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

Teleassessment using five times sit-to-stand test in older adults with and without Parkinson's disease: Guidelines and barriers

BACKGROUND AND PURPOSE

Assessing lower limb strength, balance, and fall risk are crucial components of rehabilitation, especially for the older adult population. With the growing interest in telehealth, teleassessment has been investigated as an alternative when in-person assessments are not possible. The Five Times Sit-to-Stand test (5TSTS) provides a quick measure of balance during chair transfers, muscle power, endurance, and the hability to change and maintain body position, and is highly recommended by guidelines. However, the literature is unclear about the viability and safety of teleassessment using the 5TSTS in older adults with and without Parkinson's disease (PD). This study aimed to evaluate the reliability of teleassessment using the 5TSTS and to determine its feasibility and safety for older adults with and without PD.

METHODS

This cross-sectional study included older adults with and without PD who were evaluated remotely through a videoconference platform. To ensure effective and comprehensive instructions for the test, we developed a guideline called OMPEPE (an acronym for: Objective; Materials; Position-Start; Execution; Position-End; Environment). We assessed the 5TSTS intra- and inter-rater reliability by comparing scores obtained from the same examiner and from different examiners, respectively. Participants and examiners completed online surveys to provide information about feasibility and safety.

RESULTS

Twelve older adults with PD and 17 older adults without PD were included in this study (mean ages 69.0 and 67.6 years, respectively). Based on the participants' perspectives and the absence of adverse effects, teleassessment using the 5TSTS is feasible and safe for older adults with and without PD. Excellent intra- and inter-rater reliability (intraclass correlation coefficient >0.90) was found for all measurements of the 5TSTS.

DISCUSSION

This study demonstrated the feasibility, safety, and reliability of teleassessment using the 5TSTS. The guidelines developed may help health professionals minimize barriers and safely conduct an online assessment that includes a physical test such as the 5TSTS in older adults with or without PD. In addition to addressing technological barriers, the OMPEPE guideline might ensure the optimal execution of evaluations.

CONCLUSION

Teleassessment using the 5TSTS for older adults with and without PD is feasible and safe. Both synchronous (i.e., live) and asynchronous (i.e., recorded) online 5TSTS tests demonstrate excellent intra- and inter-rate reliability.

Investigating the Use of Telemedicine by Health Care Providers to Diagnose and Manage Patients With Musculoskeletal Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Access to care is a major challenge for patients with musculoskeletal disorders (MSKDs). Telemedicine is one of the solutions to improve access to care. However, initial remote diagnosis of MSKDs involves some challenges, such as the impossibility of touching the patient during the physical examination, which makes it more complex to obtain a valid diagnosis. No meta-analysis has been performed to date to synthesize evidence regarding the initial assessment including a physical evaluation using telemedicine to diagnose patients with MSKDs.

OBJECTIVE

This study aims to appraise the evidence on diagnostic and treatment plan concordance between remote assessment using synchronous or asynchronous forms of telemedicine and usual in-person assessment for the initial evaluation of various MSKDs.

METHODS

An electronic search was conducted up to August 2023 using terms related to telemedicine and assessment of MSKDs. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Random-effect model meta-analyses were performed. The Grading of Recommendations, Assessment, Development, and Evaluations framework was used to synthesize the quality and certainty of the evidence.

RESULTS

A total of 23 concordance studies were eligible and included adult participants (N=1493) with various MSKDs. On the basis of high certainty, pooled κ and prevalence-adjusted and bias-adjusted κ for the diagnostic concordance between remote and in-person assessments of MSKDs were 0.80 (95% CI 0.72-0.89; 7 studies, 353 patients) and 0.83 (95% CI 0.76-0.89; 6 studies, 306 patients). On the basis of moderate certainty, pooled Gwet AC1 for treatment plan concordance between remote and in-person assessments of MSKDs was 0.90 (95% CI 0.80-0.99; 2 studies, 142 patients).

CONCLUSIONS

The diagnostic concordance for MSKDs is good to very good. Treatment plan concordance is probably good to excellent. Studies evaluating the accuracy to detect red and yellow flags as well as the potential increase in associated health care resources use, such as imaging tests, are needed.

Usage, Attitudes, Facilitators, and Barriers Toward Digital Health Technologies in Musculoskeletal Care: Survey Among Primary Care Physiotherapists in Norway

BACKGROUND

Work burden increases for physiotherapists in the primary health care sector as the prevalence of musculoskeletal disorders (MSDs) increases. Digital health technologies (DHTs) are proposed as a viable solution to secure the sustainability of the health care system and have shown promising results in a range of conditions. However, little is known about use of DHTs among physiotherapists in the primary health care sector in Norway.

OBJECTIVE

This study aimed to investigate the use of and attitudes toward DHTs among physiotherapists treating patients with MSDs in primary care, and potential facilitators or barriers for adopting DHTs in clinical practice.

METHODS

An author-developed web-based questionnaire was distributed to physiotherapists in all Norwegian municipalities in March 2023. The questionnaire included items regarding use of technologies, attitudes, suitability, and factors influencing adoption of DHT. Suitability and agreement on statements were scored on an 11-point numeric rating scale (0=very unsuitable or strongly disagree, 10=very suitable or strongly agree). Differences across employment sites and users versus nonusers of DHT were analyzed using the χ2 test, Fisher exact test, Student t test, and Mann-Whitney U test.

RESULTS

Approximately 5000 physiotherapists were invited to participate, of which 6.8% (338) completed the questionnaire. A total of 46.2% (156/338) offered DHTs in their practice, of which 53.2% (83/156) used it on a weekly basis, mostly telephone consultations (105/156, 67.3%). A higher proportion of physiotherapists in private practice offered DHT compared with those employed by municipalities (95/170, 55.9% vs 61/168, 36.3%; P<.001). A majority (272/335, 81.2%) were positive about recommending DHTs to their patients. Suitability of DHTs in physiotherapy was rated an average of 6 (SD 2.1). Apps for smartphones or tablets were rated most suitable (mean rating 6.8, SD 2.4). The most frequently reported advantages were flexibility in how physiotherapy is offered (278/338, 82.3%) and reduced travel time for the patient (235/338, 70%). The highest rated disadvantages were limited scope for physical examination (252/338, 74.6%) and difficulty in building rapport with the patient (227/338, 67.2%). The main facilitators and barriers included a functioning (median rating 10, IQR 8-10) or lack of functioning (median rating 9, IQR 8-10) internet connection, respectively. Lack of training in DHTs was prominent regarding evaluation, diagnosing, and treatment (median rating 0, IQR 0-2), with minor, but significant, differences between nonusers and users (median rating 0, IQR 0-1 vs median rating 1, IQR 0-4); P<.001).

CONCLUSIONS

Physiotherapists in Norwegian primary care treating patients with MSDs are positive about using DHTs, and almost 50% (156/338) have adopted them in clinical practice. Concerns are related to lack of a physical examination and technical aspects. Training in the use of DHTs should be addressed in implementation processes.

Clinician-administered performance-based tests via telehealth in people with chronic lower limb musculoskeletal disorders: Test-retest reliability and agreement with in-person assessment

INTRODUCTION

Uptake of telehealth has surged, yet no previous studies have evaluated the clinimetric properties of clinician-administered performance-based tests of function, strength, and balance via telehealth in people with chronic lower limb musculoskeletal pain. This study investigated the: (i) test-retest reliability of performance-based tests via telehealth, and (ii) agreement between scores obtained via telehealth and in-person.

