Internet and Telerehabilitation-Delivered Management of Rotator Cuff-Related Shoulder Pain (INTEL Trial): Randomized Controlled Pilot and Feasibility Trial

The effects of telemedicine on Rotator cuff-related shoulder function and pain symptoms: a meta-analysis of randomized clinical trials

BACKGROUND

The effectiveness of telemedicine in aiding rehabilitation exercises among patients with rotator cuff (RC) disorders remains unknown. Therefore, this meta-analysis aimed to assess the effectiveness of telemedicine in patients with RC disorders.

METHODS

Randomized clinical trials (RCTs) on the effectiveness of telemedicine in patients with RC disorders were summarized through a meta-analysis. A systematic search for these RCTs was conducted in PubMed, Cochrane, Embase, and Web of Science databases up to July 2024. Statistical analysis was performed using Stata 16. Publication bias was estimated with the funnel plot and Egger's test.

RESULTS

Ten studies involving 497 participants (telemedicine group = 248 and conventional group = 249) were enrolled, with follow-up durations ranging from 8 weeks to 48 weeks. Functional outcomes measured by the Constant-Murley score were markedly improved after treatment in the telemedicine group compared to the conventional group. Moreover, compared to conventional treatment, telemedicine significantly improved shoulder function evaluated by Quick Disabilities of the Arm, Shoulder, and Hand Score, relieved pain assessed by visual analog scale pain score, and improved range of motion after treatment and in the final follow-up period.

CONCLUSION

Telemedicine has demonstrated potential in alleviating pain and enhancing shoulder function and motion in patients with RC injuries. It may be a feasible intervention for rehabilitation exercises. Further research with a large sample size and standardized treatment is warranted to validate these findings.

Which Multimodal Physiotherapy Treatment Is the Most Effective in People with Shoulder Pain? A Systematic Review and Meta-Analyses

The study aimed to determine if combined physiotherapy treatments offer additional benefits over exercise-only programs for shoulder pain and to identify the most effective combined treatment. A systematic review, registered in PROSPERO (CRD42023417709), and meta-analyses were conducted. Quality analysis was performed using the PEDro scale on randomized clinical trials published from 2018 to 2023. Twenty articles met the inclusion criteria. The most commonly used combination was exercise plus manual therapy, without being statistically superior to exercise alone. The meta-analysis indicated that combining exercise with low-level laser therapy (mean difference of -1.06, 95% CI: -1.51 to -0.60) and high-intensity laser therapy (mean difference of -0.53, 95% CI: -1.12 to 0.06) resulted in the greatest reduction in SPADI scores. Adding manual therapy provided limited additional benefit (mean difference of -0.24, 95% CI: -0.74 to 0.27). Progressive exercise with advice or telerehabilitation yielded modest improvements. The multimodal meta-analysis for DASH scores showed significant improvement (mean difference of -1.06, 95% CI: -1.51 to -0.60). In conclusion, therapeutic exercise is the cornerstone of shoulder pain treatment, with the addition of laser therapy showing substantial benefits. Manual therapy and educational interventions offer some benefits but are not consistently superior. More rigorous studies are needed.

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).

Comparing Telerehabilitation and Home-based Exercise for Shoulder Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to quantitatively compare the effects of telerehabilitation and home-based exercise for shoulder disorders.

DATA SOURCES

We conducted a search for eligible studies in PubMed, EMBASE, Web of Science, Cochrane Library, and MEDLINE databases following Preferred Reporting Items for Systematic Review and Meta-analyses guidelines.

STUDY SELECTION

Independent reviewers selected randomized controlled trials that compared the effects of telerehabilitation and home-based exercise in individuals with shoulder disorders.

DATA EXTRACTION

Two reviewers independently conducted data extraction and assessed the risk of bias using the Cochrane Risk of Bias tool.

