Telehealth Physical Therapy and Hybrid Care: A PT Guide

Telehealth physical therapy works for many musculoskeletal problems, as long as you pick the patient and the visit with care. A systematic review by Cottrell and colleagues found that live video treatment improved function and pain about as much as in-person care. The 2024 American Physical Therapy Association (APTA) telerehabilitation guideline supports telehealth for examination as well as treatment, either fully remote or as hybrid care. It will not replace the clinic for every patient, or for every visit. Each video session still needs consent, privacy, a red flag screen and an emergency plan, and the home exercise program (HEP) carries the work between sessions.

This guide is for physical therapists and physios, and for clinic owners, working in the USA, the UK, Europe, Canada, Australia or New Zealand. Registration and privacy rules differ by country, and often by state or province as well. Check the rules where you are and where your patient is.

What counts as telehealth physical therapy and hybrid care?

The APTA guideline uses the term telerehabilitation for physical therapists who use telehealth technology to examine and diagnose patients and to treat them. In most clinics that means live video visits, and sometimes phone calls. Hybrid care mixes the two: some visits in the clinic, some on video, with one home program running through both.

The Chartered Society of Physiotherapy (CSP) sees hybrid care as a choice made visit by visit rather than a fixed model. Its guidance suggests agreeing the format of the next session with the patient, based on what that session is for and what it needs. Compare a first assessment of a knee that swelled after a twisting injury with a two-week check on a program the patient already knows. They are very different visits.

Does telehealth physical therapy work? What the evidence says

Video treatment compared with in-person care

Cottrell and colleagues pooled 13 studies with 1,520 participants who had musculoskeletal conditions treated through real-time telerehabilitation. When video care replaced face-to-face care, the gain in physical function was equivalent. When it was added to usual care, results beat usual care alone.

Pain improvement was comparable between video and in-person care. Some pooled results, pain among them, varied widely between studies. The search also stopped at November 2015, so newer trials are missing.

Suso-Martí and colleagues went a level higher and pooled existing reviews across physical therapist practice. They found no statistically significant difference in physical function between telerehabilitation and usual rehabilitation for people with cardiorespiratory and musculoskeletal conditions.

Two trials worth knowing

Moffet and colleagues randomized 205 patients leaving hospital after total knee replacement to one of two options for 2 months: in-home telerehabilitation by live video, or face-to-face home visits. At 4 months after discharge, the difference between groups in their gains on the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) was close to zero. The authors concluded that telerehabilitation was not inferior. Whatever the format, rehab after joint replacement still follows the surgeon's protocol.

Bennell and colleagues gave 148 people aged 50 or over with chronic knee pain 7 video sessions with a physiotherapist across 3 months, to prescribe and progress home exercise, plus online training in pain-coping skills. Compared with online education alone, pain on walking and physical function improved more at 3 months, and a smaller difference was still there at 9 months.

Note the comparison group. They got education, not in-person physiotherapy. So the trial shows that video-guided exercise with pain-coping training helps. It does not show that it matches the clinic.

What the APTA guideline recommends

The APTA clinical practice guideline, written by Lee and colleagues, came out in 2024 with 7 recommendations. On moderate evidence, it says physical therapists should recommend telerehabilitation or hybrid care. For certain conditions it found them at least as acceptable to patients as in-person care, with better adherence and attendance. It also recommends telerehabilitation to achieve outcomes similar to in-person care for certain conditions, and total knee and hip replacement are on that list.

The safety data are reassuring, within limits. Across the studies the guideline reviewed, 19 of 3,256 patients (0.58%) had an adverse event. These were things like fatigue or pain after a session, caused by the treatment itself, and none was linked to the video format. But those were closely supervised trials, in people with stroke, heart failure, lung disease or a joint replacement, so rates in everyday practice may differ. The guideline still makes it a strong recommendation that physical therapists anticipate and prevent adverse events specific to telehealth, and manage and document any that occur.

Hybrid care: similar results with fewer clinic visits in one trial

Kloek and colleagues ran a cluster-randomized trial of a blended program for hip and knee osteoarthritis, with 208 patients from 143 primary care physical therapist practices. The 3-month e-Exercise program combined about 5 face-to-face sessions with an online app that offered graded activity and exercises, plus information. The usual care group averaged 12 sessions. Physical functioning and physical activity did not differ between the groups at 3 or 12 months.