METHODS

Fifty-seven adults aged ≥45 years with chronic lower limb musculoskeletal pain underwent three testing sessions: one in-person and two via videoconferencing. Tests included 30-s chair stand, 5-m fast-paced walk, stair climb, timed up and go, step test, timed single-leg stance, and calf raises. Test-retest reliability and agreement were assessed via intraclass correlation coefficients (ICC; lower limit of 95% confidence interval (CI) ≥0.70 considered acceptable). ICCs were interpreted as poor (<0.5), moderate (0.5-0.75), good (0.75-0.9), or excellent (>0.9).

RESULTS

Test-retest reliability was good-excellent with acceptable lower CI for stair climb test, timed up and go, right leg timed single-leg stance, and calf raises (ICC = 0.84-0.91, 95% CI lower limit = 0.71-0.79). Agreement between telehealth and in-person was good-excellent with acceptable lower CI for 30-s chair stand, left leg single-leg stance, and calf raises (ICC = 0.82-0.91, 95% CI lower limit = 0.71-0.85).

DISCUSSION

Stair climb, timed up and go, right leg timed single-leg stance, and calf raise tests have acceptable reliability for use via telehealth in research and clinical practice. If re-testing via a different mode (telehealth/in-person), clinicians and researchers should consider using the 30-s chair stand test, left leg timed single-leg stance, and calf raise tests.

Agreement and concurrent validity between telehealth and in-person diagnosis of musculoskeletal conditions: a systematic review

OBJECTIVES

To assess the concurrent validity and inter-rater agreement of the diagnosis of musculoskeletal (MSK) conditions using synchronous telehealth compared to standard in-person clinical diagnosis.

METHODS

We searched five electronic databases for cross-sectional studies published in English in peer-reviewed journals from inception to 28 September 2023. We included studies of participants presenting to a healthcare provider with an undiagnosed MSK complaint. Eligible studies were critically appraised using the QUADAS-2 and QAREL criteria. Studies rated as overall low risk of bias were synthesized descriptively following best-evidence synthesis principles.

RESULTS

We retrieved 6835 records and 16 full-text articles. Nine studies and 321 patients were included. Participants had MSK conditions involving the shoulder, elbow, low back, knee, lower limb, ankle, and multiple conditions. Comparing telehealth versus in-person clinical assessments, inter-rater agreement ranged from 40.7% agreement for people with shoulder pain to 100% agreement for people with lower limb MSK disorders. Concurrent validity ranged from 36% agreement for people with elbow pain to 95.1% agreement for people with lower limb MSK conditions.

DISCUSSION

In cases when access to in-person care is constrained, our study implies that telehealth might be a feasible approach for the diagnosis of MSK conditions. These conclusions are based on small cross-sectional studies carried out by similar research teams with similar participant demographics. Additional research is required to improve the diagnostic precision of telehealth evaluations across a larger range of patient groups, MSK conditions, and diagnostic accuracy statistics.

Telerehabilitation in Physical Therapist Practice: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on telerehabilitation was developed by an American Physical Therapy Association volunteer guideline development group consisting of international physical therapists and physiotherapists, a physician, and a consumer. The guideline was based on systematic reviews of current scientific literature, clinical information, and accepted approaches to telerehabilitation in physical therapist practice. Seven recommendations address the impact of, preparation for, and implementation of telerehabilitation in physical therapist practice. Research recommendations identify current gaps in knowledge. Overall, with shared decision-making between clinicians and patients to inform patients of service delivery options, direct and indirect costs, barriers, and facilitators of telerehabilitation, the evidence supports the use of telerehabilitation by physical therapists for both examination and intervention. The Spanish and Chinese versions of this clinical practice guideline, as well as the French version of the recommendations, are available as supplementary material (Suppl. Materials).

Agreement of synchronous remote and in-person application of the Alberta Infant Motor Scale: Cohort study

INTRODUCTION

Using standardized scales to assess motor development via telemedicine can increase access for low-income populations. Our aim was to verify the agreement and feasibility between remotely and synchronously applying the Alberta Infant Motor Scale (AIMS) and the in-person format.

METHODS

This was a concordance study, with 77 typical infants aged 4-18 months (mean = 13 months). The AIMS was applied remote via video calls and face-to-face. We applied a questionnaire to caregivers to verify feasibility.

RESULTS

There was a high level of agreement between the remote and in-person assessments, with intraclass correlation coefficients above 0.98 and low standard error measure values (<1 item for each posture, <2 items for the total raw score, and =5% for the normative score). The smallest detectable change was between 1.67 and 2.45 for each posture, 3 for the total raw score, and 6% for the normative score. The Bland-Altman analysis showed low bias with the mean difference close to zero (<0.80) and low error with little dispersion of the difference points around the mean. Caregivers' perspectives on the synchronous remote assessment were positive, with good quality, clear information during the assessment, and comfort with the method.

DISCUSSION

The synchronous remote application of the AIMS may be an alternative for families without access to in-person services that assess motor development.

Performance of key physical tests for temporomandibular disorder via telehealth: Establishing validity and reliability

BACKGROUND

During the COVID-19 pandemic, many individuals sought healthcare virtually. Physiotherapy is integral in managing temporomandibular disorders (TMDs); therefore, establishing how key physical tests can be appropriately adapted to telehealth is paramount.

OBJECTIVES

To establish the validity and reliability of telehealth (specifically videoconferencing) assessments against in-person assessments on a battery of TMD physical tests.

METHOD

A repeated-measures study design was undertaken. Thirty-six adult participants (19 healthy and 17 TMD) underwent concurrent temporomandibular joint (TMJ) physiological movement measurements via videoconferencing and in-person as per standard clinical practice. Inclusion criteria included the presence of central incisors and no significant comorbidities precluding a safe telehealth examination. Participants with TMD completed seven additional pain provocation physical tests.

RESULTS

Agreement between telehealth and in-person physiological movement measures was excellent (ICC >0.90, 95% CI: 0.53 to >0.99). Inter- and intra-rater reliability for telehealth measures indicated excellent reliability (ICC >0.97, 95% CI: 0.91 to >0.99). Exact agreement between telehealth and in-person for provocation tests ranged between 58.8% and 94.1%. Fourteen of the twenty-six individual measures produced substantial to near perfect agreement (PABAK = 0.65-0.88), seven produced moderate agreement (PABAK = 0.53), while five produced poor to fair agreement (PABAK = 0.18-0.29).

CONCLUSION

There is high level of agreement between telehealth and in-person measurements of TMJ physiological movement and pain provocation tests.

Developing and embedding an advanced practice musculoskeletal physiotherapy service in public specialist outpatient services in Queensland: A health service masterclass

INTRODUCTION

The Musculoskeletal Physiotherapy Screening Clinic and Multi-disciplinary Service (MPSC&MDS) is an advanced practice physiotherapist-led model of care developed initially to address overburdened specialist orthopaedic outpatient public hospital services across Queensland, Australia.

PURPOSE

This Masterclass explores the experiences and success of embedding the MPSC&MDS state-wide across the Queensland public health system and its expansion in scale and reach to other specialist services. Key characteristics and development strategies are described that have collectively underpinned the expansion and sustainability of the service, using relevant stream sections and themes from a recommended musculoskeletal model of care framework.

