Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients With Nonacute Musculoskeletal Conditions? A Systematic Rapid Review

Understanding Negative and Positive Feelings About Telerehabilitation in People With Chronic Knee Pain: A Mixed-Methods Study

OBJECTIVES: To explore (1) initial feelings of people with knee osteoarthritis who are unexpectedly offered telerehabilitation, and (2) if their experiences met their expectations, and their willingness to use telerehabilitation in the future. DESIGN: Mixed-methods study of 122 people with knee osteoarthritis who were randomized to receive physiotherapist-delivered telerehabilitation in a clinical trial. METHODS: At enrollment in the trial, participants were unaware care would be delivered via telerehabilitation. At completion, quantitative (Likert scales, analyzed descriptively) and qualitative (open-text, underwent content/thematic analysis) questions asked participants about their initial feelings when randomized to telerehabilitation, if experiences met expectations, and willingness to use telerehabilitation in the future. RESULTS: Data were collected between October 2021 to March 2023. At enrollment, 44 (36% of 122) participants initially felt negative toward telerehabilitation (doubts about effectiveness, physiotherapist can't see/touch, believe in-person is better, can't communicate effectively, not good with technology), 18 (15%) were neutral, and 60 (49%) felt positive. After experiencing telerehabilitation, 43 (72%) people who were initially positive and 27 (61%) who were initially negative believed telerehabilitation exceeded their expectations (easier than expected, surprised by benefits/effectiveness, strong rapport with physiotherapist, convenience). Twenty-eight (23% of 122) people were not at all or slightly willing to use telerehabilitation in future (prefer hands-on, doesn't allow adequate assessment/observation, prefer in-person, don't like telerehabilitation). CONCLUSION: One in 2 people were positive about telerehabilitation from the outset, and 6 in 10 people who initially felt negative about telerehabilitation found that their experiences were better than expected. One in 4 people were unwilling to use telerehabilitation in the future, even after they had experienced it. J Orthop Sports Phys Ther 2024;54(9):1-14. Epub 11 June 2024. doi:10.2519/jospt.2024.12383.

Care at a distance: Understanding lived experiences of people with MSK disorders receiving non-pharmacological interventions delivered through synchronous telehealth: A systematic rapid review

Background

Little is known about lived experience of synchronous telehealth in patients with musculoskeletal (MSK) disorders.

Objective

We conducted a rapid systematic review to answer: (1) what are the lived experiences and/or perspectives of people with MSK disorders receiving non-pharmacological interventions delivered through synchronous telehealth; and (2) what clinical implications can be inferred from qualitative studies focusing on lived experiences for how telehealth is delivered in the management of MSK disorders?

Data sources

A comprehensive search of MEDLINE, CINAHL, PsycINFO, ProQuest, and Google Scholar from June 2010 to July 2023. Eligible qualitative and mixed methods studies capturing lived experiences of adults with MSK disorders receiving non-pharmacological interventions via synchronous telehealth were included.

Study methods

Systematic rapid review conducted according to WHO guidelines. Titles and abstracts screened by reviewers independently, eligible studies critically appraised, and data was extracted. Themes summarized using the Consolidated Framework for Implementation Research (CFIR). GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) used to assess confidence in synthesis findings.

Results

We identified 9782 references, screened 8029, and critically appraised 22, and included 17 studies. There is evidence to suggest that the experience of telehealth prior to and during the pandemic was shaped by (1) patient perception of telehealth, (2) existing relationships with practitioners, (3) availability and accessibility of telehealth technologies, and (4) perceptions about the importance of the role of the physical exam in assessing and treating MSK disorders.

Conclusion

The five identified implications could be used to inform future research, policy, and strategy development.

Effectiveness of remote physiotherapeutic e-Health interventions on pain in patients with musculoskeletal disorders: a systematic review

PURPOSE

To systematically review the literature on effectiveness of remote physiotherapeutic e-Health interventions on pain in patients with musculoskeletal disorders.

MATERIALS AND METHODS

Using online data sources PubMed, Embase, and Cochrane in adults with musculoskeletal disorders with a pain-related complaint. Remote physiotherapeutic e-Health interventions were analysed. Control interventions were not specified. Outcomes on effect of remote e-Health interventions in terms of pain intensity.

