Use of a modified treatment-based classification system for subgrouping patients with low back pain: Agreement between telerehabilitation and face-to-face assessments

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.

Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review

Background

Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. This scoping review aimed to identify current areas of smartphone apps use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development.

Methods

We searched PubMed, PEDro and Embase for articles published in English up to May 3 rd, 2021 that investigated smartphone use for LBP healthcare and their purpose. All types of study design were accepted. Studies concerning telemedicine or telerehabilitation but without use of a smartphone were not included. The same search strategy was performed by two researchers independently and a third researcher validated the synthesis of the included studies.

Results

We included 43 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=6), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use.

Conclusions

This scoping review revealed a notable interest in the scientific literatures regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage.

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).

The effect of visual feedback-based clinical monitoring application in patients with chronic low back pain: a randomized controlled trial

PURPOSE

No study has addressed the effect of patient-reported outcomes as a visual feedback tool during telerehabilitation. This study aimed to investigate the effect of a visual feedback-based monitoring application PhysioAnalyst on pain, pain catastrophizing, physical functions, quality of life, usability, satisfaction, and exercise adherence in individuals with chronic low back pain (CLBP).

METHODS

A single-blind, randomized controlled trial was conducted with 44 CLBP patients. Participants were randomized into two groups: the tele-assessment feedback group (TAFG) (n = 22) and the control group (CG) (n = 22). Participants were assessed before the intervention, at the 4th week and after the intervention. Individuals were assessed using the Visual Analog Scale (VAS), Nottingham Health Profile (NHP), Pain Catastrophizing Scale (PCS), Oswestry Disability Index (ODI), Telehealth Usability Questionnaire (TUQ), Telemedicine Satisfaction Questionnaire (TSQ), and Exercise Adaptation Rating Scale (EARS) via PhysioAnalyst. Individuals in the TAFG group received graph-based visual feedback on assessment data in week 4.

RESULTS

The improvement in VAS, NHP, ODI, TUQ, TSQ, and EARS of individuals in TAFG was statistically significant (p < 0.05). Only ODI and PCS scores in CG showed significant improvement (p < 0.05). After the graphics-based visual feedback presented to the TAFG, the VAS, NHP-Emotional, NHP-Sleep, NHP-Total, PCS, TUQ, TSQ, ODI, and EARS scores gained more than CG (p < 0.05).

CONCLUSION

The results confirmed the additional contribution of telerehabilitation's graphics-based visual feedback in pain, pain catastrophizing, disability, quality of life, and exercise participation. Since the importance of continuity in long-term rehabilitation in patients with CLBP is comprehended, feedback to increase patient motivation can be added to telerehabilitation applications.

Design and evaluation of an intelligent physical examination system in improving the satisfaction of patients with chronic disease

Background

and Purpose: Enhancing patient satisfaction remains crucial for healthcare quality. The utilization of artificial intelligence (AI) in the Internet of Health Things (loHT) can streamline the medical examination process. Most Traditional Chinese Medicine (TCM) examinations are non-invasive and contribute significantly to patient satisfaction. Our aim was to establish an intelligent physical examination system that amalgamates TCM and Western medicine and to conduct a preliminary investigation into its effectiveness in enhancing the satisfaction of patients with chronic diseases.

Materials and methods

Experts from clinical departments, the equipment department, and the software development department were invited to participate in group discussions to determine the design principles and organizational structure of the intelligent physical examination system. This system integrates TCM and Western medicine. We compared the satisfaction levels of patients examined using the intelligent physical examination system with those examined using the traditional medical examination system.

Results

An intelligent physical examination system, combining TCM and Western medicine, was developed. A total of 106 patients were finally enrolled (intelligent group vs. control group) to evaluate satisfaction. There were no statistically significant differences between the intelligent group and the control group in age, gender, education, or income level. We identified significant differences in five aspects of satisfaction: 1) the physical examination environment; 2) the attitude and responsiveness of doctors; 3) the attitude and responsiveness of nurses; 4) the effectiveness of obtaining results; and 5) the information regarding physical examination and medical advice (p < 0.05). Furthermore, these differences remained statistically significant even after adjusting for age, gender, education, and income level.

