Experience of patients and practitioners with a team and technology approach to chronic back disorder management

What are the Perceptions and Lived Experiences of Canadian Injured Workers about the Provision of Physiotherapy Services using Telerehabilitation?

PURPOSE

Despite evidence of efficacy, the effectiveness of telerehabilitation in real-world clinical settings is still largely unknown. Telerehabilitation requires a substantial transformation of the organization and delivery of traditional services. Considering that a virtual setting can create unique challenges for providing physiotherapy services and given the physical and potential hands-on nature of evidence-based assessments and interventions, it is important to investigate what injured workers think of receiving physiotherapy care via telerehabilitation and to examine if rehabilitation needs are adequately met.

METHODS

A qualitative interpretive description study was conducted to explore the perspectives and experiences of 17 injured workers receiving physiotherapy via telerehabilitation. Data were collected through semi-structured interviews with participants from three provinces in Western Canada and analysed using thematic analysis. Qualitative rigour criteria of epistemological integrity, analytic logic, interpretive authority, and representative credibility were considered throughout this study.

RESULTS

Implementation of telerehabilitation during the COVID-19 pandemic resulted in mixed perceptions from injured workers. Some viewed telerehabilitation as a resourceful option for providing services during the pandemic lockdown, resulting in maintained communications while overcoming barriers to services (e.g., rural/remote workers, transportation barriers, etc.). However, many thought telerehabilitation was inferior to in-person therapy for assessment and when 'hands-on' interaction was needed. Many believed a hybrid option may be ideal now that pandemic restrictions are lifted, with telerehabilitation supplementing in-person physiotherapy when needed.

CONCLUSIONS

Telerehabilitation was viewed as a resourceful option during the pandemic and in certain clinical situations (e.g., rural/remote). Workers should be able to make informed choices about service delivery format.

Experiences, impacts, and requirements of synchronous video consultations between nurses, allied health professionals, psychological therapists, and adult service-users: A review of the literature

BACKGROUND

Telemedicine is increasingly used within healthcare worldwide. More is known about its efficacy in treating different conditions and its application to different contexts than about service-users' and practitioners' experiences or how best to support implementation.

AIMS

To review adult service-users' experiences of synchronous video consultations with nurses, allied health professionals and psychological therapists, find out how consultations impact different groups of service-users and identify requirements for their conduct at individual, organisational, regional, and national levels.

METHOD

CINAHL, Embase, Medline, PsycINFO Scopus were searched for papers published between 01/01/2018 and 19/03/2021. One reviewer independently reviewed citations and a second reviewed those excluded by the first, in a liberal accelerated approach. Quality assessment was undertaken using the Mixed Methods Appraisal Tool and data were synthesised narratively.

RESULTS

65 papers were included. Service-users' experiences of video consultations ranged from feelings of connection to disconnection and ease of access to challenges to access. Many were excluded from video consultation services or research, for example because of lack of access to technology. Individual service-users required clear orientation and ongoing technical support, whereas staff needed support to develop technical and online-relational skills. At organisational levels, technology needed to be made available to users through equipment loan or service models such as hub-and-spoke; services required careful planning and integration within organisational systems; and security needed to be assured. Regional and national requirements related to interorganisational cooperation and developing functionality.

CONCLUSION

To support safe and equitable video consultation provision, we recommend: (1) providers and researchers consider how to maximise participation, for example through inclusive consent processes and eligibility criteria; (2) sharing video consultation user guides and technical support documentation; and (3) continuing professional development for practitioners, focusing on the technical and relational skills that service-users value, such as the ability to convey empathy online.

"How can we help you?": results of a scoping review on the perceived needs of people living with chronic pain regarding physiotherapy

BACKGROUND

Physiotherapy is effective to reduce pain and improve the quality of life of people living with chronic pain. To offer high-quality physiotherapy services, these services must be patient-centred and respond to patients' needs. However, few studies seem to target patients' perceived needs, whereas more studies tend to focus on needs assessed by healthcare experts, which are not always in line with patients' perceived needs. In addition, people living with chronic pain are often faced with several health inequities and may have varied perceived needs depending on their personal conditions. To offer services that truly meet patients' needs, it is therefore crucial to understand these needs. This scoping review aims to identify and map the perceived needs of people living with chronic pain towards physiotherapy services.

