Project ECHO®: a global cross-sectional examination of implementation success.

BACKGROUND: Organizations implement innovations to disrupt the status quo and create value. Within sectors such as healthcare, innovations need to navigate large scale system and organizational factors to succeed. This research explores the implementation of a global innovation- Project ECHO®. Project ECHO® is a validated virtual communities of practice model organizational teams implement to build workforce capacity and capability. Project ECHO® has experienced broad global adoption, particularly within the healthcare sector, and is experiencing growth across other sectors. This study sought to examine the state of implementation success for Project ECHO® globally, to understand how these implementations compare across geographic and sectoral contexts, and understand what enablers/barriers exist for organizational teams implementing the innovation. METHODS: An empirical study was conducted to collect data on 54 Project ECHO® implementation success indicators across an international sample. An online survey questionnaire was developed and distributed to all Project ECHO® hub organizations globally to collect data. Data was analyzed using descriptive statistics. RESULTS: The 54 implementation success indicators measured in this survey revealed that the adoption of Project ECHO® across 13 organizations varied on a case-by-case basis, with a strong rate of adoption within the healthcare sector. Implementation teams from these organizations successfully implemented Project ECHO® within 12-18 months after completing Immersion partner launch training and operated 51 ECHO® Networks at the time of data collection. Implementation teams which liaised more regularly with ECHO® Superhub mentors often went on to launch a higher number of ECHO® Networks that were sustained over the longer term. This suggests that these implementation teams better aligned and consolidated their Project ECHO® pilots as new innovations within the local context and strategic organizational priorities. Access to research and evaluation capability, and a more automated digital client relationship management system were key limitations to showcasing implementation success outcomes experienced by the majority of implementation teams. CONCLUSIONS: These findings make a valuable contribution to address a knowledge gap regarding how a global sample of organizations adopting Project ECHO® measured and reported their implementation successes. Key successes included pre-launch experimentation and expansion, Superhub mentorship, stakeholder engagement, and alignment to strategic priorities.

Cost analysis of home telerehabilitation for speech treatment in people with Parkinson's disease.

INTRODUCTION: Geographical barriers and impaired physical mobility among people with Parkinson's disease (PD) hinder their timely access to speech pathology services. We compared the costs of delivering a speech treatment via in-person consultation versus telerehabilitation. METHODS: We used data from a non-inferiority randomised controlled trial delivering the Lee Silverman Voice Treatment (LSVT LOUD®), where patients with dysarthria associated with PD were assigned to either the urban in-person group (N = 16) or the urban online group (N = 15), supplemented with a non-randomised group (regional online; N = 21). We compared costs over a one-month treatment period from a health-system perspective and a patient perspective. RESULTS: The mean treatment costs of both urban online ($1076) and regional ($1206) treatments tended to be slightly higher than urban in-person ($1020) from a health-system perspective. From a patient perspective, the mean treatment cost was $831 in the urban in-person group, $247 in the urban online group and $200 in the regional group. DISCUSSION: LSVT LOUD® may be delivered via telerehabilitation at a slightly higher cost than in-person delivery from a health-system perspective, but it is cost saving from a patient perspective. Telerehabilitation is an economically beneficial alternative for the delivery of the LSVT LOUD® programme in PD patients with speech disorders.

Cost-effectiveness of telerehabilitation versus traditional care after total hip replacement: A trial-based economic evaluation.