RESULTS

From 11,811 studies identified, 27 studies were included. There is limited evidence for the effectiveness for remote e-Health for patients with back pain based on five articles. Twelve articles studied chronic pain and the effectiveness was dependent on the control group and involvement of healthcare providers. In patients with osteoarthritis (five articles), total knee surgery (two articles), and knee pain (three articles) no significant effects were found for remote e-Health compared to control groups.

CONCLUSIONS

There is limited evidence for the effectiveness of remote physiotherapeutic e-Health interventions to decrease pain intensity in patients with back pain. There is some evidence for effectiveness of remote e-Health in patients with chronic pain. For patients with osteoarthritis, after total knee surgery and knee pain, there appears to be no effect of e-Health when solely looking at reduction of pain. Implications for rehabilitationThis review shows that e-Health can be an effective way of reducing pain in some populations.Remote physiotherapeutic e-Health interventions may decrease pain intensity in patients with back pain.Autonomous e-Health is more effective than no treatment in patients with chronic pain.There is no effect of e-Health in reduction of pain for patients with osteoarthritis, after total knee surgery and knee pain.

Impact of COVID-19 pandemic on nonpharmacological pain management trials in military and veteran healthcare settings: an evaluation informed by implementation science

The coronavirus disease (COVID-19) pandemic disrupted healthcare and clinical research, including a suite of 11 pragmatic clinical trials (PCTs), across clinics within the Department of Veterans Affairs (VA) and the Department of Defense (DOD). These PCTs were designed to evaluate an array of nonpharmacological treatments and models of care for treatment of patients with pain and co-occurring conditions. The aims of the study are to (a) describe modifications to PCTs and interventions to address the evolving pandemic and (b) describe the application of implementation science methods for evaluation of those PCT modifications. The project used a two-phase, sequential, mixed-methods design. In Phase I, we captured PCT disruptions and modifications via a Research Electronic Data Capture questionnaire, using Periodic Reflections methods as a guide. In Phase II, we utilized the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) taxonomy to develop a focus group interview guide and checklist that would provide more in-depth data than Phase I. Data were analyzed using directed content analysis. Phase I revealed that all PCTs made between two and six trial modifications. Phase II, FRAME-guided analyses showed that the key goals for modifying interventions were increasing treatment feasibility and decreasing patient exposure to COVID-19, while preserving intervention core elements. Context (format) modifications led eight PCTs to modify parts of the interventions for virtual delivery. Content modifications added elements to enhance patient safety; tailored interventions for virtual delivery (counseling, exercise, mindfulness); and modified interventions involving manual therapies. Implementation science methods identified near-real-time disruptions and modifications to PCTs focused on pain management in veteran and military healthcare settings.

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world's leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: -0.55, 95% CI: -2.42 to 5.81, P = 0.412) or program-end scores (-1.05, 95% CI: -4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

Virtual Tools to Enable Management of Knee Osteoarthritis

Purpose of review

There is increasing recognition that virtual tools, enabled by the internet and telecommunications technology, can increase access to health care. We review evidence about the clinical effectiveness and acceptability of telephone-delivered and videoconferencing clinician consultations, websites and internet-delivered programs, and SMS and mobile applications in enabling the management of people with knee osteoarthritis (OA). We discuss barriers to using virtual tools and suggest strategies to facilitate implementation in clinical settings.

Recent findings

An increasing number of systematic reviews, meta-analyses, and clinical trials provide evidence showing the effectiveness of virtual tools for improving knee OA management. Qualitative research shows that virtual tools increase patient access to knee OA care, are generally acceptable and convenient for patients, but can be associated with barriers to use from patient and clinician perspectives.

Summary

Virtual tools offer new opportunities to enable people with knee OA to manage their condition and receive care that may otherwise be difficult or not possible to access. Telephone calls and videoconferencing can be used for real-time synchronous consultations between clinicians and patients, increasing the geographic reach of health services. Websites and internet-based programs can be used to educate patients about their condition, as well as deliver exercise, weight management, and psychological interventions. Mobile apps can monitor and track OA symptoms, exercise, and physical activity, while SMS can facilitate positive behaviour changes for self-management over the long-term when sustained clinician contact may not be possible.