METHODS

To conduct this review, we followed the six stages framework proposed by Arksey and O'Malley. We searched four databases (Medline, Embase, CINHAL and APA PsycINFO) as well as the grey literature. We included all studies describing the needs, demands, preferences or expectations of adults living with chronic pain towards physiotherapy. We then performed an inductive thematic analysis of the results and discussion sections of these studies to identify the perceived needs. Once those needs were identified, we mapped them into the seven dimensions of the patient-centred healthcare delivery framework.

RESULTS

Our review included 96 studies. Various perceived needs were identified through the thematic analysis, such as the needs for an empathetic relationship; for a clear, adapted and supervised exercise program; and for personalized treatment. Our mapping into the patient-centred healthcare delivery framework showed that most studies reported needs associated with the dimensions of interpersonal care, individualized healthcare and professional care. Needs associated with the other dimensions of the framework (access; coordination and continuity; services and facilities; data and information) were less frequently mentioned.

CONCLUSIONS

The results of this review have enabled us to identify and better understand multiple needs perceived by people living with chronic pain regarding physiotherapy services. The perceived needs identified through this scoping review were mapped within the seven dimensions of the Patient-centred healthcare delivery framework.

A physical therapist and nurse practitioner model of care for chronic back pain using telehealth: Diagnostic and management concordance

INTRODUCTION

Virtual care using videoconference links between urban-based physical therapists and nurse practitioners in rural primary care may overcome access challenges and enhance care for rural and remote residents with chronic low back disorders (CBD). The purpose of this study was to evaluate the concordance of this new model of care with two traditional models.

METHODS

In this cross-sectional study design, each of 27 participants with CBD were assessed by: 1) a team of a nurse practitioner (NP) located with a patient, joined by a physical therapist (PT) using videoconferencing (NP/PTteam); 2) in-person PT (PTalone); and 3) in-person NP (NPalone). Diagnostic and management concordance between the three groups were assessed with percent agreement and kappa.

RESULTS

Overall diagnostic categorization was compared for PTalone versus NPalone and NP/PTteam: percent agreement was 77.8% (k = 0.474, p = 0.001) and 74.1% (k = 0.359, p = 0.004), respectively. In terms of management recommendations, the PTalone and NPalone demonstrated strong agreement on "need for urgent surgical referral" (92.6%, k = 0.649 (p < 0.00) and slight agreement for "refer to primary physician for pharmacology, lab or imaging" (81.5%, k = 0.372 (p = 0.013). The PTalone and NP/PTteam demonstrated strong agreement on "need for urgent surgical referral" (96.3%, k = 0.649, p = 0.000) and "recommendation for PT follow up" (88.9%, k = 0.664, p = 0.000).

DISCUSSION

The diagnostic categorization and management recommendations of the team using videoconferencing for CBD were similar to decisions made by an in-person PT. This model of care may provide a method for enhancing access to PT for CBD assessment and initial management in underserved areas.

"Navigating chaos": Urban, Rural, and Remote Patient Experiences in Accessing Healthcare with Indigenous and Non-Indigenous Perspectives of Living with Chronic Low Back Pain

Background

Healthcare access for chronic low back pain is complex and should consider not only the health system, but patient care seeking experiences as well. People who live in rural and remote communities and/or identify as being Indigenous may often encounter additional barriers to accessing care for chronic low back pain; thus, these contexts must be considered to fully understand barriers and facilitators.

Aims

The aim of this study was to understand care-seeking experiences of people living with chronic back pain in Saskatchewan and determine unique experiences facing urban, rural, remote, and/or Indigenous peoples.

Methods

Thirty-three participants with chronic low back pain completed a preliminary survey followed by individual semistructured interviews. Participants were categorized as urban, rural, or remote including Indigenous status. A qualitative interpretive research approach with inductive thematic analysis was employed.