DATA SYNTHESIS

A total of 7 studies with 508 participants were included. Compared with home-based exercise, telerehabilitation showed superior improvements in range of motion (flexion: standardized mean difference [SMD] 0.35, 95% confidence interval [CI] 0.14 to 0.56; abduction: SMD 0.37, 95% CI 0.16 to 0.58; external rotation: SMD 0.43, 95% CI 0.22 to 0.64; internal rotation: SMD 0.33, 95% CI 0.08 to 0.58), functional outcomes (Shoulder Pain and Disability Index: SMD -0.37, 95% CI -0.61 to -0.12; shortened Disabilities of the Arm, Shoulder and Hand questionnaire: mean difference [MD] -4.51, 95% CI -8.70 to -0.32), and quality of life (EuroQol Five Dimensions Questionnaire: MD 0.04, 95% CI 0.01 to 0.07). Telerehabilitation was not different from home-based exercise in terms of pain relief (SMD -0.19, 95% CI -0.60 to 0.23). Subgroup analysis demonstrated that telerehabilitation provided significant pain relief when sustained for over 12 weeks (SMD -0.46, 95% CI -0.81 to -0.11).

CONCLUSIONS

Telerehabilitation is more effective than home-based exercise in improving range of motion, functional outcomes, and quality of life for patients with shoulder disorders. Telerehabilitation significantly outperforms home-based exercise in relieving pain when continued for over 12 weeks.

Rotator cuff disorders: An updated survey of current (2023) UK physiotherapy practice

BACKGROUND

Clinical guidelines recommend treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorder. Despite this recommendation, research evidence supporting the effectiveness of treatment by a physiotherapist is uncertain. While developing a randomised controlled trial to test the effectiveness of treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorders, we first aimed to understand current practice as a basis for defining usual care.

METHODS

An online survey was developed based on a clinical vignette used in a previous survey exploring physiotherapy practice for people with shoulder pain due to rotator cuff disorder. UK-based physiotherapists were invited to complete the survey via X and email across professional networks.

RESULTS

One Hundred Seventy complete responses were received. 167 (98%) respondents would offer advice/education to patients with shoulder rotator cuff disorders; 146 (86%) would use isotonic exercise (including concentric/eccentric strengthening); 20 (12%) would offer a corticosteroid injection; 7 (4%) would use joint mobilisation. 168/169 (99%) would offer in-person assessment; 115 (68%) expect to deliver treatment over three to four sessions. Fifty percent agreed there is uncertainty about the effectiveness of physiotherapy treatment for patients with shoulder rotator cuff disorders. Seventy six percent agreed that patients with this condition can recover without physiotherapy intervention.

CONCLUSIONS

Exercise and advice remain the most common treatments offered by physiotherapists for people with shoulder pain due to rotator cuff disorder. Corticosteroid injections are infrequently considered. Uncertainty about the effectiveness of treatment by a physiotherapist for shoulder pain due to rotator cuff disorder is evident.

Behaviour change and rehabilitation adherence in adults with tendinopathy: a scoping review

PURPOSE

This scoping review aimed to identify behaviour change strategies influencing rehabilitation adherence in adults with tendinopathy, a common musculoskeletal condition requiring prolonged rehabilitation with poor adherence and variable outcomes.

METHODS

Following the Joanna Briggs Institute (JBI) methodology, seven databases were searched until April 2023. Records included reviews, intervention, and qualitative studies published in English. Behaviour change strategies were deductively coded and mapped to the capability, opportunity, and motivation model of behaviour (COM-B).

RESULTS

Eighty-six articles were retained. The primary behaviour change strategies in tendinopathy rehabilitation reports addressed Psychological Capability; from knowledge through education, instruction, and self-monitoring using exercise diaries. Also, Social Opportunity involves demonstration and monitoring of rehabilitation behaviour, and Physical Opportunity focuses on time-efficient programs with access to equipment and health professionals. Few reports addressed Automatic Motivation (positive reinforcement and habit formation). Barriers identified in the reports were Reflective Motivation (negative beliefs and fears), Physical Opportunity (time-constraints), and Physical Capability (pain and comorbidities).

CONCLUSIONS

Further research should explore the impact of education on beliefs, fears, and pain-management, as well as the effectiveness of teaching habit formation for improved time-management. Implementing these behaviour change strategies may enhance tendinopathy rehabilitation adherence, improving clinical trial efficacy, guiding clinical practice, and impacting patient outcomes.