IMPLICATIONS

The aim of this masterclass is to be informative for readers involved in the future development or refinement of similar models of care.

Level of diagnostic agreement in musculoskeletal shoulder diagnosis between remote and face-to-face consultations: A retrospective service evaluation

Background and Aims

To determine the level of diagnostic agreement between remote and face-to-face consultation in assessing shoulder complaints.

Methods

A retrospective service evaluation with three groups of patient data; those assessed only face-to-face (group 1), remotely then face-to-face (group 2), remotely only (group 3). Patient data were extracted from 6 secondary care shoulder Advanced Physiotherapy Practitioner's (APPs) records, covering six sites. Three-hundred-and-fifty-nine sets of patient data were included in the final evaluation. The main outcome measure was the percentage of agreement between diagnosis at initial and follow-up consultation, when assessed by APPs across the three groups. A Pearson χ 2 test was used to assess the relationship between the method of consultation and the level of diagnostic agreement. Diagnoses were categorized as either the same, similar, or different by an independent APP. Secondary outcome measures investigated whether age or the length of time between appointments had any effect in determining the level of diagnostic concordance.

Results

There was exact agreement of 77.05% and 85.52% for groups 1 and 3, respectively, compared with 34.93% for patient data in group 2. Similar clinical impressions across both initial and follow-up were seen 16.39% of the time in group 1, 7.24% of the time in group 3, and 36.99% in group 2. Lastly, the percentage of times a diagnosis was changed between initial and review appointments occurred in only 6.56% of group 1 contacts, 7.24% of group 3 contacts, but 28.08% of the time in group 2.

Conclusion

There was a large mismatch in the diagnosis of musculoskeletal shoulder complaints, when patients are initially assessed remotely and then followed-up in-person. This has implications for the future provision of shoulder assessment in physiotherapy.

The psychometric properties and feasibility of the Alberta infant motor scale used in telehealth: A scoping review

BACKGROUND

Telehealth can be a viable option for improving equitable access to early motor assessment for financially vulnerable individuals.

AIM

This review aimed to identify the psychometric properties of the Alberta Infant Motor Scale (AIMS) when applied via telehealth and assess its feasibility.

METHODS

Papers were systematically retrieved from electronic databases until October 4, 2023. We included studies that assessed the motor development of infants using the AIMS through telehealth.

RESULTS

Thirteen studies, encompassing 897 infants (449 male and 396 female), were included in this review. Among them, 805 were typical infants and 92 were at risk of motor delay. The age range of participants spanned from 4.9 weeks to 20 months. The studies found good concurrent validity between telehealth and in-person assessments (ICC > 0.98, SEM < 1.6, mean difference = 0.5) and good to excellent reliability (ICC > 0.80) using home videos recorded by parents or video calls with researchers. Telehealth was perceived as feasible by parents, who expressed high satisfaction, and the quality of images and assessments met commendable standards.

CONCLUSION

Considering the limited number of studies that have assessed infants with neuromotor disorders, this scale has the potential for telehealth application in evaluating typical infants.

Patient, Provider, and Organizational Considerations for Implementing Rehabilitation Telehealth

Introduction: While telehealth services (THS) have been around for some time, for many in the rehabilitation services, it is a new mode of service delivery. THS can be as effective as face-to-face care and are valued by patients and clinicians. However, THS present considerable challenges and may not be appropriate for everyone. Clinicians and organizations must be prepared to triage and manage patients in this environment. Aims of this study were to capture clinician perceptions of the implementation of THS in rehabilitation and use the insights gained to provide strategies for overcoming implementation challenges. Methods: An electronic survey was emailed to 234 rehabilitation clinicians in a large urban hospital. Completion was voluntary and anonymous. Qualitative analysis of the open-ended responses consisted of an iterative consensus-driven interpretivist approach. Multiple strategies were used to minimize bias and optimize trustworthiness. Results: From the 48 responses received, four themes were identified: (1) THS provide unique benefits for patients, providers, and organizations; (2) challenges arose in multiple domains (clinical, technological, environmental, and regulatory); (3) clinicians require specific personal, clinical, and technological knowledge, skills, and attributes to be effective; and (4) individual characteristics, session type, home environment, and needs must be considered in patient selection. Discussion and Conclusion: From the themes identified, a conceptual framework illustrating the keys to effective implementation of THS was developed. Recommendations addressing challenges across multiple domains (clinical, technological, environmental, and regulatory), and at all levels of care delivery (patient, provider, and organization) are provided. Insights gained from this study can be used by clinicians in advocating for and designing effective THS programs. Educators would also gain from using these recommendations to train students and clinicians to recognize and address the challenges they may encounter in providing THS in rehabilitation.

Co-development and evaluation of the Musculoskeletal Telehealth Toolkit for physiotherapists

INTRODUCTION

In-person physiotherapy services are not readily available to all individuals with musculoskeletal conditions, especially those in rural regions or with time-intensive responsibilities. The COVID-19 pandemic highlighted that telehealth may facilitate access to, and continuity of care, yet many physiotherapists lack telehealth confidence and training. This project co-developed and evaluated a web-based professional development toolkit supporting physiotherapists to provide telehealth services for musculoskeletal conditions.

METHODS

A mixed-methods exploratory sequential design applied modified experience-based co-design methods (physiotherapists [n = 13], clinic administrators [n = 2], and people with musculoskeletal conditions [n = 7]) to develop an evidence-informed toolkit. Semi-structured workshops were conducted, recorded, transcribed, and thematically analysed, refining the toolkit prototype. Subsequently, the toolkit was promoted via webinars and social media. The usability of the toolkit was examined with pre-post surveys examining changes in confidence, knowledge, and perceived telehealth competence (19 statements modelled from the theoretical domains framework) between toolkit users (>30 min) and non-users (0 min) using chi-squared tests for independence. Website analytics were summarised.

RESULTS

Twenty-two participants engaged in co-design workshops. Feedback led to the inclusion of more patient-facing resources, increased assessment-related visual content, streamlined toolkit organisation, and simplified, downloadable infographics. Three hundred and twenty-nine physiotherapists from 21 countries completed the baseline survey, with 172 (52%) completing the 3-month survey. Toolkit users had greater improvement in knowledge, confidence, and competence than non-users in 42% of statements. Seventy-two percentage of toolkit users said it changed their practice, and 95% would recommend the toolkit to colleagues. During the evaluation period, the toolkit received 5486 total views.

DISCUSSION

The co-designed web-based Musculoskeletal Telehealth Toolkit is a professional development resource that may increase physiotherapist's confidence, knowledge, and competence in telehealth.

[Remote management of musculoskeletal pain : A pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice. German version]

INTRODUCTION

Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations.

OBJECTIVES

This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain.

METHODS

Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience.

RESULTS

The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication.

CONCLUSION

This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Interobserver Agreement and Satisfaction With the use of Telemedicine for Evaluating low Back Pain: A Primary, Observational, Cross-Sectional, Analytical Study

STUDY DESIGN

A primary, observational, cross-sectional, analytical study.

OBJECTIVE

The development of a framework for systematic telemedicine (TM) for orthopedic physicians in frequent clinical care may increase agreement in diagnosis and satisfaction among users of TM. Therefore, this study aimed to estimate the agreement in the diagnosis of low back pain (LBP) between TM, systematized by a self-completed digital questionnaire, and face-to-face (FF) care in patients with LBP.

