The Art of Hybrid Rehabilitation Is Knowing When Presence Matters More Than Convenience

By: Chad E. Cook, PT, PhD, FAPTA

A Model Born of Necessity, Now Here to Stay: Hybrid rehabilitation blends in‑person therapy with digitally delivered supported telehealth visits, remote monitoring, and app‑based exercise programs, to create a flexible, personalized model of care [1]. Once a niche experiment, it became a global necessity during the COVID‑19 pandemic. Clinics scrambled to deliver care remotely, and many of us were surprised by how quickly patients adapted, stretching, strengthening, and self‑managing through phone calls and video screens. In the years since, hybrid rehabilitation has not only persisted but matured, becoming a permanent and influential part of the rehabilitation landscape.

But with permanence comes controversy. What began as an emergency workaround has revealed a philosophical fault line within the rehabilitation community. Some clinicians see hybrid care as a modern, accessible, empowering evolution of practice; others view it as a dilution of the hands‑on, relational work that has long defined the profession. Patients are equally conflicted. Many appreciate the flexibility, but others worry that digital care is a sign they are receiving something less; this includes less attention, less safety, and less expertise.

This blog explores that tension. And it builds on the reflections I’ve gathered since publishing “Building Effective Hybrid Rehabilitation Programs: Clinical, Operational, and Technological Considerations” on the Duke Center of Excellence website [2]. At its core, the argument is simple: the art of hybrid rehabilitation is knowing when presence matters more than convenience.

Why Hybrid Rehabilitation Works: Access, Adherence, and Evidence: Although the evidence behind hybrid rehabilitation is still emerging, direct comparisons suggest that hybrid and digital rehabilitation can match traditional outcomes. A 2024 systematic review and meta‑analysis [3] found that telerehabilitation produced comparable improvements in physical functioning, mental health, and pain reduction when compared to face‑to‑face, onsite care.

But the benefits extend beyond outcomes alone. Hybrid care improves access and reduces barriers that are consistent with onsite care. Access remains one of the most significant challenges in musculoskeletal (MSK) care. Nearly 75% of patients who receive a prescription for physical therapy never schedule an appointment [4], and almost 30% discontinue care after their first visit [5]. Hybrid models help address these gaps by reducing transportation barriers, offering flexible scheduling, and allowing patients to engage in care from their own homes.

Hybrid care strengthens continuity of care. Continuity of care is especially valuable for MSK problems because consistent follow‑up allows clinicians to monitor subtle changes in pain, function, and movement patterns that evolve. It may also strengthen the therapeutic relationship, improving adherence and enabling timely adjustments before small issues become chronic setbacks.

Hybrid care offers operational advantages, and clinics benefit as well. Hybrid models can reduce no‑show rates, improve scheduling efficiency, and support more consistent reimbursement. These operational gains help sustain care delivery in environments where staffing shortages and rising demand are ongoing challenges.

Lastly, hybrid care has broad institutional support: Advocacy groups, including NARA, CPR, NRA, the Kessler Institute (via AMRPA partnerships), and the Falling Forward Foundation, have endorsed hybrid models. Major insurers, including Centers for Medicare & Medicaid Services, United Healthcare, Aetna/CVS, Blue Cross Blue Shield plans, and Cigna/Evernorth, have also supported or piloted hybrid MSK programs. With this level of institutional backing, it is difficult not to recognize hybrid rehabilitation as a legitimate and valuable delivery platform.

Why Hybrid Rehabilitation Fails Some Patients: Inequity, Quality, and Clinical Blind Spots: Ironically, one of the strongest arguments for hybrid rehabilitation, its promise of inclusivity, also exposes its greatest vulnerability. Digitized care carries a real risk of widening health inequalities. Our work involving use of a patient portal system (MyChart) [6] showed that being older than 65, non-White, unemployed, non-English-speaking, male, not-partnered, uninsured or publicly insured (Medicaid, Medicare and under 65 years of age, or other government insurance), and living in a rural environment were all risk factors for decreased patient portal utilization among surgical spine patients. In some cases, greater than 50% of individuals with the selected characteristics did not access the patient portal.

People with lower socioeconomic status, certain racial or ethnic minority backgrounds, and limited access to technology face additional risks that can widen existing health disparities [7]. Individuals with low digital literacy and unreliable internet access are especially likely to struggle with telehealth, making early risk stratification crucial for identifying who may have difficulty in a hybrid care model. Low digital health literacy can also undermine confidence in using technology, increase frustration, and lead to avoidance of telehealth altogether, ultimately limiting timely care, disrupting continuity of treatment, and reducing engagement with the healthcare system.

There are concerns about assessment accuracy. I’ve been involved in prior studies examining the diagnostic accuracy of shoulder tests [8,9] and clinical trials comparing digital care to traditional measures [10,11]. None of these studies found significant differences between onsite and digital-focused groups, but concerns remain, particularly around subtle clinical findings that may go unnoticed in a digital examination. Gait deviations, joint restrictions, or nuanced movement patterns can be difficult to detect through a digital screen. Assessing changes (worsening or improvements) digitally, that were identified during onsite findings, may also be a challenge.