If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain

OBJECTIVE

The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial.

METHODS

Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers.

RESULTS

Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program.

CONCLUSION

In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement.

IMPACT

These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.

Effects of Interactive Telerehabilitation Practices in Office Workers with Chronic Nonspecific Neck Pain: Randomized Controlled Study

Aim: Aim of this study is to investigate the effects of interactive telerehabilitation exercises in office workers with chronic nonspecific neck pain. Methods: Office workers (n = 120) were randomly divided into three groups between February and July 2022, taking into account the inclusion and exclusion criteria, and office ergonomics training was given to all of the participants. Group 1 participants were given an interactive telerehabilitation program (strengthening, motor control, and posture correction exercises) for 45 min per day, 3 days a week, for a total of 6 weeks. Group 2 participants were trained to do the home exercise program on their own for 45 min per day, 3 days a week, for a total of 6 weeks. Only office ergonomics training was given to Group 3 patients. Results: Statistically significant improvement in pain (p < 0.001), range of motion (ROM) (p < 0.001), neck disability status (p < 0.001), functional status (p < 0.001), and quality of life (p < 0.001) of 6-week interactive telerehabilitation application in office workers was found. Discussion: In addition to office ergonomics training, interactive telerehabilitation program is the most effective method on pain, ROM, and neck disability compared with home exercise program and office ergonomics training alone, and studies are needed on the long-term effectiveness of telerehabilitation applications and telerehabilitation treatment diversity.

Online Chair Yoga and Digital Learning for Rural Underserved Older Adults at Risk for Alzheimer's Disease and Related Dementias

OBJECTIVES

We evaluated the feasibility and preliminary efficacy of a home-based online chair yoga (OCY) program for racially and ethnically diverse rural community-dwelling older adults.

METHODS

We randomly assigned participants to OCY or a computer brain game (CBG). After a computer literacy training led by high school students, participants engaged in remotely supervised OCY or CBG in twice-weekly 45-minute sessions for 12 weeks. Outcome data (pain interference, cognitive function, mobility, computer skills) were collected at baseline, post-intervention, and 3-month follow-up.

RESULTS

A total of 32 eligible residents with mean age of 71 years participated in this intervention study. The interventions were feasible (100% recruitment rate, 96.8% retention rate, 100% safety rate). There were significant improvements in pain interference, cognitive function, mobility, and computer skills from baseline to follow-up among participants in both OCY and CBG but no significant differences in outcomes between groups.

CONCLUSIONS

Preliminary results indicated that the CBG was as effective as online OCY in clinical outcomes in these participants. However, this should be confirmed in future studies.

CLINICAL IMPLICATIONS

This telehealth-based intervention is feasible for older adults in rural and digitally underserved communities and could provide a strategy for delivering health-promoting interventions for home-bound older adults at risk for Alzheimer's disease and related dementias (ADRD) and connect caregivers to online resources.

Physiotherapist-led exercise versus usual care (waiting-list) control for patients awaiting rotator cuff repair surgery: A pilot randomised controlled trial (POWER)

BACKGROUND

Once a decision to undergo rotator cuff repair surgery is made, patients are placed on the waiting list. It can take weeks or months to receive surgery. There has been a call to move from waiting lists to 'preparation' lists to better prepare patients for surgery and to ensure it remains an appropriate treatment option for them.

OBJECTIVE

To evaluate the feasibility, as measured by recruitment rates, treatment fidelity and follow-up rates, of a future multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of undertaking a physiotherapist-led exercise programme while waiting for surgery versus usual care (waiting-list control).

DESIGN

Two-arm, multi-centre pilot randomised controlled trial with feasibility objectives in six NHS hospitals in England.

METHOD

Adults (n = 76) awaiting rotator cuff repair surgery were recruited and randomly allocated to a programme of physiotherapist-led exercise (n = 38) or usual care control (n = 38).

RESULTS

Of 302 eligible patients, 76 (25%) were randomised. Of 38 participants randomised to physiotherapist-led exercise, 28 (74%) received the exercise programme as intended. 51/76 (67%) Shoulder Pain and Disability Index questionnaires were returned at 6-months. Of 76 participants, 32 had not received surgery after 6-months (42%). Of those 32, 20 were allocated to physiotherapist-led exercise; 12 to usual care control.

