisites of a conducive telemedicine environment [19, 28, 32]. Ideally, the latter should be a quiet room or corner, with minimal distractions from other family members and good network coverage. Any fees and costs involved in the TR service must be declared at the outset by the TR provider.

IT support and infrastructure are critical components of TR service(s), but may be limited in LMIC. Quick solutions such as on-the-job (OTJ) training among HCPs or appointing IT representatives in each unit or department may be useful to bridge gaps in IT support. HCPs who are not trained in ICT may have to switch roles from becoming TR providers to TR clients. ICT training and technology-transfer in TR may be conducted via teleeducation and telementoring.

2.3.3 Policies and guidelines

Since the COVID-19 pandemic, many countries around the world have updated their policies on telemedicine. Telemedicine guidelines should not be physician-centric and must cater for the needs of AHP, patients, and their caregivers. These guidelines must cover points of service such as healthcare settings, homes, or community-based worksites [5].

A scoping review of telemedicine guidelines in South East Asia (SEA) revealed most countries had guidelines on clinical governance, confidentiality, ICT infrastructure, data security, record keeping, and licensing [6]. However, only Singapore and Indonesia have policies on telemedicine fee structure, insurance coverage, or reimbursement for medical practitioners. Policymakers and organizations should have clear billing and coding processes designated for TR so that payers can reimburse costs to TR providers [5], especially those offered by AHPs.

Most guidelines on telemedicine tend to regulate HCPs, rather than the technologies, platforms, or types of telemedicine services [1, 6, 33]. Telemedicine guidelines should have clear credentialing, privileging and regulatory requirements for licensure, certification, and use of telemedicine and its applications [5, 6, 11]. Mobile apps and internet of things (IoTs) are usually regulated by Medical Device Acts in the country they are registered (MDA) [34, 35, 36]. TR providers should adhere to their respective organizations and regulating bodies to ensure the safe and effective delivery of TR services to their clients [1, 5, 6, 15, 16, 17].

3. Setting up telerehabilitation services in low- and middle-income countries

TR providers must identify the service(s) which can be converted to TR exclusively or as a hybrid model. Clear inclusion and exclusion criteria for patient selection must be outlined in the TR Standard Operating Procedure (SOP) [5, 32, 33]. A feasibility study should be conducted to familiarise every stakeholder prior to the roll-out of the TR service [19]. Any hiccups should be addressed accordingly.

There are four main phases in telerehabilitation [32, 33]:

• Precontact (Pre-C)

• Actual contact (AC)

• Postcontact (Post-C)

• Data collection

Pre-C activities comprise calling the TR client and introducing the purpose of TR, obtaining verbal and/or written consent, clarifying contact details of the TR client and determining the medical or rehabilitation requirements. Details on the date, time, platform of AC and fee should also be conveyed clearly to the TR clients during the Pre-C phase. Technical assistance (TA) such as ICT literacy, translation, or physical assistance should also be pre-determined in the Pre-C phase. TA may comprise any family member, neighbor or the local HCPs closest to the TR client’s home.

Pre-C activities may be simplified by using questionnaires or assessment tools, which may be sent via email, text message and/or Google Doc formats. For example, in a tele home visit, TR clients can send measurements, pictures and videos of their home environment to their Occupational Therapist (OT) via email or WhatsApp messages or videos. The OT can then make the necessary recommendations for home modifications, prescribe rehabilitation equipment and arrange for a F2F assessment if required. Another example is when TR clients send audio recordings of their vocal exercises to their Speech Therapist or Audiologist prior to AC sessions.

A standard script, template, and checklist [32] would be useful to standardize communication between both parties. All communications and interventions involving TR clients should be documented clearly in the client's medical records [5, 6, 19, 25, 32, 33].

AC activities may range from teleconsultation to teleassessment, teletherapy, telemonitoring and teleeducation. Details such as patient identification, diagnoses, medications, investigation results, progress report, rehabilitation equipment, funding options and treatment needs should be addressed in the AC phase and documented in the clients’ medical records. TR providers should determine the outcome measures, assessment tools and equipment involved in the AC activities. Several trials of Pre-C and AC activities should be conducted prior to the roll-out of TR services to address pitfalls and additional TR requirements.