The Real Issue: Hybrid Rehabilitation Isn’t Good or Bad: It’s Conditional: Some clinicians view digital tools as an extension of their clinical reach; others see them as an erosion of clinical identity. Patients are equally divided. For some, hybrid care feels liberating: it fits their schedules, respects their autonomy, and brings therapy into the rhythm of their daily lives. For others, it feels like abandonment, a move away from the human connection, tactile assessment, and in‑person reassurance they rely on to feel safe and supported. The same model that offers freedom to one person can feel like distance to another. That tension sits at the heart of the hybrid rehabilitation debate.

The truth is that hybrid rehabilitation is neither inherently superior nor inherently inferior. It is a tool. And like any tool, its value depends on how, when, and for whom it is used. For this to work, patient selection is going to be a key focus. Further, additional training and resources are required as digital care is different than onsite care; it demands additional skills and considerations. The following recommendations may improve the likelihood of successful implementation, and future blogs will attempt to expand further on these concepts.

• Build hybrid models that augment, not replace, in‑person care. Integrating these models with onsite visits is likely the best delivery system.
• Invest in digital literacy and access programs. This includes partnering with organizations that specialize in engagement methods.
• Use evidence‑based digital tools, not generic exercise applications. Digital care has a much greater opportunity to provide integrated, personalized exercise approaches.
• Maintain strong clinician–patient communication. This includes building communication milestones throughout the longitudinal care process.

Closing Narrative: Hybrid rehabilitation forces us to confront what we value in healthcare: access, autonomy, precision, connection, or tradition. The controversy isn’t a sign of failure; it’s a sign that the field is evolving. And evolution, by definition, is uncomfortable. The art of hybrid rehabilitation lies in knowing when presence matters more than convenience, and in having the wisdom to choose the right mode of care for the right person at the right time.

Artificial intelligence tools were used to assist with editing and improving the clarity of the manuscript. All intellectual content, analysis, and conclusions are the authors’ own

References

1. Palagin OV, Malakhov KS, Velychko VY, Semykopna TV. Hybrid e‑rehabilitation services: SMART‑system for remote support of rehabilitation activities and services. Int J Telerehabil.
2. Cook CE. Building effective hybrid rehabilitation programs: clinical, operational, and technological considerations. Duke Center of Excellence in Manual and Manipulative Therapy; 2026. https://sites.duke.edu/cemmt/2026/03/02/building-effective-hybrid-rehabilitation-programs/
3. Correia FD, Nogueira A, Magalhães I, et al. Effectiveness of telerehabilitation for musculoskeletal conditions: a systematic review and meta‑analysis. JAMA Netw Open. 2024;7(1):e235123.
4. Sharpe JA, Martin BI, Fritz JM, et al. Identifying patients who access musculoskeletal physical therapy: a retrospective cohort analysis. Fam Pract. 2021 Jun 17;38(3):203-209.
5. Thomas AC, Shaver SN, Young JL, Cook CE. Reasons for patient no-shows and drop-offs after initial evaluation in physical therapy outpatient care: a qualitative study. Musculoskelet Sci Pract. 2025 Jun;77:103326.
6. Owolo E, Petitt Z, Charles A, Baëta C, Poehlein E, Green C, Cook C, Sperber J, Chandiramani A, Roman M, Goodwin CR, Erickson M. The Association Between Sociodemographic Factors, Social Determinants of Health, and Spine Surgical Patient Portal Utilization. Clin Spine Surg. 2023 Oct 1;36(8):301-309.
7. Arias López MP, Ong BA, Borrat Frigola X, et al. Digital literacy as a new determinant of health: A scoping review. PLOS Digit Health. 2023;2(10):e0000279. doi:10.1371/journal.pdig.0000279
8. Bradley KE, Cook C, Reinke EK, Vinson EN, Mather RC 3rd, Riboh J, Lassiter T, Wittstein JR. Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology. J Shoulder Elbow Surg. 2021 May;30(5):1042-1052. doi: 10.1016/j.jse.2020.08.016.
9. Glover MA, Bradley KE, Casey PM, Cook C, Reinke EK, Vinson EN, Mather RC, Riboh J, Lassiter T, Wittstein JR. Telehealth physical examinations show comparable accuracy and results to clinical exams for MRI-confirmed shoulder pathologies. J Telemed Telecare. 2025 Sep 25:1357633X251375155.
10. Myers H, Keefe FJ, George SZ, Kennedy J, Lake AD, Martinez C, Cook CE. Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial. BMC Musculoskelet Disord. 2023 Dec 1;24(1):930.
11. George SZ, Coffman CJ, Allen KD, Lentz TA, Choate A, Goode AP, Simon CB, Grubber JM, King H, Cook CE, Keefe FJ, Ballengee LA, Naylor J, Brothers JL, Stanwyck C, Alkon A, Hastings SN. Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial. Pain Med. 2020 Dec 12;21(Suppl 2):S62-S72.