METHODS

This study included adults up to 75 years of age with LBP for more than 6 weeks. They were evaluated at 2 independent time points (TM and FF) by different orthopedists with 3 different levels of expertise. Professionals evaluated the sample without prior knowledge of the diagnosis, and each orthopedist provided a diagnosis. Diagnostic agreement was the primary outcome. Secondary outcomes were the duration of the visit and satisfaction among healthcare professionals.

RESULTS

A total of 168 participants were eligible, of whom 126 sought care through TM and 122 sought FF care (mean age, 47 years [range, 18-75 years]; 66.4% women). The agreement among professionals regarding the diagnosis was moderate (kappa = .585, P = .001). TM was faster than FF (11.9 minutes (standard deviation = 4.1) vs 18.6 (SD = 6.9), P < .001). Professional satisfaction was higher among spine specialists than among orthopedic residents and orthopedists who were not specialists in spine surgery.

CONCLUSION

Agreement in diagnosis was moderate for TM, with a 30% shorter visit duration than FF. Satisfaction varied by professional expertise and was higher among spine specialists than among professionals with other expertise.

Telemedicine Effectiveness in the First Elective Orthopedic Care Compared to a Standard Face-to-face Visit

Objective  The study aimed to compare whether the diagnoses of orthopedic diseases at telemedicine (TM) consultations are the same as those established at face-to-face visits. Method  Primary, observational, prospective, analytical study, with subjects from the local municipal network who were referred to the orthopedics outpatient clinic from May to June 2021. Subjects underwent two assessments: a telemedicine (TM) consultation and a face-to-face (FF) visit. Two different physicians attended to the patients and established a diagnosis. The physician performing the FF visit was not aware of the previous diagnoses. We compared the diagnoses obtained at both modalities to assess the degree of similarity. In addition, we determined the time required for consultations and the degree of satisfaction of the physicians. Results  We evaluated 43 patients and seven physicians, totaling 44 TM and 43 FF visits. The diagnostic similarity index was 81.4%. TM consultations were shorter (mean time, 4.8 minutes) than FF visits. Physicians were less satisfied with TM in the four criteria evaluated (respective scores of 79.1, 23.3, 46.6, and 37.2). Conclusion  TM consultations have a diagnoses agreement higher than 80% compared with FF visits. On the other hand, TM consultations were faster, and physicians were less satisfied with them in comparison with FF visits.

Clinician Perspectives on Providing Concussion Assessment and Management via Telehealth: A Mixed-Methods Study

OBJECTIVE

To examine clinician perspectives regarding the use of telehealth for concussion assessment and management.

SETTING

A Pan-Canadian survey.

PARTICIPANTS

Twenty-five purposively sampled multidisciplinary clinician-researchers with concussion expertise (female, n = 21; physician, n = 11; and other health professional, n = 14).

DESIGN

Sequential mixed-method design: (1) electronic survey and (2) semistructured interviews with focus groups via videoconference. Qualitative descriptive design.

MAIN OUTCOME MEASURES

Survey : A 59-item questionnaire regarding the suitability of telehealth to perform recommended best practice components of concussion assessment and management. Focus groups : 10 open-ended questions explored survey results in more detail.

RESULTS

Clinicians strongly agreed that telehealth could be utilized to obtain a clinical history (96%), assess mental status (88%), and convey a diagnosis (83%) on initial assessment; to take a focused clinical history (80%); to monitor functional status (80%) on follow-up; and to manage symptoms using education on rest (92%), planning and pacing (92%), and sleep recommendations (91%); and to refer to a specialist (80%). Conversely, many clinicians believed telehealth was unsuitable to perform a complete neurologic examination (48%), cervical spine (38%) or vestibular assessment (61%), or to provide vestibular therapy (21%) or vision therapy (13%). Key benefits included convenience, provision of care, and patient-centered approach. General and concussion-specific challenges included technology, quality of care, patient and clinician characteristics, and logistics. Strategies to overcome identified challenges are presented.

CONCLUSIONS

From the perspective of experienced clinicians, telehealth is suited to manage symptomatic concussion patients presenting without red flags or following an initial in-person assessment, but may have limitations in ruling out serious pathology or providing return-to-sport clearance without an in-person physical examination.

Implementation of a telerehabilitation program for children with neurodevelopmental disorders during the lockdown caused by COVID-19

Introduction

Telerehabilitation is a tool for patients who, for different reasons, cannot participate in person with their physical presence. We aimed to identify the factors associated with satisfaction with telerehabilitation in families with children with neurodevelopmental disorders through a program that included physiotherapy, occupational therapy, and speech therapy.

Methods

The program was developed during the COVID-19 lockdown period. Outcome measures: Child's age, the school stage to which they belonged, the person of reference in their daily care at home. The resources provided to the families, as well as the frequency of activities and difficulties detected, were evaluated through a survey.

Findings

One hundred thirteen families responded to the survey. The general assessment resources were classified as very good. The average frequency of carrying out the activities was two times a week, with an average of 30 minutes per session. The ability to understand the information in the manual was not affected by the academic status of the caregivers (p = 0.286).

Conclusions

This is the first study to quantify the multidisciplinary approach to children with neurodevelopmental disorders using telerehabilitation. The results show high levels of participation and satisfaction. The resources could be shared for their applicability in other countries whose families have similar needs conditioned by COVID-19.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review

BACKGROUND

This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness.

METHODS

Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE.

RESULTS

Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment.

DISCUSSION

Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access.

TRIAL REGISTRATION

The review was registered in the PROSPERO database, CRD42021277624.

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.

Telerehabilitation as a Therapeutic Exercise Tool versus Face-to-Face Physiotherapy: A Systematic Review

Digital physiotherapy, often referred to as "Telerehabilitation", consists of applying rehabilitation using telecommunication technologies. The objective is to evaluate the effectiveness of therapeutic exercise when it is telematically prescribed.

METHODS

We searched PubMed, Embase, Scopus, SportDiscus and PEDro (30 December 2022). The results were obtained by entering a combination of MeSH or Emtree terms with keywords related to telerehabilitation and exercise therapy. RCTs on patients over 18 years and two groups were included, one working with therapeutic exercise through telerehabilitation and one working with conventional physiotherapy group.

RESULTS

a total of 779 works were found. However, after applying the inclusion criteria, only 11 were selected. Telerehabilitation is most frequently used to treat musculoskeletal, cardiac and neurological pathologies. The preferred telerehabilitation tools are videoconferencing systems, telemonitoring and online platforms. Exercise programs ranged from 10 to 30 min and were similar in both intervention and control groups. In all the studies, results proved to be similar for telerehabilitation and face-to-face rehabilitation in both groups when measuring functionality, quality of life and satisfaction.

CONCLUSION

this review generally concludes that intervention through telerehabilitation programs is as feasible and efficient as conventional physiotherapy in terms of functionality level and quality of life. In addition, telerehabilitation shows high levels of patients' satisfaction and adherence, being values equivalent to traditional rehabilitation.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Digital physical therapy practice and payment during the COVID-19 pandemic: A case series

BACKGROUND

Insurance regulation and reimbursement are barriers to physical therapy-delivered digital practice.