Post-C activities may include documenting and storing data collected in the Pre-C and AC phases, referrals to other parties, teleprescriptions of medications, information and/or home-based programs to TR clients, issuing medical certificates, and other activities similar to F2F consultations. All TR activities must be documented clearly and securely stored to ensure patient confidentiality, data security, and storage.

Finally, TR providers must be trained in data collection on TR activities and compare them with those in the standard-care pathway(s). The TR coordinator should review all TR services periodically and provide feedback to all stakeholders for quality assurance (QA) and improvements [32].

4. Challenges to deliver telerehabilitation in low- and middle-income countries

Challenges to deliver telerehabilitation in LMIC [11, 12, 37, 38, 39, 40, 41, 42, 43, 44] can be categorized into human, organizational, and technical factors (Figure 3). These factors usually overlap with one another, such as guidelines and laws on telemedicine (human and organizational); lack of digital knowledge and skills (human and technical); and lack of technical support and training (organizational, and technical). Table 1 is a summary comparing challenges to delivering TR in five LMIC. The recurring themes in LMIC are lack of ICT training and infrastructure, lack of political will, and time-constraint. TR providers should review these challenges regularly and provide solutions so that TR services can be improved and be sustainable. A scoping review on telemedicine guidelines in South East Asia by Sabrina and Defi suggested that there should be a comprehensive and universal telemedicine guideline for any country to adopt based on the local context [6].

Figure 3.

Challenges in telerehabilitation in low- and middle-income countries (Source: Adapted from Leochico et al. 2020. Telerehabilitation Challenges in Developing Country; Table 2, page 10 [12]; and IFNR Research Task Force et al. 2021. TeleNeurorehabilitation During COVID-19 in LMICs, 2021; Table 2, page 4 [11]).

Challenges	Malaysia5,18; (UMIC)	Indonesia19,20,40–43; (LMIC)	Philippines13; (LMIC)	India10; (LMIC)	Africa23,36–39; (LIC)
Human/personal factors; Lack of knowledge/awareness in TR Lack in ICT skills/literacy Poor participation Poor adherence Resistance to change Lack of satisfaction Lack of trust/effectiveness/quality Paper/physical culture Concerns on ICT/ethics/medicolegal Lack of TR leadership	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes	Yes; Yes; Yes; Yes; Yes; Yes; -; Yes; -; -	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes
Organizational/administrative factors; Lack of guidelines/ law Lack of governance Lack of financing/reimbursement Lack of technical support/training/literacy Lack of ICT resources Time constraints/busy schedule Lack of partnerships among stakeholders Unclear roles; Accountability Liabilities Environmental constraints/limited space	No; Yes; Yes; Yes; Yes; Yes; Yes; -; Yes; -; Yes	No; Yes; Yes; Yes; Yes; Yes; Yes; -; Yes; Yes; Yes	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes; Yes	Yes; -; Yes; Yes; Yes; Yes; Yes; -; -; -; -	Yes; Yes; Yes; Yes; Yes; Yes; Yes; -; Yes; Yes; Yes
Technical factors: ICT-related Slow internet speed Limited ICT coverage in rural areas ICT failure/ limitations Dependence on electricity/battery-life/internet Hardware/software limitations Unclear video display Inadequate infrastructure Licenced property of mobile Apps/ TR software High cost Limited AI Service delivery Lack of correlation with F2F assessment Difficulty in physical examination and treatment Lack of capacity for empathy Time-consuming Data security	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Not all; Yes; Yes; Yes; Yes; Yes; Yes; -	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Not all; Yes; Yes; Yes; Yes; Yes; Yes; Yes	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Not all; Yes; Yes; Yes; Yes; Yes; Yes; -	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Not all; Yes; Yes; Yes; Yes; Yes; Yes; -	Yes; Yes; Yes; Yes; Yes; Yes; Yes; Not all; Yes; Yes; Yes; Yes; Yes; Yes; Yes

Table 1.

Challenges to deliver telerehabilitation in low-and middle-income countries.

AI – artificial intelligence; Apps – applications; F2F – face-to-face; ICT – information and communication technologies; LIC – low-income country; LMIC – lower middle-income country; TR – telerehabilitation; UMIC – upper middle-income country.