Results

Three overarching themes were identified with the following subthemes: (1) healthcare access challenges: challenges to accessing care, challenges within the health system, and challenges leading to self-directed management/coping strategies; (2) healthcare access facilitators: funded care, participant education and knowledge, patient-provider communication, and care closer to home; and (3) participant recommendations for improved care provision: coordination of care, integrative and holistic care, and patient-centered care and support. Rural and remote participants highlighted travel as a main barrier. Indigenous participant experiences emphasized communication with healthcare providers and past experiences influencing desire to access care.

Conclusion

Participants identified a range of challenges and facilitators as well as recommendations for improving access to care for chronic low back pain, with unique barriers for rural, remote, and Indigenous participants.

Effectiveness of an interprofessional assessment and management approach for people with chronic low back disorders delivered via virtual care: A randomized controlled trial pilot intervention

Objective

Virtual care for chronic conditions has seen uptake due to COVID-19. Evaluation of virtual models is important to ensure evidence-based practice. There is a paucity of research in the use of virtual care for management of chronic back disorders. The objective of this study was to evaluate effectiveness of a team-based virtual care model for back disorder assessment where a physical therapist uses virtual care to join a nurse practitioner and patient in a rural Saskatchewan, Canada community.

Methods

Sixty-four rural adults with chronic back disorders were randomly allocated to receive either: (1) team-based virtual care (n = 24); (2) care from an urban physical therapist travelling to community (n = 20); or (3) care from a rural nurse practitioner (n = 20). The team-based care group involved a nurse practitioner located with a rural patient, and a physical therapist joining using virtual care. The physical therapist alone and the nurse practitioner alone groups received in-person assessments. Groups with a physical therapist involved had follow-up treatments by in-person physical therapy. Outcomes over six months included pain, disability, back beliefs, satisfaction, quality-adjusted health status and management-related costs.

Results

There were no significant differences for pain, disability, back beliefs and satisfaction between groups. The average cost per patient for implementing in-person physical therapist assessment ($135) was higher compared with the team over virtual care ($118) and NP care ($59).

Conclusion

Primary outcomes were not different by group. Physical therapist alone was more costly than other groups. Future research should include more participants, longer follow-up time and refined cost parameters.

Trial Registration

ClinicalTrials.gov NCT02225535; https://clinicaltrials.gov/ct2/show/NCT02225535 (Archived by WebCite at http://www.webcitation.org/6lqLTCNF7).

Telerehabilitation is as effective as outpatient visits in the management of early osteoarthritis knee and mechanical low backache

PURPOSE

Teleconsultation services can be used to overcome the barriers imposed by the Covid-19 pandemic in providing basic orthopaedic rehabilitation services. Aim of the study is to compare the effectiveness of rehabilitation provided via outpatient and teleconsultation in patients with mechanical low backache (LBA) and early osteoarthritis (OA) of the knee joint utilizing Patient-Reported Outcome Measures. The satisfaction level of patients receiving teleconsultation will also be assessed.

METHODOLOGY

This study was a hospital-based prospective observational study. The study's participants were divided into two groups (Outpatient and Teleconsultation, respectively), and each group was further divided into two subgroups of 100 participants each (Knee-pain subgroup 1; LBA subgroup 2). SF-12 questionnaire, visual analogue scale (VAS) score for pain, and functional outcome scores (KOOS score for knee pain and the modified Oswestry Disability Index-MODI for LBA) were assessed at initial presentation and 6 months follow-up. Participants' satisfaction for teleconsultation service was assessed at final follow-up by 5 points Likert scale (5, very satisfied; 1, very dissatisfied).

RESULTS

Mean consultation time was significantly longer in the outpatient group (p < 0.001). No statistically significant difference in the VAS score, KOOS score (58.0 ± 7.6 vs. 57.8 ± 9.2; p = 0.893), and MODI Score (24.7 ± 13.3 vs. 27.4 ± 12.4; p = 0.128) between the corresponding subgroups of the two groups at final follow-up. Eighty-seven percentage of the participants were satisfied (Likert score ≥ 4) with the teleconsultation services.