Effectiveness of biofeedback-assisted asynchronous telerehabilitation in musculoskeletal care: A systematic review

Background

Musculoskeletal conditions are the leading cause of disability worldwide. Telerehabilitation may be a viable option in the management of these conditions, facilitating access and patient adherence. Nevertheless, the impact of biofeedback-assisted asynchronous telerehabilitation remains unknown.

Objective

To systematically review and assess the effectiveness of exercise-based asynchronous biofeedback-assisted telerehabilitation on pain and function in individuals with musculoskeletal conditions.

Methods

This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using three databases: PubMed, Scopus, and PEDro. Study criteria included articles written in English and published from January 2017 to August 2022, reporting interventional trials evaluating exercise-based asynchronous telerehabilitation using biofeedback in adults with musculoskeletal disorders. The risks of bias and certainty of evidence were appraised using the Cochrane tool and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE), respectively. The results are narratively summarized, and the effect sizes of the main outcomes were calculated.

Results

Fourteen trials were included: 10 using motion tracker technology (N = 1284) and four with camera-based biofeedback (N = 467). Telerehabilitation with motion trackers yields at least similar improvements in pain and function in people with musculoskeletal conditions (effect sizes: 0.19-1.45; low certainty of evidence). Uncertain evidence exists for the effectiveness of camera-based telerehabilitation (effect sizes: 0.11-0.13; very low evidence). No study found superior results in a control group.

Conclusions

Asynchronous telerehabilitation may be an option in the management of musculoskeletal conditions. Considering its potential for scalability and access democratization, additional high-quality research is needed to address long-term outcomes, comparativeness, and cost-effectiveness and identify treatment responders.

Characteristics of Chiropractic Patients in the Veterans Health Administration During the COVID-19 Pandemic: A Cross-Sectional Analysis

OBJECTIVE

The purpose of this study was to determine whether patient characteristics were associated with face-to-face (F2F) and telehealth visits for those receiving chiropractic care for musculoskeletal conditions in the US Veterans Health Administration (VHA) during the COVID-19 pandemic.

METHODS

A retrospective cross-sectional analysis of all patients (veterans, dependents, and spouses) who received chiropractic care nationwide at the VHA from March 1, 2020, to February 28, 2021, was performed. Patients were allocated into 1 of the following 3 groups: only telehealth visits, only F2F visits, and combined F2F and telehealth visits. Patient characteristics included age, sex, race, ethnicity, marital status, and Charlson Comorbidity Index. Multinomial logistic regression estimated associations of these variables with visit type.

RESULTS

The total number of unique patients seen by chiropractors between March 2020 and February 2021 was 62 658. Key findings were that patients of non-White race and Hispanic or Latino ethnicity were more likely to attend telehealth-only visits (Black [odds ratio 1.20, 95% confidence interval {1.10-1.31}], other races [1.36 {1.16-1.59}], and Hispanic or Latino [1.35 {1.20-1.52}]) and combination telehealth and F2F care (Black [1.32 {1.25-1.40}], other races [1.37 {1.23-1.52}], and Hispanic or Latino [1.63 {1.51-1.76}]). Patients younger than 40 years of age were more likely to choose telehealth visits ([1.13 {1.02-1.26}], 66-75 years [1.17 {1.01-1.35}], and >75 years [1.26 {1.06-1.51}] vs those 40-55 years of age). Sex, visit frequency, and Charlson Comorbidity Index showed significant relationships as well, while marital status did not.

CONCLUSION

During the COVID-19 pandemic, VHA patients with musculoskeletal complaints using chiropractic telehealth were more ethnically and racially diverse than those using F2F care alone.

Telehealth Content From United States Chiropractic State Board Websites Compared With Medical and Physical Therapy Websites During the Early Stages of the COVID-19 Pandemic

Objective

The purpose of this descriptive study was to evaluate the presence of telehealth content on chiropractic state board websites compared with websites from the medical and physical therapy professions during the early COVID-19 pandemic.