NB: This summary is based on a scoping review on Telemedicine Guidelines in South East Asia by the authors and published in Front. Neurol. 11:581649. doi: 10.3389/fneur.2020.581649

Challenges	Solutions
Human/personal factors; Lack of knowledge/skills in ICT and TR.; Lack of partnerships among stakeholders.; Negative attitude towards TR.; Paper/physical culture.; Concerns on ICT/ethics/medicolegal; Lack of TR champion/leadership	Train HCPs in general and specific TR services. Simplify user experience. Normalize the use of technology Use familiar technology (WhatsApp video, telephone). Use teleeducation and telementoring. Start a small group of TR providers, then expand gradually. Build rapport/therapeutic relationships with TR clients. Engage with stakeholders and perform feasibility studies on TR. Conduct cost-benefit analysis of TR and compare with existing service. Try hybrid TR service(s) into existing system. Devise a visual and written framework for remote musculoskeletal assessments to modify traditional tests. Provide continuous feedback and motivation to TR clients to increase participation and discipline. Have clear inclusion and exclusion criteria for TR. Create local policies, guidelines, and laws on specific TR services. Enforce clinical governance. Provide an online helpdesk. Appoint internal medicolegal advisors. Appoint champions of TR for each TR service. Have regular feedback sessions and rotations in TR leadership.
Organizational/administrative factors; Lack of policies/guidelines/law; Lack of governance; Lack of financing/reimbursement; Lack of ICT resources/technical support/training/literacy; Time constraints/busy schedule; Unclear roles; Accountability Liabilities Environmental constraints/limited space	Create local policies, guidelines, and laws on specific TR services. Enforce clinical governance. Lobby for TR funding with relevant authorities/governing bodies. On-the-job ICT training for HCPs in TR services. Have practice runs prior to starting TR service with TR providers and users. Appoint champions of TR as ICT support staff. Try hybrid TR service(s) into existing system.; Policies on TR should outline clear roles and responsibilities of TR providers with each organization/TR service.; Reorganize or share working space. Review space utility and efficiency with other stakeholders/departments.
Technical factors: ICT-related; Slow internet speed; Limited ICT coverage in rural areas; ICT failure/limitations; Dependence on electricity/ battery-life/internet Hardware/ software limitations Unclear video display Inadequate infrastructure Licenced property; Mobile Apps TR Software High cost/limited AI; Service delivery Lack of correlation with F2F assessment Difficulty in physical examination and treatment Lack of capacity for empathy Time-consuming Data security	Policymakers and government need to invest in ICT infrastructure. Organizations should allocate resources and IT support for TR providers and clients. ICT equipment must be maintained to ensure safety and effectiveness. Ensure only licenced Apps are used to avoid medicolegal implications. Use free mobile apps familiar to TR clients. Try hybrid TR service(s) into existing system. Devise a visual and written framework for remote musculoskeletal assessments to modify traditional tests. Provide online measurement tools and sensors to measure force, position, and sound for assessments. Maintain eye-contact and provide continuous feedback and motivation to TR clients to build rapport. Schedule TR service(s) into existing system.; Ensure data privacy, storage, retrieval, and sharing follow federal and state laws and guidelines. Ensure compliance with professional organization or society. Use authentication and/or encryption technology. Limit data access to privileged personnel.

Table 2.

Recommendations to overcome barriers and challenges to telerehabilitation in low- and middle-income countries.

5. Recommendations and future threats

Telerehabilitation will continue to be an integral component of health services in LMIC across the world. Digital health is the new norm. It is projected that mHealth will be a key player in complementing and adding value to healthcare services globally, particularly in LMIC [4, 10, 11, 25, 41]. Current trends in digital technologies indicate that mHealth is the go-to option in LMIC. Advances in AI, algorithms, and mobile apps may replace human-to-human interactions. Thus, HCPs should be equipped with the necessary skills to embrace the changing trends in healthcare delivery, especially those which do not require physical presence or touch.

In conclusion, TR in LMIC is challenging. However, affordable and quick solutions such as free mobile apps may overcome barriers in TR.