CONCLUSIONS

A future multi-centre randomised controlled trial is feasible but would require planning for variable recruitment rates between sites, measures to improve treatment fidelity and opportunity for surgical exit, and optimisation of follow-up. A fully powered, randomised controlled trial is now needed to robustly inform clinical decision-making.

Exercise into pain in chronic rotator cuff related shoulder pain: a prospective single-group feasibility study

OBJECTIVES

This study evaluated the feasibility of exercising into pain in rotator cuff related shoulder pain (RCRSP), data collection procedures, feedback from physiotherapists and patients, and clinically important changes in patient-reported outcome measures (PROMs).

DESIGN

Unblinded non-randomised single-group study.

SETTING

Physiotherapy clinic in Belgium.

PARTICIPANTS

Twelve patients with unilateral RCRSP for minimum 3 months, aged 18-65 years.

INTERVENTIONS

Twelve weeks of four individualised exercises, with nine physiotherapist-led sessions with pain ratings 4-7 out of 10 on a verbal Numeric Pain Rating Scale for 9 weeks and then pain ratings 0-2 for 3 weeks. Every physiotherapy session included 15 min of manual therapy. Non-supervised exercises were: 2×/week in weeks with physiotherapy session, 3×/week in weeks without physiotherapy session.

OUTCOME MEASURES

Primary: adherence, where patients were considered adherent with 78% (7/9 sessions) attendance for supervised sessions and 81% (22/27 sessions) completion for non-supervised exercises, and Shoulder Pain and Disability Index (SPADI); secondary: fear-avoidance behaviour, fear of pain, physical outcomes (strength, range of motion, scapular dyskinesis); others: ultrasound (US) imaging outcomes (acromionhumeral distance, supraspinatus tendon thickness, occupation ratio), global perceived effect (GPE). PROMs were collected via online survey, except for the GPE (via closed envelope). US measures were taken after physical measures.

RESULTS

Adherence and adverse effects were analysed in patients who had the possibility to attend minimum seven supervised sessions (n=8): 88% of them adhered to supervised sessions, 50% to non-supervised exercises; none of them withdrew from the study, three of them obtained individual clinically important improvements in SPADI score above 20 points. The measurement protocol of physical and ultrasonographic outcomes took around 60 min.

CONCLUSIONS

Adherence to supervised sessions was satisfactory, the adherence to non-supervised exercises must be improved. Data collection procedures were feasible to perform, but some changes are recommended.

TRIAL REGISTRATION NUMBER

NCT04154345.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Effect of a telerehabilitation exercise program versus a digital booklet with self-care for patients with chronic non-specific neck pain: a protocol of a randomized controlled trial assessor-blinded, 3 months follow-up

BACKGROUND

Neck pain is the fourth worldwide leading cause of disability and represents 22% of musculoskeletal disorders. Conservative intervention has been strongly recommended to treat chronic neck pain and Telerehabilitation is the alternative for the treatment of musculoskeletal conditions. There is a lack of high-quality research on the effects of telerehabilitation in patients with neck pain and functional disability. Therefore, this study aims to evaluate the effect of a telerehabilitation exercise program versus a digital booklet only with self-care information in individuals with non-specific chronic neck pain.

METHODS

This is a prospectively registered, assessor-blinded, two-arm randomized controlled trial comparing a telerehabilitation exercise program versus a digital booklet with self-care information. Seventy patients will be recruited with non-specific chronic neck pain. Follow-ups will be conducted post-treatment, 6 weeks, and 3 months after randomization. The primary outcome will be disability at post-treatment (6 weeks) measured using neck pain disability. Secondary outcomes will be pain intensity levels, global perceived effect, self-efficacy, quality of life, kinesiophobia, and adherence to treatment. In our hypothesis, patients allocated to the intervention group experience outcomes that are similar to those of those assigned to the self-care digital booklet. Our hypothesis can then be approved or disapproved based on the results of the study.