Conclusions

The intelligent physical examination system effectively capitalized on the advantages of combining AI with the integration of TCM and Western medicine, substantially optimizing the medical examination process. In comparison to the traditional physical examination system, the intelligent system significantly enhanced patient satisfaction. Future improvements could involve integrating chronic disease follow-up technology into the system.

Tele-Assessment of Functional Capacity: Validity, Intra- and Inter-rater Reliability

BACKGROUND

Functional capacity evaluation is a standardized tool that assesses work-related skills. Although there are different test batteries, the most frequently used one is Work Well Systems. This study aims to determine the validity and inter- and intra-rater reliability of remote implementation of functional capacity tests (repetitive reaching, lifting object overhead, and working overhead) in asymptomatic individuals.

METHODS

A total of 51 asymptomatic individuals were included in the study. Participants completed all tests both face-to-face and remotely. Remote assessment videos were rewatched by the same researcher and different researchers for intra- and inter-rater reliability. All processes were scored by two independent researchers.

RESULTS

Remotely performing repetitive reaching (intraclass correlation coefficient [ICC]: 0.85-0.92, p < .001), lifting object overhead (ICC: 0.98, p < .001), and working overhead (ICC: 0.88 p < .001) tests are valid and reliable.

DISCUSSION

Repetitive reaching, lifting an object overhead, and sustained overhead work tests in the Work Well Systems-Functional Capacity Evaluation test battery can be performed remotely through videoconferencing. Remotely evaluating these tests, which are especially important in work-related situations, may be important in pandemic conditions and hybrid working conitions.

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.

A Systematic Review of Physical Examination Components Adapted for Telemedicine

Introduction: The COVID-19 pandemic ushered in a rapid, transformative adoption of telemedicine to maintain patient access to care. As clinicians made the shift from in-person to virtual practice, they faced a paucity of established and reliable clinical examination standards for virtual care settings. In this systematic review, we summarize the accuracy and reliability of virtual assessments compared with traditional in-person examination tools. Methods: We searched PubMed, Embase, Web of Science, and CINAHL from inception through September 2019 and included additional studies from handsearching of reference lists. We included studies that compared synchronous video (except allowing for audio-only modality for cardiopulmonary exams) with in-person clinical assessments of patients in various settings. We excluded behavioral health and dermatological assessments. Two investigators abstracted data using a predefined protocol. Results: A total of 64 studies were included and categorized into 5 clinical domains: neurological (N = 41), HEENT (head, eyes, ears, nose, and throat; N = 5), cardiopulmonary (N = 5), musculoskeletal (N = 8), and assessment of critically ill patients (N = 5). The cognitive assessment within the neurological exam was by far the most studied (N = 19) with the Mini-Mental Status Exam found to be highly reliable in multiple settings. Most studies showed relatively good reliability of the virtual assessment, although sample sizes were often small (<50 participants). Conclusions: Overall, virtual assessments performed similarly to in-person exam components for diagnostic accuracy but had a wide range of interrater reliability. The high heterogeneity in population, setting, and outcomes reported across studies render it difficult to draw broad conclusions on the most effective exam components to adopt into clinical practice. Further work is needed to identify virtual exam components that improve diagnostic accuracy.

Digital Rehabilitation for Acute Low Back Pain: A Prospective Longitudinal Cohort Study

Background

Low back pain (LBP) has a lifetime prevalence of 70–80%. Access to timely and personalized, evidence-based care is key to prevent chronic progression. Digital solutions may ease accessibility to treatment while reducing healthcare-related costs.

Purpose

We aim to report the results of a fully remote digital care program (DCP) for acute LBP.