CONCLUSION

Teleconsultation is equally effective to that as face-to-face outpatient consultation in the rehabilitation of patients with early OA knee and mechanical LBA.

LEVEL OF STUDY

Level 2, Prospective comparative study.

Protocol for a Parallel Group Randomized Clinical Trial Comparing a Culturally Adapted Cognitive Behavioral Telerehabilitation Intervention to Usual Physical Therapy for Latino Patients With Chronic Spine Pain

OBJECTIVE

Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral-based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral-based hybrid telerehabilitation intervention for Latino patients with chronic spine pain.

METHODS

A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses.

IMPACT

This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain.

Healthcare Access Challenges and Facilitators for Back Pain Across the Rural-Urban Continuum in Saskatchewan, Canada: Cross-Sectional Results From a Provincial-Wide Telephone Survey

Background

Chronic back pain is a common musculoskeletal disorder, disproportionately affecting rural and Indigenous people. Saskatchewan has a relatively high proportion of rural and Indigenous residents; therefore, understanding barriers and facilitators to accessing healthcare are needed to improve healthcare service delivery.

Methods

A provincial-wide telephone survey explored experiences and perceived healthcare access barriers and facilitators among 384 Saskatchewan residents who experienced chronic low back pain. Chi-squared tests were performed to determine if people who lived in urban versus rural areas differed in the proportion who had accessed services from various healthcare practitioners. T-test and Mann-Whitney U analyses were conducted to determine differences between urban and rural, and Indigenous and non-Indigenous respondents.

Results

Of 384 residents surveyed, 234 (60.9%) reported living in a rural location; 21 (5.5%) identified as Indigenous. Wait times (47%), cost (40%), travel (39%), and not knowing how to seek help (37%) were the most common barriers for Saskatchewan residents seeking care, with travel being the only barrier that was significantly different between rural and urban respondents (P ⩽ .001). Not knowing where to go to access care or what would help their low back pain (P = .03), lack of cultural sensitivity (P = .007), and comfort discussing problems with health care professionals (P = .26) were greater barriers for Indigenous than non-Indigenous participants. Top facilitators (>50% of respondents) included publicly funded healthcare, locally accessible healthcare services, and having supportive healthcare providers who facilitate referral to appropriate care, with urban respondents considering the latter 2 as greater facilitators than rural respondents. Telehealth or virtual care (P = .013) and having healthcare options nearby in their community (P = .045) were greater facilitators among Indigenous participants compared to non-Indigenous respondents.

Conclusions

Rural, urban, Indigenous, and non-Indigenous people report overlapping and unique barriers and facilitators to accessing care for chronic low back pain. Understanding perceived access experiences will assist in developing more effective care models for specific communities or regions.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Use of Virtual Care Strategies to Join Multidisciplinary Teams Evaluating Work-Related Injuries in Rural Residents

Background: Rural injured workers requiring multidisciplinary assessments for musculoskeletal disorders face health access disparities, which include travel to urban centers. Virtual care can enhance access to multidisciplinary team care for musculoskeletal conditions in rural areas. Materials and Methods: A retrospective chart audit of 136 multidisciplinary assessment reports of injured workers was conducted. Comprehensive management recommendations from the health care assessment team were extracted for analysis. The health care team used virtual technologies to join with patients and at least one local rural health practitioner in one of three locations. Remote presence robotics (RPR; Xpress Technology™) or laptop-based telehealth was used to complete the assessments. Results: RPR were used in 46% of assessments over two sites, with 54% using laptop-based telehealth at a third site. Frequencies of team members' assessment using technologies were as follows: physical therapist (100%), psychologist (78%), plastic surgeon (8%), and physician (43%). Spine (42%) and shoulder (32%) disorders were the most common problems. Most workers (79%) were 3 or more months postinjury. The most common management recommendation was the need for daily comprehensive rehabilitation care (76%). Travel time was saved by 89% of participants. Conclusions: Virtual care was used to unite multidisciplinary assessment teams for the evaluation of injured rural workers with complex musculoskeletal injuries. Future research recommendations include comparing between virtual and fully in-person multidisciplinary assessment and recommendation findings, and evaluation of patient and practitioner experiences with comprehensive virtual team assessments.