DISCUSSION

This randomized clinical trial will provide reliable information on the use of telerehabilitation to treat patients with chronic non-specific neck pain.

TRIAL REGISTRATION

The study was prospectively registered at the Brazilian Registry of Clinical Trials (number: RBR-10h7khvk). Registered on 16 September 2022.

Comparing Digital to Conventional Physical Therapy for Chronic Shoulder Pain: Randomized Controlled Trial

BACKGROUND

Chronic shoulder pain (CSP) is a common condition with various etiologies, including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation has gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no previous randomized controlled trial has compared fully remote digital physical therapy to in-person rehabilitation for nonoperative CSP.

OBJECTIVE

The aim of this study is to compare clinical outcomes between digital physical therapy and conventional in-person physical therapy in patients with CSP.

METHODS

We conducted a single-center, parallel-group, randomized controlled trial involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education, and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy, including exercises, manual therapy, education, and CBT. The primary outcome was the change (baseline to 8 weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire. Secondary outcome measures included self-reported pain, surgery intent, analgesic intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically.

RESULTS

A total of 90 participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function measured by the short-form of the Disabilities of the Arm, Shoulder, and Hand questionnaire, with no differences between groups (-1.8, 95% CI -13.5 to 9.8; P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake, and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which, given the small effect sizes (least pain 0.15 and average pain 0.16), are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups, with no adverse events.

CONCLUSIONS

This study shows that fully remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage in-person rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04636528); https://clinicaltrials.gov/study/NCT04636528.

Comparison of the effectiveness of eHealth self-management interventions for pain between oncological and musculoskeletal populations: a systematic review with narrative synthesis

OBJECTIVES

The aim of this systematic review is to compare the effectiveness of eHealth self-management interventions on pain intensity between oncological and musculoskeletal populations and to examine barriers and facilitators of the use of eHealth self-management tools.

CONTENT

In March 2021, a systematic search of the literature was conducted using the databases PubMed and Web of Science. Studies that investigated the effect of eHealth self-management interventions on pain intensity in an oncological and/or a musculoskeletal population were included.

SUMMARY

No study was found with a direct comparison of the two populations. Of the ten included studies, only one (musculoskeletal) found a significant interaction effect in favor of the eHealth program and three (musculoskeletal and breast cancer) showed a significant time-effect of the eHealth intervention. In both populations user-friendliness of the tool was considered as a facilitator, the length of the program and the lack of an in-person session as barrier. Due to the absence of a direct comparison, no conclusion can be made on how the effectiveness differs between both populations.

OUTLOOK

Further research should incorporate patient-experienced barriers and facilitators and there is a high need of studies making the direct comparison of the effect of an eHealth self-management intervention on pain intensity in an oncological vs. a MSK population.

Telemedicine in Care of Sarcoma Patients beyond the COVID-19 Pandemic: Challenges and Opportunities

BACKGROUND

The COVID-19 pandemic has created a challenging environment for sarcoma patients. Most oncology societies published guidelines or recommendations prioritizing sarcoma patients and established telehealth as an efficient method of approaching them. The aim of this review is the assessment of current evidence regarding the utilization of telemedicine in diagnosis, treatment modalities, telerehabilitation and satisfaction among sarcoma patients and healthcare providers (HP).

METHODS

This systematic review was carried out using the databases PubMed and Ovid MEDLINE according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

The application of telemedicine to the management of sarcoma has yielded improved clinical and psychological outcomes. Specifically, significant progress has been demonstrated in the areas of tele-oncology and telerehabilitation during the last decade, and the COVID-19 outbreak has accelerated this transition toward them. Telehealth has been proven efficient in a wide spectrum of applications from consultations on physical therapy and psychological support to virtual care symptom management. Both HP and patients reported satisfaction with telehealth services at levels comparable to in-person visits.

CONCLUSIONS

Telehealth has already unveiled many opportunities in tailoring individualized care, and its role in the management of sarcoma patients has been established in the post-COVID-19 era, as well.