Methods

State board websites for chiropractic, medicine, and physical therapy for each of the 50 United States and the District of Columbia were searched for the word "tele" to determine if there was a link on the homepage for content related to telehealth guidance. If there was none, the homepage was queried for the word "COVID" to determine if there was a link for COVID-19-related guidance. If yes, that linked COVID-19 page was queried for the word "tele." Consensus of 4 of 5 reviewers was sought. Binary results were entered into a separate spreadsheet for each profession (telehealth content easily accessible, yes or no). Easily accessible was defined as information found within 1 or 2 clicks. This search was performed between January 1, 2021, and March 1, 2021.

Results

There were 11 of 51 (21%) chiropractic state board websites that provided content regarding telehealth on the main page, 8 of 51 (16%) provided content on a separate COVID-19-related page, and 32 of 51 (63%) did not provide content that was accessible within 1 or 2 clicks. Comparatively, 9 of 51 (18%) medical state board websites provided content regarding telehealth on the main page, 20 of 51 (39%) provided content on a COVID-19-related page, and 22 of 51 (43%) did not provide content that was accessible within 1 or 2 clicks. Lastly, 10 of 51 (20%) physical therapy state board websites provided content regarding telehealth on the main page, 19 of 51 (37%) provided content on a COVID-19-related page, and 22 of 51 (43%) did not provide content that was accessible within 1 or 2 clicks.

Conclusion

Telehealth content was more readily available on medical and physical therapy state board websites compared with chiropractic state board websites in the early stages of the COVID-19 pandemic.

"Much better than I thought it was going to be": Telehealth delivered group-based education and exercise was perceived as acceptable among people with knee osteoarthritis

Objective

To understand patient perceived acceptability of participating in a telehealth delivered group-based education and exercise-therapy program for knee osteoarthritis.

Design

This qualitative study involved semi-structured, one-on-one interviews with knee osteoarthritis patients who have completed the Good Living with osteoArthritis from Denmark (GLA:D®) program via telehealth or in-person. Interviews were recorded, transcribed verbatim, coded, and analysed using an inductive content analysis approach, focusing on themes related to telehealth.

Results

Nineteen participants [12 (63%) female, mean aged 62 years, range 49-72 years] were included. Eleven (58%) received GLA:D® via telehealth and 8 (42%) attended in-person sessions. Two overarching themes (6 sub-themes) related to telehealth perceived acceptability were identified: 1) Perceptions of telehealth acceptability was highly influenced by exposure. Individuals who had received telehealth considered it easy, convenient, and flexible, whereas telehealth was perceived to be inferior and misunderstood by those without exposure. 2) Telehealth participants reported similar program benefits to in-person participants, including reduced fear of pain and joint damage, changed beliefs in value of exercise, and stated improvements in pain and function.

Conclusions

Telehealth delivery of group-based education and exercise-therapy for knee osteoarthritis was acceptable for people who had experienced it and provides similar benefits as in-person care for pain and beliefs about the safety and value of exercise. Wider implementation of telehealth group-based education and exercise-therapy may improve access to high value care for people with knee osteoarthritis.

The impact and public health response of chiropractors to the COVID-19 pandemic: a survey across four continents

BACKGROUND

The unprecedented impact of COVID-19 on healthcare professionals has implications for healthcare delivery, including the public health guidance provided to patients. This study aims to assess the response and impact of COVID-19 on chiropractors internationally, and examines the public health response of chiropractors to the COVID-19 pandemic practising under a musculoskeletal spine-care versus subluxation-based care paradigm.

METHODS

A survey was distributed to chiropractors in Australia, Canada, Denmark, Hong Kong, United Kingdom and United States (Oct. 2nd-Dec. 22nd, 2020) via professional bodies/publications, and social media. Questions were categorised into three domains: socio-demographic, public health response and business/financial impact. Multivariable logistic regression explored survey items associated with chiropractors practising under different self-reported paradigms.