Read that result carefully. The trial was built to show the blended program was better, and it was not, which is not the same as proving the two are equal. Sedentary time rose more in the blended group by 12 months, and only 65% of participants responded at that point. Still, both groups ended up in a similar place, and the blended group had fewer than half the clinic visits.

Where the evidence is thin

The APTA recommendation on similar outcomes names specific conditions. On the musculoskeletal side, those are knee and hip replacement. For a shoulder, an ankle or a tendon problem, you are extending the findings rather than applying them directly. Trial participants had also agreed to take part in a video study, so they may not represent the patient who is wary of technology.

Can you assess a patient over video?

Partly. Mani and colleagues reviewed internet-based physiotherapy assessment for musculoskeletal disorders. Pain, swelling, range of motion and muscle strength showed good agreement with in-person assessment (concurrent validity). Balance and gait did too, as did functional assessment, and reliability was excellent. The exceptions were lumbar spine posture and scar assessment, along with orthopedic special tests and neurodynamic tests.

A later review by Bernhardsson and colleagues looked at 10 studies with 193 participants aged 23 to 62. Validity ran from moderate to excellent for most parts of the assessment, but was variable for spinal posture. Reliability was excellent for clinical tests, range of motion, pain, patient-reported outcome measures (PROMs) and neck posture. The certainty of the evidence ranged from very low to high, and was highest for PROMs and pain assessment.

The APTA guideline is more cautious. It gives only a weak recommendation, on low-quality evidence, that findings from a video examination can inform the diagnosis with accuracy comparable to an in-person visit for certain conditions. Most of the studies behind it were small and run in laboratory or clinic settings, not in patients' homes. Clinicians in the studies it reviewed consistently said they could not complete a full assessment, and some felt they could not observe the patient fully.

In practice, video does well with the history and questionnaires, and with watching the patient move and do functional tasks. It falls down on anything that needs your hands, and on neurodynamic tests. If the diagnosis hangs on those, book the patient in.

Patient-reported measures carry over to a call almost unchanged. The Patient-Specific Functional Scale is one: the patient names the activities and rates each from 0 to 10. The outcome measures guide lists others worth repeating at review.

Who suits telehealth, and who needs to be seen in person?

Regulators treat this as a judgment for each patient and each visit. The Australian Health Practitioner Regulation Agency (Ahpra), whose guidance covers physiotherapists, says telehealth can be used when the practitioner has the skills for it, when it is safe and clinically appropriate for the service, and when it suits the patient. It also says telehealth is not appropriate for every consultation, because the lack of in-person contact can limit safe and effective care. In New Zealand, the Physiotherapy Board's digital health standard says physiotherapists must consider whether an in-person consultation is more appropriate when planning telehealth. If the limits of the technology make care unsafe, they must find another way to see the patient.

The CSP adds a point about fairness. No one should be automatically excluded from digital services because of their condition, age, literacy or background. So don't ask whether a patient is too old for video. Ask whether this patient, with the right support, can get what this visit needs on a screen.

In the studies behind the APTA guideline, patients valued better access and flexible scheduling, and not having to travel, especially in rural areas or when their condition made travel hard. The main human barrier they reported was missing human contact. Technology problems, including limited digital skills, came up in every study. Ask about these at the start rather than guessing.

Often a good fit for video

These are common practice patterns, not tested rules:

Follow-up visits for a diagnosed musculoskeletal problem where the plan is mostly exercise and education, progressed over time.
HEP reviews: checking technique, adjusting the dose and adding the next step.
Patients who find the trip to the clinic difficult because of distance, work hours, caring duties or pain.
Patients who are comfortable on video calls and have a private room with space to move.

Book an in-person visit when

This list follows from the assessment evidence and the regulators' guidance above. It is clinical reasoning, not a tested rule:

The diagnosis depends on hands-on tests, neurodynamic tests or palpation.
New or changing numbness, tingling or weakness needs a hands-on neurological examination, including reflexes.
A new injury needs a hands-on examination before you can rule out a fracture or a serious tissue injury.
You plan balance work without support for a patient at risk of falling, and nobody can be with them.
The patient has no private, safe space, or the technology keeps failing.
The patient would rather be seen in person, or is not improving as expected on video.