A randomized controlled trial of postoperative rehabilitation using digital healthcare system after rotator cuff repair

A digital healthcare system based on augmented reality (AR) has promising uses for postoperative rehabilitation. We compare effectiveness of AR-based and conventional rehabilitation in patients after rotator cuff repair (RCR). This study randomly allocates 115 participants who underwent RCR to digital healthcare rehabilitation group (DR group) and conventional rehabilitation group (CR group). The DR group performs AR-based home exercises using UINCARE Home+, whereas the CR group performs brochure-based home exercises. The primary outcome is a change in the Simple Shoulder Test (SST) score between baseline and 12 weeks postoperatively. The secondary outcomes are the Disabilities of the Arm, Shoulder and Hand (DASH) score; Shoulder Pain And Disability Index (SPADI) score; EuroQoL 5-Dimension 5-Level (EQ5D5L) questionnaire score; pain; range of motion (ROM); muscle strength; and handgrip strength. The outcomes are measured at baseline, and at 6, 12, and 24 weeks postoperatively. The change in SST score between baseline and 12 weeks postoperatively is significantly greater in the DR group than in the CR group (p = 0.025). The SPADI, DASH, and EQ5D5L scores demonstrate group×time interactions (p = 0.001, = 0.04, and = 0.016, respectively). However, no significant differences over time are observed between the groups in terms of pain, ROM, muscle strength, and handgrip strength. The outcomes show significant improvement in both groups (all p < 0.001). No adverse events are reported during the interventions. AR-based rehabilitation shows better improvement in terms of shoulder function after RCR compared to conventional rehabilitation. Therefore, as an alternative to the conventional rehabilitation, the digital healthcare system is effective for postoperative rehabilitation.

Disruptions in Standard Care in Patients After Arthroscopic Rotator Cuff Repair During the COVID-19 Pandemic

Background

The coronavirus disease-2019 (COVID-19) pandemic led to disruptions in care for orthopaedic patients who underwent surgery just before the outbreak, rendering some unable to participate in standard postoperative care. Many of these patients underwent clinical follow-up and physical therapy via telehealth.

Purpose

To evaluate the methods of postoperative care in patients who underwent arthroscopic rotator cuff repair (RCR) and had follow-ups during the height of the pandemic versus those who received prior standard of care. We aimed to compare the 1-year outcomes between these cohorts.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective chart review was used to identify patients who underwent primary RCR in February and March 2020 (COVID cohort) and the same period in 2019 (control cohort) at a single institution. Excluded were patients who underwent revision RCR, used workers' compensation, or were incarcerated or deceased. The included patients reported the postoperative care received, their satisfaction with care, physical therapy appointment type (in person, home based, telehealth, or self-guided), satisfaction with physical therapy, and minimum 1-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn Shoulder Score (PSS) outcomes.

Results

Overall, 428 patients were included for final analysis--199 in the COVID cohort and 229 controls. Follow-up data were collected for 160 patients in the COVID group (80.4%) and 169 control patients (73.8%). In the COVID group, 110 patients (68.8%) had ≥1 clinical visit conducted via telehealth, compared with zero in the control group. There were no differences between the COVID and control groups in the ASES (84.2 ± 16.5 vs 86.5 ± 17; P = .27 ), SANE (83.9 ± 15.4 vs 84.8 ± 17.5; P = .66), PSS (84.8 ± 15.3 vs 87.1 ± 15.1; P = .22), or patient satisfaction with the care received (81.7 ± 22.6 vs 86.3 ± 23.5; P = .09). Satisfaction with physical therapy was significantly higher in the control group (88.3 ± 18.9 vs 81.9 ± 22.5; P = .01).

Conclusion

Despite disruptions in care, RCR patients had comparable 1-year outcomes during the pandemic versus before the pandemic. Telehealth clinical follow-up appointments did not adversely affect patient-reported outcome measures and may be appropriate for RCR patients beyond the pandemic.

The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study

OBJECTIVES

This study aimed to investigate the feasibility of conducting a full-scale study investigating the influence of patient-related factors on rehabilitation outcomes in Achilles tendinopathy (AT). A secondary aim was to investigate preliminary relationships between patient-related factors and clinical outcomes at 12- and 26- weeks.