RESULTS

A total of 2061 chiropractors representing four global regions completed the survey. Our recruitment method did not allow the calculation of an accurate response rate. The vast majority initiated COVID-19 infection control changes within their practice setting, including increased disinfecting of treatment equipment (95%), frequent contact areas (94%) and increased hand hygiene (94%). While findings varied by region, most chiropractors (85%) indicated that they had implemented regulator advice on the use of personal protective equipment (PPE). Suspension of face-to-face patient care during the peak of the pandemic was reported by 49% of the participants with 26% implementing telehealth since the pandemic began. Chiropractors practising under a musculoskeletal spine-care paradigm were more likely to implement some/all regulator advice on patient PPE use (odds ratio [OR] = 3.25; 95% confidence interval [CI]: 1.57, 6.74) and practitioner PPE use (OR = 2.59; 95% CI 1.32, 5.08); trust COVID-19 public health information provided by government/World Health Organisation/chiropractic bodies (OR = 2.47; 95% CI 1.49, 4.10), and initiate patient telehealth in response to COVID-19 (OR = 1.46; 95% CI 1.02, 2.08) compared to those practising under a subluxation-based paradigm.

CONCLUSIONS

Chiropractors who responded to our survey made substantial infectious control changes in response to COVID-19. However, there was regional variation in the implementation of the advised practitioner and patient use of PPE and limited overall use of telehealth consultations by chiropractors during COVID-19. Musculoskeletal spine-care chiropractors were more adaptive to certain COVID-19 public health changes within their practice setting than subluxation-based chiropractors.

Electromyographic Analysis of the Lumbar Extensor Muscles during Dynamic Exercise on a Home Exercise Device

Resistance exercise with devices offering mechanisms to isolate the lumbar spine is effective to improve muscle strength and clinical outcomes. However, previously assessed devices with these mechanisms are not conducive for home exercise programs. The purpose of this study was to assess the surface electromyographic (EMG) activity of the lumbar extensor muscles during dynamic exercise on a home back extension exercise device. Ten adults (5 F, 5 M) performed dynamic lumbar extension exercise on a home device at three loads: 1.00 × body weight (BW), 1.25 × BW and 1.50 × BW. Surface EMG activity from the L3/4 paraspinal region was collected. The effect of exercise load, phase of movement, and position in the range of motion on lumbar extensor EMG activity (normalized to % maximum voluntary isometric contraction) was assessed. Lumbar extensor EMG activity significantly increased from 1.00 BW to 1.50 BW loads (p = 0.0006), eccentric to concentric phases (p < 0.0001), and flexion to extension positions (p < 0.0001). Exercise using a home back extension exercise device progressively activates the lumbar extensor muscles. This device can be used for home-based resistance exercise programs in community-dwelling adults without contraindications.

Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients With Nonacute Musculoskeletal Conditions? A Systematic Rapid Review

OBJECTIVE

To determine whether nonpharmacologic interventions delivered through synchronous telehealth are as effective and safe compared with in-person interventions for the management of patients with musculoskeletal conditions in improving pain, functioning, self-reported recovery, psychological outcomes, or health-related quality of life using rapid review methods.

DATA SOURCES

We searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials from 2010 to August 2020 for randomized controlled trials (RCTs) published in English or French; we updated our search in January 2021.

STUDY SELECTION

One reviewer screened citations in 2 phases (phase 1: title/abstract; phase 2: full-text) selecting RCTs comparing synchronous telehealth with in-person care for the management of musculoskeletal conditions. A random 10% sample was screened by 2 independent reviewers with minimum 95% agreement prior to full screening. One reviewer critically appraised and one reviewer validated appraisal for eligible RCTs.

DATA EXTRACTION

One author extracted participant characteristics, setting, sample size, interventions, comparisons, follow-up period, and outcome data. A second author validated data extraction.

DATA SYNTHESIS

We summarized the findings narratively. Low- to moderate-quality evidence suggests that synchronous telehealth (ie, videoconference or telephone calls) alone or in combination with in-person care leads to similar outcomes as in-person care alone for nonspecific low back pain, generalized osteoarthritis, hip or knee osteoarthritis, and nonacute headaches in adults.

CONCLUSIONS

Synchronous telehealth may be an option for the management of nonacute musculoskeletal conditions in adults. However, our results may not be generalizable to rural or low socioeconomic populations. Future research should investigate the outcomes associated the use of new technologies, such as videoconference.