Experiences of Health Care Access Challenges for Back Pain Care Across the Rural-Urban Continuum in Canada: Protocol for Cross-sectional Research

BACKGROUND

Back pain is common and costly, with negative impacts on both individuals and the health care system. Rural, remote, and Indigenous populations are at greater risk of experiencing back pain compared to urban and non-Indigenous populations. Potential barriers to health care access among Canadians with chronic back pain (CBP) have been identified; however, no study has used lived experiences of people with CBP to drive the selection, analysis, and interpretation of variables most meaningful to patients.

OBJECTIVE

The aims of this study are to (1) engage with rural, remote, and urban Indigenous and non-Indigenous patients, health care providers, and health system decision makers to explore lived experiences among people with CBP in Saskatchewan, Canada; (2) cocreate meaningful indicators of CBP care access and effectiveness; and (3) identify program and policy recommendations to overcome access barriers to CBP care.

METHODS

In phase 1, one-on-one interviews with 30 people with current or past CBP and 10 health care providers residing or practicing in rural, remote, or urban Saskatchewan communities will be conducted. We will recruit Indigenous (n=10) and non-Indigenous (n=20) rural, remote, and urban people. In phase 2, findings from the interviews will inform development of a population-based telephone survey focused on access to health care barriers and facilitators among rural, remote, and urban people; this survey will be administered to 383 residents with CBP across Saskatchewan. In phase 3, phase 1 and 2 findings will be presented to provincial and national policy makers; health system decision makers; health care providers; rural, remote, and urban people with CBP and their communities; and other knowledge users at an interactive end-of-project knowledge translation event. A World Café method will facilitate interactive dialogue designed to catalyze future patient-oriented research and pathways to improve access to CBP care. Patient engagement will be conducted, wherein people with lived experience of CBP, including Indigenous and non-Indigenous people from rural, remote, and urban communities (ie, patient partners), are equal members of the research team. Patient partners are engaged throughout the research process, providing unique knowledge to ensure more comprehensive collection of data while shaping culturally appropriate messages and methods of sharing findings to knowledge users.

RESULTS

Participant recruitment began in January 2021. Phase 1 interviews occurred between January 2021 and September 2022. Phase 2 phone survey was administered in May 2022. Final results are anticipated in late 2022.

CONCLUSIONS

This study will privilege patient experiences to better understand current health care use and potential access challenges and facilitators among rural, remote, and urban people with CBP in Saskatchewan. We aim to inform the development of comprehensive measures that will be sensitive to geographical location and relevant to culturally diverse people with CBP, ultimately leading to enhanced access to more patient-centered care for CBP.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42484.

Healthcare Professionals' Experience of Performing Digital Care Visits-A Scoping Review

The use of digital care visits has been increasing during the COVID-19 pandemic. Learning more about healthcare professionals' technology experiences provides valuable insight and a basis for improving digital visits. This study aimed to explore the existing literature on healthcare professionals' experience performing digital care visits. A scoping review was performed following Arksey & O'Malley's proposed framework using the Preferred Reporting Items for Systematic reviews and Meta-Analyses. The collected data were analyzed using thematic content analysis. Five main themes were identified in the literature: positive experiences/benefits, facilitators, negative experiences/challenges, barriers, and suggestions for improvement. Healthcare professionals mostly reported having an overall positive experience with digital visits and discovered benefits for themselves and the patients. However, opinions were mixed or negative regarding the complexity of decision making, workload and workflow, suitability of this type of care, and other challenges. The suggestions for improvement included training and education, improvements within the system and tools, along with support for professionals. Despite overall positive experiences and benefits for both professionals and patients, clinicians reported challenges such as physical barriers, technical issues, suitability concerns, and others. Digital care visits could not fully replace face-to-face visits.

Group and individual telehealth for chronic musculoskeletal pain: A scoping review

BACKGROUND CONTEXT

Musculoskeletal (MSK) pain presents a global challenge. Individual and group pain management programmes (PMPs) are recommended approaches for patients with chronic MSK disorders. With advances in remote healthcare capability, telehealth, and the recent COVID-19 pandemic, the importance of telehealth PMPs has become even more evident. Nevertheless, it is not known how patients perceive PMPs for their MSK complaint when delivered via telehealth.