Patients and Methods

This was an interventional, single-arm, cohort study of patients with acute LBP who received a DCP. Primary outcome was the mean change in disability (Oswestry Disability Index – ODI) after 12 weeks. Secondary outcomes included change in pain (NPRS), analgesic consumption, surgery likelihood, depression (PHQ-9), anxiety (GAD-7), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

A total of 406 patients were enrolled in the program and of those, 332 (81.8%) completed the intervention. A significant disability reduction of 55.1% (14.93, 95% CI 13.95; 15.91) was observed, corresponding to a 76.1% responder rate (30% cut-off). Disability reduction was accompanied by significant improvements in pain (61.0%), depression (55.4%), anxiety (59.5%), productivity (65.6%), fear-avoidance beliefs (46.3%), intent to pursue surgery (59.1%), and analgesic consumption (from 35.7% at baseline to 10.8% at program end). DCP-related patient satisfaction score was 8.7/10.0 (SD 1.4).

Conclusion

This study demonstrated the utility of a multimodal DCP for patients with acute LBP. Very high adherence rates and patient satisfaction were observed, alongside significant reductions in all assessed outcomes, consistent with the growing body of evidence supporting the management of acute LBP with DCPs.

Effectiveness of remote care interventions: a systematic review informing the 2022 EULAR Points to Consider for remote care in rheumatic and musculoskeletal diseases

OBJECTIVE

To perform a systematic literature review (SLR) on different outcomes of remote care compared with face-to-face (F2F) care, its implementation into clinical practice and to identify drivers and barriers in order to inform a task force formulating the EULAR Points to Consider for remote care in rheumatic and musculoskeletal diseases (RMDs).

METHODS

A search strategy was developed and run in Medline (PubMed), Embase and Cochrane Library. Two reviewers independently performed standardised data extraction, synthesis and risk of bias (RoB) assessment.

RESULTS

A total of 2240 references were identified. Forty-seven of them fulfilled the inclusion criteria. Remote monitoring (n=35) was most frequently studied, with telephone/video calls being the most common mode of delivery (n=30). Of the 34 studies investigating outcomes of remote care, the majority addressed efficacy and user perception; 34% and 21% of them, respectively, reported a superiority of remote care as compared with F2F care. Time and cost savings were reported as major benefits, technical aspects as major drawback in the 13 studies that investigated drivers and barriers of remote care. No study addressed remote care implementation. The main limitation of the studies identified was the heterogeneity of outcomes and methods, as well as a substantial RoB (50% of studies with high RoB).

CONCLUSIONS

Remote care leads to similar or better results compared with F2F treatment concerning efficacy, safety, adherence and user perception outcomes, with the limitation of heterogeneity and considerable RoB of the available studies.

Future challenges in rheumatology - is telemedicine the solution?

The COVID-19 pandemic has become an unprecedented facilitator of rapid telehealth expansion within rheumatology. Due to demographic shifts and workforce shortages in the future, new models of rheumatology care will be expected to emerge, with a growing footprint of telehealth interventions. Telehealth is already being used to monitor patients with rheumatic diseases and initial studies show good results in terms of safety and disease progression. It is being used as a tool for appointment prioritization and triage, and there is good evidence for using telehealth in rehabilitation, patient education and self-management interventions. Electronic patient-reported outcomes (ePROs) offer a number of long-term benefits and opportunities, and a routine collection of ePROs also facilitates epidemiological research that can inform future healthcare delivery. Telehealth solutions should be developed in close collaboration with all stakeholders, and the option of a telehealth visit must not deprive patients of the possibility to make use of a conventional 'face-to-face' visit. Future studies should especially focus on optimal models for rheumatology healthcare delivery to patients living in remote areas who are unable to use or access computer technology, and other patient groups at risk for disparity due to technical inequity and lack of knowledge.