The College of Physiotherapists of Ontario says that if similar care cannot be delivered virtually, physiotherapists may arrange or recommend in-person services, and document why. Some warning signs call for a doctor or emergency care rather than any physio visit, on video or in person. They are listed under the emergency plan below.

Two groups need extra care. After surgery, work within the surgeon's protocol, on video or in the clinic. For patients under 18, the APTA guideline says a parent or guardian needs to be present for a video examination.

How to run a safe telehealth session

Before the first video visit

Use a video platform your organization has approved for health care. The APTA guideline calls for systems with adequate security that meet the required standards, and gives HIPAA in the USA and GDPR in Europe as examples.
Check that you may treat the patient where they are. The Ontario college notes that physiotherapists treating patients outside the province may need to be registered where the patient is located. The APTA guideline warns that clinicians must know the practice rules for the patient's location. In the USA, the PT Compact is an agreement between member states: physical therapists and physical therapist assistants can buy a compact privilege to work in other member states, linked to their home state license. Before you see the patient, check that their state takes part and what it requires.
Confirm that your professional indemnity or liability insurance covers virtual care. Ahpra and the Ontario college both raise this.
Get informed consent for video care. The patient should understand what it involves and what the alternatives are, as well as its risks and benefits. The Ontario guidelines list these points, and Ahpra asks practitioners to explain what the patient can expect from a telehealth consultation.
Send a short set-up note: a quiet private room, the phone or laptop propped where it can show the whole body, space to lie down and to stand, a sturdy chair without wheels, and any equipment you plan to use. If your clinic has a cancellation and no-show policy, tell the patient whether it applies to video visits too.

At the start of every session

Confirm the patient's identity and introduce every practitioner on your side, as Ahpra asks. Then ask who else is in the room with the patient.
Confirm the patient's exact location and a reliable callback number in case the call drops, as the Ontario guidelines recommend.
Check that the patient can talk privately. Ahpra asks practitioners to make sure the patient joins from an environment that protects privacy and confidentiality.
Ask what has changed since the last visit, run through your usual red flag questions, and decide whether video is still right for today. Ahpra asks practitioners to assess, and keep reassessing, whether telehealth is safe and clinically appropriate.

Set up the room for movement

Ask the patient to move the device until you can see the whole movement. For squats, lunges or step-ups, look from the side as well as the front. Clear rugs and cables out of the way, and for standing exercises keep a sturdy chair or a kitchen counter within reach.

For balance work, give the patient the same footwear line you would use in the clinic: "Wear flat shoes that fit well and grip the floor, not socks, tights or bare feet." If the patient has fallen in the past year or feels unsteady, they keep a hand on the counter throughout, and balance work without support waits for a session when someone is with them, or for the clinic.

Have an emergency plan

The Ontario college says physiotherapists must have a plan in case a patient has an emergency during a virtual session. As best practice it lists checking the patient's location at the start of every session, a callback number, emergency contact details and clear steps for what you will do if the patient becomes unwell, injured or unresponsive. The CSP asks services to have safety risk assessments, escalation plans and urgent referral pathways for in-person assessment. Write your plan down before the first video visit.

A workable plan covers:

The address the patient is at for this session, confirmed at the start.
How to reach emergency services where the patient is. If you are in a different area, your own emergency call may reach a service far from them, so keep a local number for the patient's area or have someone with the patient make the call.
A person nearby who can help, if the patient agrees to name one.
What you will do if the call drops mid-exercise and you cannot reach the patient on the callback number.
How you will record and report an adverse event.

If a patient becomes unwell on camera, ask them to stop and sit or lie down, and stay on the call. If they need emergency help, the person with them makes the call if they can. If not, you call emergency services for the patient's area, give the address you confirmed and keep the video call open so you can pass on what you see.

If the patient falls during the session, ask them to stay where they are for a couple of minutes while you check for pain or injury, and to get up slowly, with something stable to hold, only if they feel able. If they may have hurt their head, back, neck or hip, cannot get up, or cannot put weight on a leg, call emergency services for their area in the same way. A fall that leaves any pain or injury still needs medical advice the same day, even once they are up.