OBJECTIVE

To synthesise the evidence of patients' experiences of group and individual telehealth PMPs for chronic MSK pain.

DESIGN

A scoping review informed by the PRISMA extension for scoping reviews.

DATA SOURCES

Based on a planned search strategy, modified following initial searches, an electronic search was conducted of key databases: Cochrane Library, Medline, CINAHL, EMBASE, AMED, SportDiscus and APA PsychInfo from 2010 until 11 May 2021.

STUDY SELECTION

Any qualitative or mixed methods study reporting patient experiences of telehealth PMPs for patients with MSK disorders.

DATA EXTRACTION AND DATA SYNTHESIS

Data were extracted and synthesised using thematic analysis.

RESULTS

From 446 identified studies, 10 were included. Just two studies investigated group telehealth PMPs for patients with MSK disorders, with eight delivered individually. Four main themes emerged: (1) Usability of the technology, (2) Tailored care, (3) Therapeutic alliance and (4) Managing behaviour. The findings highlight patient acceptability of telehealth to support self-management for chronic MSK disorders, with appropriate clinical and technical support. Group telehealth has the potential to empower patients with peer support. Remote delivery of PMPs also impacts on how patients and providers interact, communicate and develop a therapeutic relationship.

CONCLUSIONS AND IMPLICATIONS

Barriers and enablers to engagement in telehealth PMPs for patients with chronic MSK disorders have been identified. Peer support and group cohesiveness can be achieved remotely to enhance the patient experience. There is a critical need for further research in this area.

Evaluation of the Use of Telehealth Video Visits for Veterans With Chronic Pain

BACKGROUND

Telehealth video visits are essential for delivering timely care while mitigating exposure during the COVID-19 pandemic. Telehealth video visits have the potential to improve missed appointments, reduce costs associated with Veterans Affairs (VA) travel reimbursement, and lead to positive patient and provider satisfaction.

AIMS

This evidence-based improvement project sought to evaluate whether telehealth visits reduce the occurrence of missed appointments, determine cost savings associated with the VA travel reimbursement and assess patient and provider satisfaction with telehealth video visits.

DESIGN

Evidence-based improvement project.

SETTING

A retrospective chart review was conducted on military veterans with chronic pain who completed a telehealth video visit in the VA San Diego (VASD) pain clinic.

METHODS

Missed appointment rates were compared from before (April 1, 2019-October 1, 2019) to after (April 1, 2020-October 1, 2020) implementation of the telehealth video visits. Estimated travel reimbursement for qualified patients was calculated per VA policy. Electronic satisfaction surveys were administered to patients and nurse practitioners to assess satisfaction with telehealth video visits.

RESULTS

There was an 82.5% reduction in missed appointments from pre to post implementation of telehealth video visits. There was an estimated cost savings in travel reimbursements of $3,308.30. Overall, 93.62% of patients (n = 42) were satisfied with their video visits and there was a high degree of satisfaction in implementing video visits among the nurse practitioners (n = 3).

CONCLUSIONS

The use of telehealth video visits during the COVID-19 pandemic reduced missed appointments, exhibited cost savings in VA travel reimbursement, and led to positive patient and provider satisfaction.

An Investigation Into the Use of mHealth in Musculoskeletal Physiotherapy: Scoping Review

BACKGROUND

Musculoskeletal physiotherapy provides conservative management for a range of conditions. Currently, there is a lack of engagement with exercise programs because of the lack of supervision and low self-efficacy. The use of mobile health (mHealth) interventions could be a possible solution to this problem, helping promote self-management at home. However, there is little evidence for musculoskeletal physiotherapy on the most effective forms of mHealth.

OBJECTIVE

The aim of this review is to investigate the literature focusing on the use of mHealth in musculoskeletal physiotherapy and summarize the evidence.