OBJECTIVE

The present case series describes the clinical reasoning, outcomes, and practical use of digital tools to improve pain and movement of patients seen for musculoskeletal pain during the COVID-19 pandemic.

CASE DESCRIPTION

Three patients, 2 with low back pain and 1 with cervicogenic headache, were treated at a private outpatient clinic. Collaborative reasoning was used to determine appropriate use of digital tools. Because of the pandemic, one patient used telephone visits to complete treatment (25% of total visits), one used telehealth visits only during stay-at-home orders (33% of total visits), and one was evaluated and treated entirely using telehealth (100% of total visits). All visits were billed and paid for by the patient or insurance at the same rate as an in-person visit.

OUTCOMES

All 3 patients met self-reported goals for physical therapy, met or surpassed their risk-adjusted predicted functional status score, and expressed high satisfaction with treatment.

CONCLUSION

Individualized prescription and execution of digital physical therapy practice allowed patients with musculoskeletal pain to have effective physical therapy care during the COVID-19 pandemic. Removal of regulatory and payment barriers were necessary for the provision of care.

The state of the art in telerehabilitation for musculoskeletal conditions

BACKGROUND

Given the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future.

MAIN BODY

Telerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users.

CONCLUSIONS

Telerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

Does the Integration of Telehealth into Occupational Therapy Practice Impact Clinical Outcomes for Hand and Upper Limb Rehabilitation? A Matched Case Control Study

Health services are capitalizing on the rise of telehealth and seeking to develop sustainable models incorporating telehealth into standard care. Further research is required to explore the service and clinical outcomes of telehealth in occupational therapy hand and upper limb practice. This research utilized a case-control study to explore the feasibility and clinical outcomes of case matched patients who received a telehealth hybrid model versus traditional in-person care. One hundred and two patients were recruited (n=51 in the controls and cases) with a mean age of 45 years. Telehealth was not inferior to standard care with no significant increase in therapy time (p=0.441) or length of referral (p=0.047). There was no difference in clinical adverse events (p=0.741). Patients who received telehealth had significantly less withdrawals from the service (p = 0.031). Patient and therapist satisfaction were high, supporting the ongoing use and continued implementation of telehealth in occupational therapy.

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.

Reliability and accuracy of telemedicine-based shoulder examinations

BACKGROUND

Telemedicine has become a critical component in the evaluation and management of patients with shoulder pathology. However, the interobserver reliability of findings on virtual physical examination relative to in-person evaluation is unclear. The purpose of this study was to determine the reliability of prerecorded video telemedicine for the evaluation of shoulder pathology compared with traditional in-person physical examination.

METHODS

New patients with unilateral shoulder pain presenting to a single-surgeon shoulder clinic were recruited between July and November 2020. In 1 visit, patients were evaluated with standardized in-person and video-guided telemedicine physical examinations in randomized order. Patients were evaluated for range of motion (ROM) and symptoms including pain, weakness, and apprehension. The telemedicine examination was recorded and consisted of a video guide displaying self-directed shoulder examination maneuvers that patients performed during remote coaching by an independent non-physician observer. The in-person physical examination was performed by the treating physician. The telemedicine videos were evaluated by two independent observers for interobserver reliability. The treating physician subsequently evaluated the telemedicine videos after a minimum two-month washout period for intraobserver reliability and intra-platform reliability. Interobserver and intraobserver reliability analyses were conducted using Kuder-Richardson formula 20 (KR-20). Specificity and likelihood ratios were calculated with P < .05 representing statistical significance.

RESULTS

A total of 32 patients (17 male and 15 female patients; average age, 50.2 ± 16.2 years) were included in the analysis. Overall Kuder-Richardson formula 20 (KR-20) reliability across 40 physical examination maneuvers was 0.391 ± 0.332 (76.4% ± 15.4% agreement) between the in-person and telemedicine examinations. Telemedicine maneuvers examining ROM limitations had the highest degree of reliability, sensitivity, specificity, and likelihood of also producing a positive finding on the in-person examination (0.700 ± 0.114, 66.5%, 81.0%, and 6.06, respectively). Telemedicine maneuvers identifying apprehension associated with glenohumeral instability were found to have the lowest reliability, sensitivity, and likelihood of producing a positive finding on the in-person examination (0.170 ± 0.440, 23.5%, and 0.518, respectively). All patients were satisfied with their telemedicine experience.

CONCLUSION

The overall reliability of a non-physician-directed video-guided telemedicine examination ranged from unacceptable to good. Shoulder ROM limitations identified during the telemedicine examinations were found to be the most reliable, whereas evaluations of instability were found to be the least reliable. Although initial telemedicine evaluation by a non-physician may be appropriate for ROM evaluation, in-person physician evaluation is recommended to confirm suspected diagnoses, especially if clinical concern for shoulder instability exists. Alternative methods of telemedicine delivery should be explored to improve the reliability of self-directed physical examination maneuvers.

What is the content of virtually delivered pain management programmes for people with persistent musculoskeletal pain? A systematic review

INTRODUCTION

Virtual consultations (VC) have been embraced by healthcare organisations during the COVID-19 pandemic. VC allows continuation of patient care while adhering to government advised restrictions and social distancing measures. Multidisciplinary pain management programmes (PMPs) are a core element of many pain services and utilising virtual methods to deliver PMPs has allowed them to continue to provide care. This systematic review aimed to explore the content of existing virtually delivered PMPs and discuss if and how these findings can be used to guide clinical delivery.

METHODS

Eligible studies included adults (aged ⩾18 years) with persistent musculoskeletal pain and any virtually delivered intervention that was described as a PMP or that had components of PMPs. Databases were searched from inception until July 2020. We performed a content analysis comparing existing interventions with established evidence-based clinical guidelines published by the British Pain Society (BPS). Intervention reporting quality was assessed using the Template for Intervention Description and Replication (TIDieR) checklist: an established checklist developed to improve the completeness of the reporting of interventions.

RESULTS

Eight studies were included. One intervention included six of the seven components recommended by the BPS; none included all seven. 'Skills training and activity management' was present in all eight interventions; 'education' and 'cognitive therapy methods' were present in six interventions; 'graded activation' and 'methods to enhance acceptance, mindfulness and psychological flexibility' were present in four interventions; 'physical exercise' was present in two interventions and 'graded exposure' was present in one intervention. None of the studies described all 12 items of the TIDieR checklist adequately enough for replication.

CONCLUSION

Published virtual PMPs partially meet established clinical guidelines. Future virtual PMPs should be based on evidence-based clinical guidelines, and more research is needed to explore the effectiveness of virtually delivered PMPs and each recommended component.

Does Telerehabilitation Help in Reducing Disability among People with Musculoskeletal Conditions? A Preliminary Study

Introduction: During the coronavirus pandemic, an initiative was launched in Saudi Arabia to provide telerehabilitation for people with musculoskeletal conditions who were unable to access in-person physiotherapy due to the associated lockdown. The purpose of this study was to explore the therapeutic impact and acceptability of telerehabilitation among the Saudi population. Methods: Ninety-five participants were recruited through an online advertisement and received a physiotherapy consultation and interventions via an online video conference platform (Google Meet). Following screening for red flags, participants received tailored education and conditioning exercises 2–3 times a week for 6 weeks. Outcome measures were recorded at baseline and 6 weeks and comprised the Pain Self-Efficacy Questionnaire, Patient-Specific Functional Scale, Musculoskeletal Health Questionnaire and a satisfaction survey. Results: The most frequent musculoskeletal conditions reported were lower back (37%), knee (14%) and neck (10%) pain and post-operative conditions (15%). Participants showed significant improvements in outcomes at the end of the program (p < 0.001) with effect sizes ranging from 0.6 to −1.9 and reported a high level of satisfaction with the telerehabilitation intervention. Conclusion: This study showed that telerehabilitation was an acceptable method of providing physiotherapy interventions for patients with musculoskeletal conditions in Saudi Arabia.