INTRODUCTION: Physical rehabilitation for total hip replacement patients following hospital discharge is beneficial; however, accessing rehabilitation is often challenging. Telerehabilitation helps negate access issues and is efficacious in total knee and hip replacement patients. This study aims to compare the cost-effectiveness of a telerehabilitation programme delivered remotely into patients' homes versus traditional care for total hip replacement patients following hospital discharge. METHODS: A cost-effectiveness (cost-utility) analysis was conducted from the perspective of a health service alongside a two-arm randomised controlled trial comparing telerehabilitation (n=35) with in-person care (n=35) following hospital discharge after total hip replacement. The primary analysis used an Incremental Cost-Effectiveness Ratio to compare the cost per Quality Adjusted Life Year (QALY) accrued in the telerehabilitation group versus in-person control using costs and effects data from the randomised trial. A secondary analysis was conducted whereby the time accrued by patients attending rehabilitation sessions (including travel time) was considered the "cost" (i.e. a time burden), rather than cost from the health service perspective. RESULTS: Estimated mean differences in healthcare costs and QALYs gained were detected but were not significant. The estimated mean (95%CI) difference in cost of telerehabilitation versus in-person was -$28.90 (-$96.37 to $40.45), favouring the telerehabilitation group. The estimated mean (95%CI) difference in QALYs gained from telerehabilitation versus in-person was -0.0025 (-0.0227 to 0.0217). The estimated mean (95%CI) difference in time burden favoured less time burden for the telerehabilitation group (-4.21 (-4.69 to -3.74) hours). DISCUSSION: Telerehabilitation in the total hip replacement population incurred similar costs and yielded similar effects to traditional in-person care. Telerehabilitation significantly reduced the time burden for patients and carers. These findings are valuable for healthcare providers seeking to implement accessible patient-centred rehabilitation services.

Cost-Utility Analysis of Home-Based Telerehabilitation Compared With Centre-Based Rehabilitation in Patients With Heart Failure.

BACKGROUND: Whilst home-based telerehabilitation has been shown non-inferior to traditional centre-based rehabilitation in patients with chronic heart failure, its economic sustainability remains unknown. This study aimed to investigate the cost-utility of a home-based telerehabilitation program. METHODS: A comparative, trial-based, incremental cost-utility analysis was conducted from a health care provider's perspective. We collected data as part of a multi-centre, two-arm, non-inferiority, randomised controlled trial with 6 months follow-up. There were 53 participants randomised to either a telerehabilitation program (consisting of 12 weeks of group-based exercise and education delivered into the home via online videoconferencing) or a traditional centre-based program. Health care costs (including personnel, equipment and hospital readmissions due to heart failure) were extracted from health system records, and calculated in Australian dollars using 2013 as the base year. Health utilities were measured using the EuroQol five-dimensional (EQ-5D) questionnaire. Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and utility differences were plotted on a cost-effectiveness plane. RESULTS: Total health care costs per participant were significantly lower in the telerehabilitation group (-$1,590, 95% CI: -2,822, -359) during the 6 months. No significant differences in quality-adjusted life years (0, 95% CI: -0.06, 0.05) were seen between the two groups. CONCLUSIONS: Heart failure telerehabilitation appears to be less costly and as effective for the health care provider as traditional centre-based rehabilitation.

Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic.

OBJECTIVE: To determine the level of agreement between a telehealth and in-person assessment of a representative sample of patients with chronic musculoskeletal conditions referred to an advanced-practice physiotherapy screening clinic. DESIGN: Repeated-measures study design. PARTICIPANTS: 42 patients referred to the Neurosurgical & Orthopaedic Physiotherapy Screening Clinic (Queensland, Australia) for assessment of their chronic lumbar spine, knee or shoulder condition. INTERVENTION: Participants underwent two consecutive assessments by different physiotherapists within a single clinic session. In-person assessments were conducted as per standard clinical practice. Telehealth assessments took place remotely via videoconferencing. Six Musculoskeletal Physiotherapists were paired together to perform both assessment types. MAIN OUTCOME MEASURES: Clinical management decisions including (i) recommended management pathways, (ii) referral to allied health professions, (iii) clinical diagnostics, and (iv) requirement for further investigations were compared using reliability and agreement statistics. RESULTS: There was substantial agreement (83.3%; 35/42 cases) between in-person and telehealth assessments for recommended management pathways. Moderate to near perfect agreement (AC1 = 0.58-0.9) was reached for referral to individual allied health professionals. Diagnostic agreement was 83.3% between the two delivery mediums, whilst there was substantial agreement (81%; AC1 = 0.74) when requesting further investigations. Overall, participants were satisfied with the telehealth assessment. CONCLUSION: There is a high level of agreement between telehealth and in-person assessments with respect to clinical management decisions and diagnosis of patients with chronic musculoskeletal conditions managed in an advanced-practice physiotherapy screening clinic. Telehealth can be considered as a viable and effective medium to assess those patients who are unable to attend these services in person.

Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series).

Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.

The feasibility and concurrent validity of performing the Movement Assessment Battery for Children - 2nd Edition via telerehabilitation technology.

BACKGROUND: In rural and remote communities children with motor difficulties have less access to rehabilitation services. Telerehabilitation technology is a potential method to overcome barriers restricting access to healthcare in these areas. Assessment is necessary to guide clinical reasoning; however it is unclear which paediatric assessments can be administered remotely. The Movement Assessment Battery for Children - 2nd Edition is commonly used by various health professionals to assess motor performance of children. AIMS: The aim of this study was to investigate the feasibility and concurrent validity of performing the Movement Assessment Battery for Children - 2nd Edition remotely via telerehabilitation technology compared to the conventional in-person method. METHODS AND PROCEDURES: Fifty-nine children enrolled in a state school (5-11 years old) volunteered to perform one in-person and one telerehabilitation mediated assessment. The order of the method of delivery and the therapist performing the assessment were randomized. After both assessments were complete, a participant satisfaction questionnaire was completed by each child. OUTCOMES AND RESULTS: The Bland-Altman limits of agreement for the total test standard score were -3.15 to 3.22 which is smaller than a pre-determined clinically acceptable margin based on the smallest detectable change. CONCLUSIONS AND IMPLICATIONS: This study establishes the feasibility and concurrent validity of the administration of the Movement Assessment Battery for Children - 2nd Edition via telerehabilitation technology. Overall, participants perceived their experience with telerehabilitation positively.

Patients are willing to use telehealth for the multidisciplinary management of chronic musculoskeletal conditions: A cross-sectional survey.

Introduction Access to specialised multidisciplinary healthcare services is difficult for many patients with chronic musculoskeletal conditions. A possible solution could be delivery of care via telehealth. This study aims to identify current barriers in accessing healthcare services, and to determine if telehealth is an acceptable mode of healthcare delivery, from the perspective of patients with chronic musculoskeletal conditions. Methods Surveys were distributed to current patients receiving care within the Neurosurgical and Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service (N/OPSC & MDS) at six facilities throughout Queensland, Australia. The 48-item survey evaluated five key areas including demographics; current barriers to attendance; satisfaction with current management provided by the N/OPSC & MDS; technology access and literacy; and attitudes and preference towards telehealth. Results In total, 85 patients (71%) completed the survey. The majority of patients were satisfied overall with the N/OPSC & MDS, but almost one-quarter of the patients reported ceasing treatment due to difficulty accessing services. Over half of the respondents were willing to use telehealth if it reduced the costs (53%) and time (57%) associated with attending appointments. Patients in paid employment were more likely (65%) to use telehealth if it reduced work absenteeism. Overall, 78% of patients were identified as having appropriate technology access to enable home telehealth. Specifically, 43% of patients would prefer home telehealth over having to travel to attend their appointments. Discussion The majority of N/OPSC & MDS patients are willing to engage in telehealth for the management of their chronic musculoskeletal condition. These findings justify consideration of telehealth as an additional method of service delivery within the existing N/OPSC & MD service.

Method-comparison studies in telehealth: Study design and analysis considerations.

When establishing telehealth services, clinicians need to be confident that the examinations, assessments and clinical decisions that they make while using technology are equivalent to conventional best practice. Method-comparison studies are ideally suited to answering these questions, however there is a lack of consistency in the telehealth literature in the study methodologies and data analysis techniques used. Methodologies should closely match clinical practice to maximise external validity and data analysis techniques should match the data types generated in order to be clinically meaningful. In this article we discuss the design, analysis and interpretation of method-comparison studies in the context of telehealth research.

Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation.