METHODS

A scoping review of 6 peer-reviewed databases was conducted in March 2021. No date limits were applied, and only articles written in the English language were selected. A reviewer screened all the articles, followed by 2 additional researchers screening a random sample before data extraction.

RESULTS

Of the 1393 studies, 28 (2.01%) were identified. Intervention characteristics comprised stretching and strengthening exercises, primarily for degenerative joint pain and spinal conditions (5/28, 18%). The most reported use of mHealth included telephone and videoconferencing calls to provide a home exercise program or being used as an adjunct to physiotherapy musculoskeletal assessment (14/28, 50%). Although patient satisfaction with mHealth was reported to be high, reasons for disengagement included a lack of high-quality information and poor internet speeds. Barriers to clinical uptake included insufficient training with the intervention and a lack of time to become familiar.

CONCLUSIONS

mHealth has some benefits regarding treatment adherence and can potentially be as effective as normal physiotherapy care while being more cost-effective. The current use of mHealth is most effective when ongoing feedback from a health care professional is available.

Is Telerehabilitation a Viable Option for People With Low Back Pain? Associations Between Telerehabilitation and Outcomes During the COVID-19 Pandemic

OBJECTIVE

The aims of this study were to examine associations between frequency of telerehabilitation (TR) and outcomes of functional status (FS), number of visits, and patient satisfaction during COVID-19 and to compare FS outcomes by TR delivery mode for individuals with low back pain.

METHODS

Propensity score matching was used to match episodes of care with or without TR exposure by the probability of receiving TR. FS, visits, and satisfaction were compared for individuals without TR and those who received care by TR for "any," "few," "most," or "all" frequencies (4 matched samples), and FS was compared for individuals receiving synchronous, asynchronous, and mixed TR modes (3 matched samples). Standardized differences were used to compare samples before and after matching. Outcomes between matched samples were compared using z tests with 95% CI.

RESULTS

The sample consisted of 91,117 episodes of care from 1398 clinics located in 46 states (58% women; mean age = 55 [SD = 18]). Of those, only 5013 episodes (5.5%) involved any amount of TR. All standardized differences between matched samples were <0.1. There was no significant difference in FS points (range = 0-100, with higher representing better FS) between matched samples, except for episodes that had ``few'' (-1.7) and ``all'' (+2.0) TR frequencies or that involved the asynchronous (-2.6) TR mode. These point differences suggest limited clinical importance. Episodes with any TR frequency involved significantly fewer visits (0.7-1.3) than episodes with no TR, except that those with the "most" TR frequency had non-significantly fewer visits (0.6). A smaller proportion of individuals with TR (-4.0% to -5.0%) than of individuals with no telerehabilitation reported being very satisfied with treatment results, except for those with the "all" TR frequency.

CONCLUSIONS

A positive association between TR and rehabilitation outcomes was observed, with a trend for better FS outcomes and fewer visits when all care was delivered through TR. Satisfaction tended to be lower with TR use. Overall, this observational study showed that for people with low back pain, physical therapy delivered through TR was equally effective as and more efficient than in-person care, with a trend of higher effectiveness when used for all visits during the episode of care. No differences in FS outcomes were observed between care delivered with synchronous and mixed TR delivery modes and care delivered with no TR. However, the asynchronous mode of TR was associated with worse functional outcomes than no TR. Although the majority of people were very satisfied with their treatment results with and without TR, very high satisfaction rates were reported by a slightly smaller proportion of individuals with TR versus those without TR. Our results suggest that TR is a viable option for rehabilitation care for individuals with low back pain and should also be considered in the post-COVID-19 era.

Clinicians' perspectives on equity of access to dialysis and kidney transplantation for rural people in Australia: a semistructured interview study

OBJECTIVES

People with chronic kidney disease requiring dialysis or kidney transplantation in rural areas have worse outcomes, including an increased risk of hospitalisation and mortality and encounter many barriers to accessing kidney replacement therapy. We aim to describe clinicians' perspectives of equity of access to dialysis and kidney transplantation in rural areas.

DESIGN

Qualitative study with semistructured interviews.

SETTING AND PARTICIPANTS

Twenty eight nephrologists, nurses and social workers from 19 centres across seven states in Australia.