The utility of physiotherapy assessments delivered by telehealth: A systematic review

BACKGROUND

Telehealth use is increasing due to its ability to overcome service access barriers and provide continued care when disease transmission is of concern. However, little is known of the validity, reliability and utility of performing physiotherapy assessments using synchronous forms of telehealth across all physiotherapy practice areas. The aim of this systematic review was to determine the current clinometric value of performing physiotherapy assessments using synchronous forms of telehealth across all areas of physiotherapy practice.

METHODS

A comprehensive search of databases (PubMed/MEDLINE, The Cochrane Library, Embase and EBSCO) was undertaken to identify studies investigating the clinometric value of performing physiotherapy assessments using synchronous forms of telehealth across all physiotherapy practice areas. Following selection, a quality appraisal was conducted using the Brink and Louw or Mixed Methods Appraisal Tool. Evidence regarding validity, reliability and utility of synchronous telehealth physiotherapy assessments was extracted and synthesised using a critical narrative approach.

RESULTS

Thirty-nine studies conducted in a variety of simulated (n = 15) or real-world telehealth environments (n = 24), were included. The quality of the validity, reliability and utility studies varied. Assessments including range of movement, muscle strength, endurance, pain, special orthopaedic tests (shoulder/elbow), Berg Balance Scale, timed up and go, timed stance test, six-minute walk test, steps in 360-degree turn, Movement Assessment Battery for Children (2nd Edition), step test, ABILHAND assessment, active straight leg raise, and circumferential measures of the upper limb were reported as valid/reliable in limited populations and settings (many with small sample sizes). Participants appeared to embrace telehealth technology use, with most studies reporting high levels of participant satisfaction. If given a choice, many reported a preference for in-person physiotherapy assessments. Some inconsistencies in visual/auditory quality and challenges with verbal/non-verbal communication methods were reported. Telehealth was considered relatively cost-effective once services were established.

CONCLUSIONS

Performing physiotherapy assessments using synchronous forms of telehealth appears valid and reliable for specific assessment types in limited populations. Further research is needed in all areas of physiotherapy practice, to strengthen the evidence surrounding its clinometric value. Clinicians contemplating using this assessment mode should consider the client/family preferences, assessment requirements, cultural needs, environment, cost considerations, access and confidence using technology.

PROTOCOL REGISTRATION

PROSPERO: CRD42018108166.

Validation of a Musculoskeletal Digital Assessment Routing Tool: Protocol for a Pilot Randomized Crossover Noninferiority Trial

Background

Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on millions of patients and an increasing demand for health care use. Digital technologies to improve health care outcomes and efficiency are considered a priority; however, innovations are rarely tested with sufficient rigor in clinical trials, which is the gold standard for clinical proof of safety and efficacy. We have developed a new musculoskeletal digital assessment routing tool (DART) that allows users to self-assess and be directed to the right care. DART requires validation in a real-world setting before implementation.

Objective

This pilot study aims to assess the feasibility of a future trial by exploring the key aspects of trial methodology, assessing the procedures, and collecting exploratory data to inform the design of a definitive randomized crossover noninferiority trial to assess DART safety and effectiveness.

Methods

We will collect data from 76 adults with a musculoskeletal condition presenting to general practitioners within a National Health Service (NHS) in England. Participants will complete both a DART assessment and a physiotherapist-led triage, with the order determined by randomization. The primary analysis will involve an absolute agreement intraclass correlation (A,1) estimate with 95% CI between DART and the clinician for assessment outcomes signposting to condition management pathways. Data will be collected to allow the analysis of participant recruitment and retention, randomization, allocation concealment, blinding, data collection process, and bias. In addition, the impact of trial burden and potential barriers to intervention delivery will be considered. The DART user satisfaction will be measured using the system usability scale.

Results

A UK NHS ethics submission was done during June 2021 and is pending approval; recruitment will commence in early 2022, with data collection anticipated to last for 3 months. The results will be reported in a follow-up paper in 2022.

Conclusions

This study will inform the design of a randomized controlled crossover noninferiority study that will provide evidence concerning mobile health DART system clinical signposting in an NHS setting before real-world implementation. Success should produce evidence of a safe, effective system with good usability, potentially facilitating quicker and easier patient access to appropriate care while reducing the burden on primary and secondary care musculoskeletal services. This rigorous approach to mobile health system testing could be used as a guide for other developers of similar applications.

Trial Registration

ClinicalTrials.gov NCT04904029; http://clinicaltrials.gov/ct2/show/NCT04904029

International Registered Report Identifier (IRRID)

PRR1-10.2196/31541

The Telemedicine-Based Pediatric Examination of the Neck and Upper Limbs: A Narrative Review

With the COVID-19 pandemic hastening the adoption of telemedicine into clinical practice, it has also prompted an abundance of new literature highlighting its capabilities and limitations. The purpose of this review is to summarize the current state of the literature on telemedicine applied in the context of a musculoskeletal examination of the neck and upper limbs for children 3 to 18 years old. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. General examination components including inspection, guided self-palpation, range of motion, sensory and motor examination, as well as special testing are described. Although the literature is focused mainly on adult populations, we describe how each component of the exam can be reliably incorporated into a virtual appointment specific to pediatric patients. Caregivers are generally needed for most consultations, but certain maneuvers can be self-performed by older children and adolescents alone. There is general feasibility, validity, and substantial reliability in performing most examination components of the upper limbs remotely, except for the shoulder exam. Compared to those made in person, clinical diagnoses established virtually were found to be either the same or similar in most cases, and management decisions also had high agreement. Despite this, there is evidence that some pediatric providers may not be able to collect all the information needed from a telemedicine visit to make a complete clinical assessment. Lastly, currently available smartphone applications measuring joint range of motion were found to have high reliability and validity. This narrative review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase physicians' confidence in incorporating telemedicine into their standard of care.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.

A qualitative investigation into the results of a discrete choice experiment and the impact of COVID-19 on patient preferences for virtual consultations

OBJECTIVES

To conduct a qualitative investigation on a subset of participants from a previously completed Discrete Choice Experiment (DCE) to understand why factors identified from the DCE are important, how they influenced preference for virtual consultations (VC) and how COVID-19 has influenced preference for VC.

METHODS

A quota sample was recruited from participants who participated in our DCE. We specifically targeted participants who were strongly in favour of face-to-face consultations (F2F - defined as choosing all or mostly F2F in the DCE) or strongly in favour of virtual consultations (VC - defined as choosing all or mostly VC consultations in the DCE) to elicit a range of views. Interviews were conducted via telephone or videoconference, audio recorded, transcribed verbatim and uploaded into NVIVO software. A directed content analysis of transcripts was undertaken in accordance with a coding framework based on the results of the DCE and the impact of COVID-19 on preference.