Introduction Lower limb musculoskeletal disorders place a heavy burden on healthcare systems. Appropriate management of these conditions is critical, however access to appropriate physiotherapy services is difficult for those in geographically remote areas or those with mobility or transport difficulties. The aim of this study was to evaluate the accuracy and reliability of an online musculoskeletal physiotherapy assessment of the knee complex using telerehabilitation compared to traditional face-to-face assessment. Methods In a repeated-measures design, 18 subjects who sought treatment for knee pain underwent a traditional face-to-face assessment and a remote telerehabilitation assessment. Telerehabilitation assessments were conducted with participants performing facilitated self-palpation, self-applied modified orthopaedic tests, active movements and functional tasks. Results Primary pathoanatomical diagnoses were in exact agreement in 67% of cases and were similar in 89% of cases. The system of pathology was found to be in agreement in 17 out of 18 cases (94%). Comparisons of objective findings from the two physical assessments demonstrated substantial agreement (kappa = 0.635) for categorical data and binary data (chi-squared = 400.36; p < 0.001). A high level of intra-rater (89%) and moderate level of inter-rater (67%) reliability was evident for telerehabilitation assessments. Discussion Telerehabilitation assessment of the knee complex appears to be feasible and reliable. This study has implications for clinical practice and the development of physiotherapy services to address the burden of lower limb musculoskeletal pain and disability.

The effect of knee flexion contracture following total knee arthroplasty on the energy cost of walking.

This study evaluated the energy cost of walking (Cw) with knee flexion contractures (FC) simulated with a knee brace, in total knee arthroplasty (TKA) recipients (n=16) and normal controls (n=15), and compared it to baseline (no brace). There was no significant difference in Cw between the groups at baseline but TKA recipients walked slower (P=0.048) and with greater knee flexion in this condition (P=0.003). Simulated FC significantly increased Cw in both groups (TKA P=0.020, control P=0.002) and this occurred when FC exceeded 20° in the TKA group and 15° in the controls. Reported perceived exertion was only significantly increased by FC in the control group (control P<0.001, TKA P=0.058). Simulated knee FCs less than 20° do not increase Cw or perceived exertion in TKA recipients.

The validity of physical therapy assessment of low back pain via telerehabilitation in a clinical setting.

BACKGROUND: Back pain is a common and disabling condition for people in rural and remote areas. In these areas, access to rehabilitation services is limited by service availability. Telerehabilitation is suggested as a solution for providing physical therapy services; however, the validity of clinical assessment is largely unproven. The aim of this study was to establish the validity of clinically pragmatic remote assessment of spinal posture, active movements of the lumbar spine, and the passive straight leg raise (SLR) test. SUBJECTS AND METHODS: Face-to-face physical therapist assessment was compared with telerehabilitation assessment of spinal posture, active movements of the lumbar spine, and the SLR test. Twenty-six participants recruited from a rural population with current or recent low back pain (LBP) were assessed by a face-to-face physical therapist and a remote physical therapist. Pain, disability, and clinical measurements were assessed. Outcomes were compared to establish agreement. RESULTS: High levels of agreement were found with detecting pain with specific lumbar movements, eliciting symptoms, and sensitizing the SLR test. Moderate agreement occurred with identifying the worst lumbar spine movement direction, SLR range of motion, and active lumbar spine range of motion. Poor agreement occurred with postural analysis and identifying reasons for limitations to lumbar movements. CONCLUSIONS: Conducted in a rural clinical setting, this study validates elements of the physical assessment of the lumbar spine and identifies technical and clinical issues to be addressed by future research. Important components of the standard musculoskeletal assessment of LBP are valid via telerehabilitation in a clinical setting.

Internet-based physical assessment of people with Parkinson disease is accurate and reliable: a pilot study.

Telerehabilitation may be an alternative service delivery model for people with Parkinson disease (PD) who live in areas where traditional rehabilitation services are not readily accessible. The aim of this study was to determine the accuracy and reliability of performing remote physical assessments of people with PD via telerehabilitation when compared with traditional face-to-face assessments. Twelve subjects were simultaneously examined by a face-to-face investigator and a remote investigator via the eHAB telerehabilitation system. The outcome measures evaluated included the timed stance test, Timed "Up and Go" test, step test, steps in 360 degree turn, Berg Balance Scale, and lateral and functional reach tests. Limits of agreements intervals and weighted kappa statistics demonstrated the telerehabilitation assessments to be accurate within clinically acceptable limits. A high level of inter- and intrarater reliability was demonstrated across all telerehabilitation assessments. This study indicates that it is possible to assess the physical ability of people with PD via telerehabilitation systems and provides support for the further development of telerehabilitation applications for patients with neurological disorders.