XR (Extended Reality: Virtual Reality, Augmented Reality, Mixed Reality) Technology in Spine Medicine: Status Quo and Quo Vadis

In recent years, with the rapid advancement and consumerization of virtual reality, augmented reality, mixed reality, and extended reality (XR) technology, the use of XR technology in spine medicine has also become increasingly popular. The rising use of XR technology in spine medicine has also been accelerated by the recent wave of digital transformation (i.e., case-specific three-dimensional medical images and holograms, wearable sensors, video cameras, fifth generation, artificial intelligence, and head-mounted displays), and further accelerated by the COVID-19 pandemic and the increase in minimally invasive spine surgery. The COVID-19 pandemic has a negative impact on society, but positive impacts can also be expected, including the continued spread and adoption of telemedicine services (i.e., tele-education, tele-surgery, tele-rehabilitation) that promote digital transformation. The purpose of this narrative review is to describe the accelerators of XR (VR, AR, MR) technology in spine medicine and then to provide a comprehensive review of the use of XR technology in spine medicine, including surgery, consultation, education, and rehabilitation, as well as to identify its limitations and future perspectives (status quo and quo vadis).

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.

Scoping Review of Telehealth for Musculoskeletal Disorders: Applications for the COVID-19 Pandemic

OBJECTIVE

The purpose of this scoping review was to identify information about telehealth and rehabilitation for the evaluation and management of musculoskeletal disorders, patient satisfaction, cost, and access as may be applicable during the COVID-19 pandemic.

METHODS

We searched MEDLINE for studies published between January 1, 2000, and June 1, 2019. Search terms consisted of MEDLINE medical subject headings and other words relevant to this review, including "telerehabilitation," "musculoskeletal," "telemedicine," "therapy," "chiropractic," "ergonomics," and "exercise." This review targeted studies of people aged 18 years and older with musculoskeletal concerns. Articles on diagnostic tests, effectiveness of treatment, patient satisfaction, access to care, and cost were included.

RESULTS

Eleven studies were included in this review. Interrater reliability and agreement were moderate to high for several assessment procedures for the lower limb, elbow, and low back. Two clinical trials demonstrated that provider and patient simultaneous telehealth were equally as effective as in-office care. Patient and provider satisfaction with telehealth were reported to be equal to or higher than for conventional rehabilitation. We found no studies reporting cost or access.

CONCLUSION

In the COVID-19 pandemic environment, telehealth is feasible for health care providers to provide rehabilitation services for their patients with various musculoskeletal conditions. Current evidence suggests that for some musculoskeletal disorders, telehealth evaluation may be reliable, treatment may be effective, and patient satisfaction may be good or better than for in-office care. Results from this study may help physiatry, physical therapy, and chiropractic health care providers in their decisions to implement telehealth during and after the COVID-19 pandemic.

Physical Examination of the Spine Using Telemedicine: A Systematic Review

STUDY DESIGN

This is a systematic review.

OBJECTIVE

To systematically review (1) the reliability of the physical examination of the spine using telehealth as it pertains to spinal pathology and (2) patient satisfaction with the virtual spine physical examination.

METHODS

We searched EMBASE, PubMed, Medline Ovid, and SCOPUS databases from inception until April 2020. Eligible studies included those that reported on performing a virtual spine physical examination. Two reviewers independently assessed all potential studies for eligibility and extracted data. The primary outcome of interest was the reliability of the virtual spine physical exam. Secondary outcomes of interest were patient satisfaction with the virtual encounter.

RESULTS

A total of 2321 studies were initially screened. After inclusion criteria were applied, 3 studies (88 patients) were included that compared virtual with in-person spine physical examinations. These studies showed acceptable reliability for portions of the low back virtual exam. Patient satisfaction surveys were conducted in 2 of the studies and showed general satisfaction (>80% would recommend).

CONCLUSIONS

These results suggest that the virtual spine examination may be comparable to the in-person physical examination for low back pain, though there is a significant void in the literature regarding the reliability of the physical examination as it pertains to specific surgical pathology of the spine. Because patients are overall satisfied with virtual spine assessments, validating a virtual physical examination of the spine is an important area that requires further research.