RESULTS

Eight F2F and 5 VC participants were included. Shorter appointments were less 'worth' travelling in for than a longer appointment and rush hour travel had an effect on whether travelling was acceptable, particularly when patients experienced pain as a result of extended journeys. Socioeconomic factors such as cost of travel, paid time off work, access to equipment and support in its use was important. Physical examinations were preferable in the clinic whereas talking therapies were acceptable over VC. Several participants commented on how VC interferes with the patient-clinician relationship. VC during COVID-19 has provided patients with the opportunity to access their care virtually without the need for travel. For some, this was extremely positive.

CONCLUSIONS

This study investigated the results of a previously completed DCE and the impact of COVID-19 on patient preferences for VC. Theoretically informative insights were gained to explain the results of the DCE. The use of VC during the COVID-19 pandemic provided opportunities to access care without the need for face-to-face social interactions. Many felt that VC would become more commonplace after the pandemic, whereas others were keen to return to F2F consultations as much as possible. This qualitative study provides additional context to the results of a previously completed DCE.

Convenience is Key for Patient Engagement with Remote Video Visits in a Musculoskeletal Practice

Background

Remote video visits (aka telemedicine, virtual care) have the potential to increase access to orthopaedic specialty evaluation while decreasing the overall cost of care. Clinical implementation of remote video visits may benefit from an understanding of potential barriers to participation.

Methods

We enrolled one hundred and thirty participants from a university-based musculoskeletal clinic with a large uninsured population. We asked participants to complete a survey, including demographics and scaled perception questions about remote video visits. Data from these surveys were analyzed with multivariable logistic regression to determine factors associated with willingness to participate in video visits, as well as the situations in which patients would consider a video visit.

Results

Willingness to participate in video visits was associated with the perception of video visits being more convenient (OR 3.0) and a decreased perceived importance of physical exam (OR 0.36) but not age, technology comfort, or travel distance to the clinic. Additionally, those with prior video visit experience were more comfortable with technology, perceived video visits to be more convenient, and were more willing to have another video visit. Fifteen percent were willing to have a video visit for their first visit, while 78% would participate for a routine non-surgical follow-up.

Conclusion

Musculoskeletal telemedicine programs can become established by focusing on people that prioritize convenience, place less importance on a hands-on exam, and are established patients.

Disparities in Service and Clinical Outcomes in State-Wide Advanced Practice Physiotherapist-Led Services

This study explored variations in the primary service and clinical outcomes of a state-wide advanced practice physiotherapist-led service embedded in public medical specialist orthopaedic and neurosurgical outpatient services across Queensland, Australia. An audit of the service database over a six-year period was taken from 18 service facilities. The primary service and clinical outcomes were described. Variations in these outcomes between facilities were explored with a regression analysis adjusting for known patient- and service-related characteristics. The findings showed substantial positive impacts of the advanced practice model across all facilities, with 69.4% of patients discharged without a need for medical specialist review (primary service outcome), consistent with 68.9% of patients reporting clinically important improvements in their condition (primary clinical outcome). However, 15 facilities significantly varied from the state average for the primary service outcome (despite only three facilities varying in the primary clinical outcome). While this disparity in the primary service outcomes appears to be influenced by potentially modifiable differences in the service-related processes between facilities, these process differences only explained part of the variation. This study described the subsequent development of a new, more comprehensive set of service evaluation metrics to better inform future service planning.

A telephone assessment and advice service within an ED physiotherapy clinic: a single-site quality improvement cohort study

BACKGROUND

In response to issues with timely access and high non-attendance rates for Emergency Department (ED) physiotherapy, a telephone assessment and advice service was evaluated as part of a quality improvement project. This telehealth option requires minimal resources, with the added benefit of allowing the healthcare professional streamline care. A primary aim was to investigate whether this service model can reduce wait times and non-attendance rates, compared to usual care. A secondary aim was to evaluate service user acceptability.

METHODS

This was a single-site quality improvement cohort study that compares data on wait time to first physiotherapy contact, non-attendance rates and participant satisfaction between patients that opted for a service based on initial telephone assessment and advice, versus routine face-to-face appointments. 116 patients were referred for ED physiotherapy over the 3-month pilot at the ED and out-patient physiotherapy department, XMercy University Hospital, Cork, Ireland. 91 patients (78%) opted for the telephone assessment and advice service, with 40% (n=36) contacting the service. 25 patients (22%) opted for the face-to-face service. Data on wait time and non-attendance rates was gathered using the hospital data reporting system. Satisfaction data was collected on discharge using a satisfaction survey adapted from the General Practice Assessment Questionnaire. Independent-samples t-test or Mann Whitney U Test was utilised depending on the distribution of the data. For categorical data, Chi-Square tests were performed. A level of significance of p ≤ 0.05 was set for this study.

RESULTS

Those that contacted the telephone assessment and advice service had a significantly reduced wait time (median 6 days; 3-8 days) compared to those that opted for usual care (median 35 days; 19-39 days) (p ≤ 0.05). There was no significant between-group differences for non-attendance rates or satisfaction.

CONCLUSION

A telephone assessment and advice service may be useful in minimising delays for advice for those referred to ED Physiotherapy for musculoskeleltal problems. This telehealth option appears to be broadly acceptable and since it can be introduced rapidly, it may be helpful in triaging referrals and minimising face-to-face consultations, in line with COVID-19 recommendations. However, a large scale randomised controlled trial is warranted to confirm these findings.

Systematic review of telemedicine in spine surgery

OBJECTIVE

The use of telemedicine (TM) has long been available, but recent restrictions to hospitals due to the coronavirus disease 2019 (COVID-19) pandemic have accelerated the global implementation of TM. However, evidence on the effectiveness of this technology for the care of spine surgery patients is limited. In this systematic review the authors aimed to examine the current utilization of TM for spine surgery.

METHODS

Using PubMed, Scopus, and the Cochrane Library, the authors performed a systematic review of the literature focused on the themes of telemedicine and spine surgery. Included in the search were randomized controlled trials, cohort studies, and case-controlled studies. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.

RESULTS

Out of 1463 references from the initial search results, 12 studies met the inclusion criteria. The majority of TM interventions focused on improving perioperative patient communication and patient education by using mobile phone apps, online surveys, or online materials for consent. The studies reported the feasibility of the use of TM for perioperative care and positive user experiences from the patients.

CONCLUSIONS

The current increase in TM adoption due to the COVID-19 crisis presents an opportunity to further develop and validate this technology. Early evidence in the literature supports the use of TM as an adjunct to traditional in-person clinical encounters for certain perioperative tasks such as supplemental patient education and postoperative surveys.

Musculoskeletal Physical Therapy After COVID-19: Time for a New "Normal"

In late 2019, a previously unknown coronavirus, SARS-CoV-2 (the coronavirus that causes COVID-19), was reported in Wuhan, China. Similar to the polio virus epidemic, the fear, uncertainty, and collective response associated with COVID-19 have disrupted daily life on a global scale. In this editorial, we argue that it is time for musculoskeletal physical therapists to grasp the opportunity provided by the COVID-19 pandemic to provide care that is (1) primarily active, (2) focused on self-efficacy and self-management, and (3) far less reliant on passive therapies. J Orthop Sports Phys Ther 2021;51(1):5-7. doi:10.2519/jospt.2021.0102.