Evaluation of a Clinical Service Model for Dysphagia Assessment via Telerehabilitation.

Emerging research supports the feasibility and viability of conducting clinical swallow examinations (CSE) for patients with dysphagia via telerehabilitation. However, minimal data has been reported to date regarding the implementation of such services within the clinical setting or the user perceptions of this type of clinical service. A mixed methods study design was employed to examine the outcomes of a weekly dysphagia assessment clinic conducted via telerehabilitation and examine issues relating to service delivery and user perceptions. Data was collected across a total of 100 patient assessments. Information relating to primary patient outcomes, session statistics, patient perceptions, and clinician perceptions was examined. Results revealed that session durations averaged 45 minutes, there was minimal technical difficulty experienced, and clinical decisions made regarding primary patient outcomes were comparable between the online and face to face clinicians. Patient satisfaction was high and clinicians felt that they developed good rapport, found the system easy to use, and were satisfied with the service in over 90% of the assessments conducted. Key factors relating to screening patient suitability, having good general organization, and skilled staff were identified as facilitators for the service. This trial has highlighted important issues for consideration when planning or implementing a telerehabilitation service for dysphagia management.

Clinical assessment, design and performance testing of mobile shower commodes for adults with spinal cord injury: an exploratory review.

PURPOSE: The purpose of this article is to explore evidence concerning clinical assessment, design and performance testing of mobile shower commodes used by adults with spinal cord injury (SCI). METHOD: Searches of electronic databases, conference proceedings and key journals were undertaken with no restriction on language or study design. Keywords included spinal cord injury, lesion, sanichair, sanitary chair, shower chair, bowel chair and commode. RESULTS: A total of 20 publications were included in this review. Common approaches to clinical assessments were questionnaires and observational analysis to assess bowel care routines, function and skin integrity. Design features addressed access for bowel care, postural support, transfers, stability, use in wet environments and skin integrity. Objective performance measures addressed requirements for static stability, backward-sloping seat angles, arm supports and seat materials. CONCLUSIONS: Evidence reviewed was of low methodological quality and lacking in validated instruments to guide clinical practice. Further high-quality research is needed to identify bathing, showering and personal hygiene tasks affecting mobile shower commodes use and to develop validated clinical assessment tools. Performance testing to published standards is also needed.

Assessment and Diagnosis of Musculoskeletal Shoulder Disorders over the Internet.

Shoulder disorders are common, debilitating, and represent a considerable burden on society. As primary contact practitioners, physiotherapists play a large role in the management and rehabilitation of people with these conditions. For those living outside of urban areas, however, access to physiotherapy can be limited. The aim of this study was to evaluate the validity and reliability of using a telerehabilitation system to collect physical examination findings and correctly identify disorders of the shoulder. Twenty-two participants with 28 shoulder disorders were recruited and underwent a face-to-face physical examination and a remote telerehabilitation examination. Examination findings and diagnoses from the two modes of assessment were used to determine validity and reliability of the new method. Diagnostic agreement and agreement on individual findings between the two methods were found to be consistent with the reliability of conventional assessment methods. This study provides important preliminary findings on the validity and reliability of musculoskeletal examinations conducted via telerehabilitation.

Validity and reliability of the assessment and diagnosis of musculoskeletal elbow disorders using telerehabilitation.

We examined the validity and reliability of a physiotherapy examination of the elbow, using telerehabilitation. The patho-anatomical diagnoses, systems diagnosis and physical examination findings of face-to-face physiotherapy examinations were compared with telerehabilitation examinations. Ten participants attended a single session, during which they were interviewed, a face-to-face physical examination was performed and a remote physical examination was conducted, guided by an examiner at a different location via a telerehabilitation system. Conventional face-to-face physiotherapy physical examination test results, diagnoses and systems diagnoses were compared to those produced by an examiner using the telerehabiliation system. There was substantial agreement for systems diagnosis (73%; P = 0.013) for validity and almost perfect agreement for intra-rater reliability (90%; P = 0.001). The inter-rater reliability had a weaker and non-significant agreement (64%; P = 0.11). Physical examination data demonstrated >68% agreement across all three datasets, between the examination methods. Performing a telerehabilitation physical examination to determine a musculoskeletal diagnosis of the elbow joint complex is both valid and reliable.