RESULTS

We identified five themes: the tyranny of distance (with subthemes of overwhelming burden of travel, minimising relocation distress, limited transportation options and concerns for patient safety on the roads); supporting navigation of health systems (reliance on local champions, variability of health literacy, providing flexible models of care and frustrated by gatekeepers); disrupted care (without continuity of care, scarcity of specialist services and fluctuating capacity for dialysis); pervasive financial distress (crippling out of pocket expenditure and widespread socioeconomic disadvantage) and understanding local variability (lacking availability of safe and sustainable resources for dialysis, sensitivity to local needs and dependence on social support).

CONCLUSIONS

Clinicians identified geographical barriers, dislocation from homes and financial hardship to be major challenges for patients in accessing kidney replacement therapy. Strategies such as telehealth, outreach services, increased service provision and patient navigators were suggested to improve access.

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.

A Descriptive Study of the Implementation of Remote Occupational Rehabilitation Services Due to the COVID-19 Pandemic Within a Workers' Compensation Context

Purpose The Coronavirus Disease (COVID-19) pandemic resulted in dramatic changes to avoid virus spread. In Canada, following provincial legislation the Workers' Compensation Board of Alberta (WCB-Alberta) stopped in-person rehabilitation services on March 23, 2020. On April 1, training began on remote service delivery using videoconferencing or telerehabilitation, which started April 3. We studied WCB-Alberta's transition to remote rehabilitation service delivery. Methods A population-based descriptive study was conducted, with data extracted from the WCB-Alberta database. This included clinical data from rehabilitation providers. We included workers completing services between January 1 and May 31, 2020. We statistically examined differences before and after the transition to remote services. Results The dataset included 4,516 individuals with work-related injuries. The mean number of work assessments per week pre-COVID was 244.6 (SD 83.5), which reduced to 135.9 (SD 74.5). Workers undergoing remote assessments were significantly more likely to work in health care or trades, did not require an interpreter, and were less likely to be working or judged as ready to return to work. Number of completed rehabilitation programs also reduced from 125.6 to 40.8 per week, with most (67.1%) remote programs being functional restoration. Few adverse effects were observed. Conclusions We describe the transition to completely remote delivery of occupational rehabilitation due to COVID-19 physical distancing restrictions in one Canadian compensation jurisdiction. It appears the use of remote services was successful but proceeded cautiously, with fewer complex cases being referred for assessment or rehabilitation. Further research examining longer-term work outcomes and stakeholder perceptions is needed.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

Outpatient Physical, Occupational, and Speech Therapy Synchronous Telemedicine: A Survey Study of Patient Satisfaction with Virtual Visits During the COVID-19 Pandemic

The COVID-19 pandemic transformed health care delivery, including rapid expansion of telehealth. Telerehabilitation, defined as therapy provided by physical therapy, occupational therapy, and speech and language pathology, was rapidly adopted with goals to provide access to care and limit contagion. The purpose of this brief report was to describe the feasibility of and satisfaction with telerehabilitation. A total of 205 participants completed online surveys after a telerehabilitation visit. Most commonly, participants were women (53.7%), 35-64 yrs old, and completed physical therapy (53.7%) for established visits of 30-44 mins in duration for primary impairments in sports, lower limb injuries, and pediatric neurology. Overall, high ratings ("excellent" or "very good" responses) were observed for all patient-centered outcome metrics (range, 93.7%-99%) and value in future telehealth visit (86.8%) across telerehabilitation visits. Women participated more frequently and provided higher ratings than male participants did. Other benefits included eliminating travel time, incorporating other health care advocates, and convenience delivering care in familiar environment to pediatric patients. Technology and elements of hands-on aspects of care were observed limitations. Recognizing reduced indirect costs of care that telerehabilitation may provide along with high patient satisfaction are reasons policy makers should adopt these services into future health care delivery models.

Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic

Objective

Public health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians’ initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing.

Design

Observational, cross-sectional design.

Participants

Twelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation.

Methods

Quantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data.

Results

The themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians’ experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth.

Conclusion

It is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.