Remote management of musculoskeletal pain: a pragmatic approach to the implementation of video and phone consultations in musculoskeletal practice

Video and phone consultations for musculoskeletal pain are effective, safe, and appreciated by patients. Implementation and execution require special consideration and such guidance is provided.

Introduction:

Remote consultations through phone or video are gaining in importance for the treatment of musculoskeletal pain across a range of health care providers. However, there is a plethora of technical options for practitioners to choose from, and there are various challenges in the adaptation of clinical processes as well as several special considerations regarding regulatory context and patient management. Practitioners are faced with a lack of high-quality peer-reviewed resources to guide the planning and practical implementation of remote consultations.

Objectives:

This Clinical Update seeks to provide practical guidance for the planning and implementation of remote consultations for the management and treatment of people with musculoskeletal pain.

Methods:

Recommendations are based on a brief overview of the relevant research regarding phone and video consultations for musculoskeletal practice and derived from the literature, relevant guidelines, and practical experience.

Results:

The technical feasibility of remote consultations for musculoskeletal complaints is good, patient satisfaction is high, and a growing body of evidence supports its comparative effectiveness to in-person consultations in some circumstances for improving pain and functioning. We consider in detail practical aspects such as the choosing of hardware and software, we touch on the legal and regulatory context, and we focus on the adaptation of clinical processes and communication.

Conclusion:

This Clinical Update draws together best-practice evidence in a practically applicable format, enabling therapists who are working with people with pain to directly apply this knowledge to their individual clinical settings and the requirements of their patients.

Advanced practice physiotherapy for adults with spinal pain: a systematic review with meta-analysis

OBJECTIVE

To appraise the available evidence on advanced practice physiotherapy (APP) models of care (MoC) in specialized secondary care such as orthopaedic, rheumatology or neurosurgery outpatients' clinics for adults with spinal pain.

METHODS

Systematic review with meta-analysis. Electronic searches were conducted up to July 2020 in Medline, Embase, Cochrane CENTRAL and CINAHL. Studies on APP MoC in specialized secondary care for adults with spinal pain were included.

RESULTS

Eighteen studies (n = 9405), including two randomized controlled trials and sixteen observational studies were included. One study was considered at high quality, fourteen studies were considered of moderate quality and three were considered of low quality. Pooled results for change in disability for patients with spinal pain reported no significant difference between APP and usual medical care (UMC). Mean wait time for initial consultation was lower with APP (1-9.4 weeks) than with UMC MoC (23-65 weeks). Following the implementation of APP MoC, wait time for a consultation with a medical specialist was reduced (6-16 weeks). Physiotherapists in APP MoC managed independently 89.2% of the patients referred (n = 8393). Stakeholders and patients reported high satisfaction with APP care.

CONCLUSIONS

APP MoC and UMC likely result in comparable pain, disability and quality of life improvement for adults with spinal pain. However, APP MoC have the potential to improve health care access by reducing wait time for consultation in specialized care and maintaining a high level of satisfaction among stakeholders and patients.

Virtual assessments of knee and wrist joint range motion have comparable reliability with face-to-face assessments

BACKGROUND

There has been increased usage of virtual telerehabilitation approach during the COVID-19 pandemic. It is crucial to establish reliability of conducting virtual assessments for musculoskeletal conditions.

OBJECTIVES

This research determined the intra- and interrater reliability of measuring knee and wrist range of motion (ROM) assessed virtually and obtained face-to-face (F2F) using a goniometer (UG) for a student and an experienced examiner.

METHOD

Knee and wrist joint ROM for 54 healthy participants was assessed virtually and F2F by a student examiner and an experienced physical therapist. Intra- (virtual vs. UG assessment) and inter-rater (virtual or UG assessment between examiners) reliabilities were examined for all ROM using Intraclass correlation coefficient (ICC). The ICC values were considered good (>0.75) or excellent (>0.90). Bland and Altman plots determined the limits of agreement (LOA) in assessing joint ROM.

RESULTS/FINDINGS

Student examiner had good reliability in virtually estimating knee extension (ICC = 0.79), wrist flexion (ICC = 0.82) and wrist extension (ICC = 0.78), whereas the experienced examiner had excellent reliability in virtually estimating all knee and wrist ROM (ICC > 0.90). The LOA in assessing knee and wrist ROM for the student examiner were wider indicating higher disagreement between virtual and UG-obtained ROM in some cases.

CONCLUSIONS

Virtual estimation of knee and wrist ROM is a reliable technique, however experience level impacts the precision of measurement. It is suggested that the same examiner conducts all the ROM assessments throughout the clinical course of a patient receiving virtual interventions for knee or wrist pathologies.

Clinicians' User Experience of Telemedicine in Neurosurgery During COVID-19

BACKGROUND

Restricted access to hospitals due to the 2019 novel coronavirus disease (COVID-19) pandemic has significantly altered practice patterns for elective neurosurgical care. Particularly, telemedicine has become the primary modality of patient visits for nonemergent conditions. This study aimed to characterize user experiences of neurosurgeons and advanced practice providers focusing on perceived utility and barriers of telemedicine in management of elective neurosurgical patients during COVID-19.

METHODS

An online survey was sent to clinicians involved in neurosurgical care using telemedicine with questions focusing on frequency of utilization, duration of patient encounters, benefits of telemedicine, and barriers to current forms of remote patient visits. Survey responses were stratified by clinical position (neurosurgeon vs. advanced practice provider) and subspecialty focus (cranial vs. spinal neurosurgery).

RESULTS

The survey was completed by 14 of 17 eligible clinicians. Respondents included 10 neurosurgeons and 4 APPs with 57% specializing in cranial neurosurgery and 43% specializing in spinal neurosurgery. During the COVID-19 period, 78% of respondents used teleconference/video conference visits multiple times in a week, and 86% planned to continue using telemedicine after the pandemic. The most common barrier for telemedicine was the inability to perform a neurological examination, while the most common perceived benefit was increased convenience for patients.

CONCLUSIONS

During the COVID-19 period, telemedicine was heavily relied on to ensure the continuation of perioperative care for patients with elective neurosurgical pathologies. While clinicians identified numerous barriers for current telemedicine platforms, the use of telemedicine will likely continue, as it has provided unique benefits for patients, clinicians, and hospitals.

Telehealth for musculoskeletal physiotherapy

INTRODUCTION

Musculoskeletal conditions are a leading cause of global morbidity. Access to traditional in-person healthcare can be difficult for some under usual conditions and has become a ubiquitous barrier throughout the COVID-19 pandemic. Telehealth, defined as the 'delivery of healthcare at a distance using information and communication technology' is a solution to many access barriers and has been rapidly adopted by many healthcare professions throughout the crisis. While significant advancements in technology has made the widespread adoption of telehealth feasible, there are many factors to be considered when implementing a telehealth service.

PURPOSE

The aims of this masterclass are to (i) introduce telehealth and outline the current research within the context of musculoskeletal physiotherapy; (ii) provide insights into some of the broader challenges in the wide-scale adoption of telehealth; and (iii) to describe a systematic approach to implementing telehealth into existing healthcare settings, along with some practical considerations.

IMPLICATIONS

Telehealth is a broad concept and should be implemented to meet the specific needs of a healthcare service. This masterclass offers a structured approach to the implementation of a musculoskeletal physiotherapy telehealth service, and highlights practical considerations required by both clinicians and healthcare organisations throughout all stages of the implementation process.