Teach the warning signs at the first visit, in writing, so the patient can act on them between sessions. They are the same stop signs our exercise pages use. Each one means stop and get help:

Chest pain or pressure, dizziness or feeling faint, a racing or irregular heartbeat, or being far more out of breath than the effort should cause.
Your calf or thigh becomes swollen, warm, tender, red or darker than usual, or has a throbbing or cramping pain that feels different from normal muscle ache. Stop and get medical advice the same day, as this can be a blood clot. If you are also short of breath or have chest pain, call emergency services.
Pins and needles, numbness or weakness in an arm or leg that does not go away after you stop. Get medical advice the same day. If one side of your face or body suddenly goes numb or weak, or your speech becomes slurred or muddled, call emergency services, even if it goes away.
Numbness around your genitals or bottom, new trouble with your bladder or bowels, pain, tingling, numbness or weakness in both legs, or loss of feeling in one leg. Call emergency services or go to an emergency department straight away.
Your leg or foot gets weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.

If chest pain, pressure or tightness does not ease quickly when you rest, spreads to your arm, neck, jaw, stomach or back, or comes with sweating, feeling sick, feeling light-headed or being short of breath, call emergency services straight away, as this can be a heart attack. If it eases quickly and none of these happen, get medical advice the same day, and do not exercise again until you have been checked. If you faint while exercising, call emergency services, even if you feel fine again quickly.

Call emergency services straight away for any sign of a stroke, even if it goes away: sudden dizziness with unsteadiness or falling over, a face that droops on one side, an arm you cannot lift or keep up, slurred or muddled speech, weakness or numbness on one side of your body or face, sudden blurred vision, double vision or loss of sight, or a sudden severe headache.

Add the stop signs for the body area you treat, as you would on any written program. Our exercise pages list them for each exercise.

Record the visit properly

The Ontario guidelines say the record must state clearly that the session was delivered virtually, with a summary of the consent discussion. Ahpra asks for clear and accurate records, as for any consultation. Note anything the format limited, too, such as a test you could not do; the next clinician will want to know. The SOAP notes guide covers what else goes in the note.

Train the team

Video care is a skill of its own. Davies and colleagues ran an international Delphi study that produced a framework of 60 capabilities for physiotherapists working by video. Its 7 domains are compliance; privacy and confidentiality; patient safety; technology skills; telehealth delivery; assessment and diagnosis; and care planning and management. It makes a useful checklist when you train new staff. The APTA guideline also found that therapists with more telerehabilitation experience generally reported fewer barriers.

Where the home exercise program fits

On video you cannot guide a movement with your hands, so the home program has to do more. Send it before the first video visit, so the patient has it open during the call. Use the session to watch each exercise and correct it, and to adjust the dose. Then send the updated version straight after. The patient's copy should match what you agreed on the call.

Does the format of a home program (paper, video or app) change adherence? Trials disagree, and the guide to writing a home exercise program goes through them. Its basics hold on video: few exercises, a clear dose, a pain rule and a review date. The pain monitoring model gives you a pain rule. If the program is not getting done, see why patients skip their home exercises.

An example of a hybrid plan

Here is an illustration for a fictional patient with knee osteoarthritis. It is not a protocol, and your own schedule will depend on the patient and on what you find at assessment.

Visit 1, in the clinic: a full assessment and baseline measures (the 30-second chair stand test is one option). Teach and practice 2 to 4 exercises, for example sit to stand and a mini squat.
The same day, the program goes to the patient's phone.
Weeks 2 and 4, on video: watch the technique, ask about pain and how many sessions they managed, and progress if the patient is ready. The exercise progression guide sets out how.
Week 6, in the clinic: repeat the same outcome measures with the same set-up, and decide on discharge or a new block.

For strength exercises like these, many programs start at 1 to 3 sets of 8 to 15 repetitions, 2 to 3 days a week. That sits within the American College of Sports Medicine (ACSM) starting ranges given in our home exercise program guide. The physio adjusts this for each patient.

PocketPhysio can carry the program side of a plan like this. Each library exercise has a video, plus a voice guide that talks the patient through the movement.