Managing Patient Factors in the Assessment of Swallowing via Telerehabilitation.

Undoubtedly, the identification of patient suitability for a telerehabilitation assessment should be carried out on a case-by-case basis. However, at present there is minimal discussion of how telerehabilitation systems can accommodate and adapt to various patient factors, which may pose challenges to successful service delivery. The current study examines a subgroup of 10 patients who underwent an online assessment of their swallowing difficulties. Although all assessments were completed successfully; there were certain patient factors, which complicated the delivery of the online assessment session. The paper presents a discussion of the main patient factors observed in this cohort including the presence of speech and/or voice disorders, hearing impairment, dyskinesia, and behavioural and/or emotional issues and examines how the assessment session, the telerehabilitation system, and the staff involved were manipulated to accommodate these patient factors. In order for telerehabilitation systems to be more widely incorporated into routine clinical care, systems need to have the flexibility and design capabilities to adjust and accommodate for patients with varying levels of function and physical and psychological comorbidities.

Training the allied health assistant for the telerehabilitation assessment of dysphagia.

We examined the effect of knowledge and task specific training provided to an allied health assistant (AHA), prior to her involvement in facilitating assessments of dysphagia (swallowing disorders) via telerehabilitation. The AHA received four hours of training, which included basic theoretical information regarding dysphagia as well as hands-on training with simulated patients. A written test examining swallowing function and its evaluation was completed pre- and then immediately post-training, and then again after the 15th and 30th of 31 consecutive patient assessments. In addition, after each set of 5 clinical dysphagia assessments completed with patients following the training, two speech pathologists rated the AHA's competence in relation to performing the tasks and activities required of her during the telerehabilitation swallowing assessment. The AHA also self-rated the perceived level of confidence at these times. Before training, the assistant's knowledge of dysphagia theory was at 40%. Following training, all tests were above the 80% level. The AHA's performance was rated as competent on each evaluation post-training. The AHA also expressed overall satisfaction with the initial training provided and reported feeling confident after the initial sessions with patients. Thus for an AHA with previous clinical experience, competence and perceived comfort in providing assistance in the sessions was achieved with only a few hours of task specific training.

Telerehabilitation mediated physiotherapy assessment of ankle disorders.

BACKGROUND AND PURPOSE: Musculoskeletal injuries are the most common source of chronic pain and disability. The ankle joint is the most common of these injuries and without adequate rehabilitation function can be severely impaired. Access to physiotherapy rehabilitation services can be limited due to geographical remoteness and a shortage of services in rural and remote areas. Telerehabilitation is a potential solution to bridge this service delivery gap. The aim of this study was to determine the criterion validity and reliability of conducting a remote musculoskeletal assessment of the ankle joint complex using telerehabilitation technologies compared with a face-to-face assessment. METHODS: This study utilized a repeated measures design to assess 15 subjects (mean age 24.5, SD 10.8 years) presenting with ankle pain. Conventional face-to-face assessments were compared with assessments performed via a telerehabilitation system. RESULTS: A similar agreement of 93.3% in patho-anatomical diagnosis and an 80% exact agreement (chi(2) = 4.267; p < 0.04) in primary systems diagnosis was found between face-to-face and telerehabilitation assessments. Clinical observations were found to have very strong agreement (k = 0.92) for categorical data and significant agreement (93.3% agreement; chi(2) = 234.4; p < 0.001) for binary data. A high level of inter- and intrarater reliability was found for the telerehabilitation assessments. CONCLUSIONS: This study demonstrates the criterion validity and reliability of remote musculoskeletal assessments of the ankle joint complex using telerehabilitation.