Multidomain Intervention for Reversal of Cognitive Frailty, Towards a Personalized Approach (AGELESS Trial): Study Design

Background:

Cognitive frailty (CF) is identified as one of the main precursors of dementia. Multidomain intervention has been found to delay or prevent the onset of CF.

Objective:

The aim of our present study is to determine the effectiveness of a comprehensive, multidomain intervention on CF; to evaluate its cost effectiveness and the factors influencing adherence toward this intensive intervention.

Methods:

A total of 1,000 community dwelling older adults, aged 60 years and above will be screened for CF. This randomized controlled trial involves recruitment of 330 older adults with CF from urban, semi-urban, and rural areas in Malaysia. Multidomain intervention comprised of physical, nutritional, cognitive, and psychosocial aspects will be provided to participants in the experimental group (n = 165). The control group (n = 165) will continue their usual care with their physician. Primary outcomes include CF status, physical function, psychosocial and nutritional status as well as cognitive performance. Vascular health and gut microbiome will be assessed using blood and stool samples. A 24-month intensive intervention will be prescribed to the participants and its sustainability will be assessed for the following 12 months. The effective intervention strategies will be integrated as a personalized telerehabilitation package for the reversal of CF for future use.

Results:

The multidomain intervention developed from this trial is expected to be cost effective compared to usual care as well as able is to reverse CF.

Conclusion:

This project will be part of the World-Wide FINGERS (Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability) Network, of which common identifiable data will be shared and harmonized among the consortia.

Patient Expectations for Synchronous Telerehabilitation Visits: A Survey Study of Telerehabilitation-Naive Patients

Background: The current study evaluated patient expectations for synchronous telerehabilitation. Because the coronavirus disease 2019 (COVID-19) pandemic decreased regulatory barriers and increased accessibility of telehealth, improved understanding of expectations may direct future educational efforts, improve implementation strategies, and inform future analyses of consumer adoption and utilization of telehealth. Methods: A cross-sectional survey design was used to measure ideal expectations (what they want to happen) and realistic expectations (what they think will happen) of telerehabilitation-naive patients for synchronous telerehabilitation. Participants were recruited through e-mail and social media and in person from seven outpatient private practice physical therapy clinics across the United States. Patients completed an online anonymous adaptation of the Patients' Expectations Questionnaire (PEQ) and were asked whether they expected synchronous telerehabilitation to benefit them personally. Open-ended responses were collected and analyzed for categories and themes. Results: Of 178 participants, the greatest mean difference between ideal and realistic expectations among PEQ subscales was for outcomes (0.49; 95% confidence interval [CI], 0.37-0.60), and the greatest mean difference among individual items was for symptom reduction (0.53; 95% CI, 0.41-0.66). Although participants appeared to appreciate the value of telerehabilitation visits, with 69.7% indicating that it would benefit them personally, many expressed a preference for face-to-face visits when possible. Discussion: Expectations were mostly positive. Lower outcomes expectations may be a potential barrier to adoption and utilization of telehealth and other types of digital physical therapy in some patients. Conclusions: To improve beliefs and address potential barriers, physical therapy clinicians should discuss expectations with patients before recommending telerehabilitation visits.

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.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study

PURPOSE

The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery.

METHODS

A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020.

RESULTS

902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication.

CONCLUSION

COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

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.

The Telemedicine Musculoskeletal Examination

Telemedicine uses modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing convenient, safe, and time- and cost-efficient care. The coronavirus disease 2019 pandemic has created marked nationwide changes in health care access and delivery. Elective appointments and procedures have been canceled or delayed, and multiple states still have some degree of shelter-in-place orders. Many institutions are now relying more heavily on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Telemedicine can also help reduce the surge in health care needs and visits as restrictions are lifted. In recent weeks, there has been a significant amount of information and advice on how to best approach telemedicine visits. Given the frequent presentation of individuals with musculoskeletal complaints to the medical practitioner, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve, even after coronavirus disease 2019 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. In addition to photographs, accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can self-perform.