You pick the dose (sets, reps, hold time) and can type your own cue under any exercise. The patient opens it from a link, an SMS or an email, or in Pocket Physio Care, the patient app, and WhatsApp is an option as well. At the next visit, in the clinic or on a call, the last program you sent is there to progress from. Run the video call itself on the secure platform your clinic has approved.

A note on billing

This guide does not cover billing. Telehealth payment rules differ between payers and countries and can change at short notice. Before you offer video visits, check each payer's current written policy and keep a copy with the date you checked it.

The short version

Telehealth physical therapy is a reasonable choice for many musculoskeletal patients. Hybrid care lets you use video where it works and keep the clinic for what needs your hands. The evidence is strongest for exercise-based care and a few well-studied conditions.

Video is good for taking a history and watching movement, and much weaker for hands-on and neurodynamic tests. Every video visit needs consent, a private space, a confirmed location and callback number, a red flag check and a written emergency plan. Between visits, a clear home program does the work.

References

Lee AC, Deutsch JE, Holdsworth L, et al. Telerehabilitation in physical therapist practice: a clinical practice guideline from the American Physical Therapy Association. Physical Therapy. 2024;104(5):pzae045. doi:10.1093/ptj/pzae045
Cottrell MA, Galea OA, O'Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clinical Rehabilitation. 2017;31(5):625-638. doi:10.1177/0269215516645148
Suso-Martí L, La Touche R, Herranz-Gómez A, et al. Effectiveness of telerehabilitation in physical therapist practice: an umbrella and mapping review with meta-meta-analysis. Physical Therapy. 2021;101(5):pzab075. doi:10.1093/ptj/pzab075
Moffet H, Tousignant M, Nadeau S, et al. In-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty: a noninferiority randomized controlled trial. Journal of Bone and Joint Surgery (American). 2015;97(14):1129-1141. doi:10.2106/JBJS.N.01066
Bennell KL, Nelligan R, Dobson F, et al. Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: a randomized trial. Annals of Internal Medicine. 2017;166(7):453-462. doi:10.7326/M16-1714
Kloek CJJ, Bossen D, Spreeuwenberg PM, et al. Effectiveness of a blended physical therapist intervention in people with hip osteoarthritis, knee osteoarthritis, or both: a cluster-randomized controlled trial. Physical Therapy. 2018;98(7):560-570. doi:10.1093/ptj/pzy045
Mani S, Sharma S, Omar B, Paungmali A, Joseph L. Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review. Journal of Telemedicine and Telecare. 2017;23(3):379-391. doi:10.1177/1357633X16642369
Bernhardsson S, Larsson A, Bergenheim A, et al. Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: a systematic review. PLoS One. 2023;18(3):e0283013. doi:10.1371/journal.pone.0283013
Davies L, Hinman RS, Russell T, Lawford B, Bennell K; International Videoconferencing Steering Group. An international core capability framework for physiotherapists to deliver quality care via videoconferencing: a Delphi study. Journal of Physiotherapy. 2021;67(4):291-297. doi:10.1016/j.jphys.2021.09.001
Chartered Society of Physiotherapy. How to ensure remote consultations work for your patients. Last reviewed 21 September 2022. https://www.csp.org.uk/professional-clinical/professional-guidance/remote-consultations/csp-guidance-1
Chartered Society of Physiotherapy. How to ensure remote consultation services are safe. Last reviewed 22 September 2022. https://www.csp.org.uk/professional-clinical/professional-guidance/remote-consultations/csp-guidance-2
Australian Health Practitioner Regulation Agency and National Boards. Telehealth: information for practitioners who provide virtual care. Page reviewed 7 October 2025. https://www.ahpra.gov.au/Resources/Information-for-practitioners-who-provide-virtual-care
College of Physiotherapists of Ontario. Virtual Care Guidelines. No date shown, accessed 28 September 2026. https://collegept.org/resource/virtual-practice/
Physical Therapy Compact Commission. PT Compact. Accessed 28 September 2026. https://ptcompact.org/
Physiotherapy Board of New Zealand. Digital health standard. Effective 1 April 2026. https://physioboard.org.nz/standards/physiotherapy-standards/digital-health-standard
NHS. Falls. Page last reviewed 6 March 2025. Accessed 28 September 2026. https://www.nhs.uk/conditions/falls/

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.