DESIGN

feasibility cohort.

SETTING

Australian healthcare settings.

METHODS

Participants with AT receiving physiotherapy in Australia were recruited via treating physiotherapists and online. Data were collected online at baseline, 12- and 26-weeks. Progression criteria for a full-scale study were recruitment rate of ≥10 per month, conversion rate ≥20%, and response rate to questionnaires ≥80%. The relationship between patient-related factors and clinical outcomes was investigated using Spearman's rho correlation coefficient.

RESULTS

The average recruitment rate was 5/month, conversion rate was 97%, and response rate to questionnaires was ≥97% at all timepoints. There was a fair to moderate correlation (rho = 0.225 to 0.683) between patient-related factors and clinical outcomes at the 12-week, but no to weak correlation at the 26-week (rho = 0.002 to 0.284).

CONCLUSIONS

Feasibility outcomes suggest a future full-scale cohort study is feasible with the caveat of utilizing strategies to improve recruitment rate. Preliminary bivariate correlations at 12-weeks warrant further investigations in larger studies.

Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review

PURPOSE

Prior to the COVID-19 pandemic, telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology. With the corona-outbreak, telemedicine was applied on a broad scale to prevent assemblage and to guarantee access to medical care protecting critical areas. The purpose of the present study was to give an overview of the spectrum of clinical applications and the efficacy of telemedicine in orthopaedic and trauma surgery as published in times of the COVID-19 pandemic.

METHODS

All published studies investigating the application of telemedicine related to orthopaedics and trauma during the COVID-19 pandemic were accessed and screened for suitability. The primary outcome of interest was the efficacy of telemedicine in various clinical applications. The secondary outcome of interest was the spectrum of different applications in which telemedicine applications were investigated.

RESULTS

The literature search resulted in 1047 articles. After the removal of duplicates, 894 articles were screened of which 31 finally met the inclusion criteria. Dimensions that were described by studies in the literature to have positive effects were preoperative patient optimisation, the usefulness of telemedicine to correctly diagnose a condition, conservative treatment, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed.

CONCLUSION

Various successful applications of telemedicine have already been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the COVID-19 years 2020-2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic.

Parsonage-Turner Syndrome mimicking musculoskeletal shoulder pain: A case report during the SARS-CoV-2 pandemic era

Parsonage-Turner Syndrome or neuralgic amyotrophy is a peripheral neuropathy typically characterized by an abrupt onset of pain, followed by progressive neurological deficits (e.g. weakness, atrophy, occasionally sensory abnormalities) that involve the upper limb, mainly the shoulder, encompassing an extensive spectrum of clinical manifestations, somehow difficult to recognize. This case report describes the proper management of a 35-year-old, bank employee and sports amateur who reported subtle and progressive upper limb disorder with previous history of neck pain. SARS-CoV-2 pandemic era made patient's access to the healthcare system more complicated. Nevertheless, proper management of knowledge, relevant aspects of telerehabilitation-based consultation for musculoskeletal pain, advanced skills, tools and technologies led the physiotherapist to suspect an atypical presentation of Parsonage-Turner Syndrome. Further, neurologist consultation and electromyography suggested signs of denervation in the serratus anterior and supraspinatus muscle. Therefore, an appropriate physiotherapist's screening for referral is conducted to correct diagnosis and thorough treatment.

Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study

BACKGROUND

Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.

OBJECTIVE

The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.

METHODS

Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis.

RESULTS

From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from -16.82, 95% CI -20.32 to -13.42 in cluster 1 to -20.10, 95% CI -32.64 to -7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).

CONCLUSIONS

A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Asynchronous and Tailored Digital Rehabilitation of Chronic Shoulder Pain: A Prospective Longitudinal Cohort Study

Background

Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs.

Purpose

Present the results of a fully remote digital care program (DCP) for chronic SP.

Patients and Methods

Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean −13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6).

Conclusion

This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.

Home-Based Tele-Exercise in Musculoskeletal Conditions and Chronic Disease: A Literature Review

Exercise training is an essential component in the treatment or rehabilitation of various diseases and conditions. However, barriers to exercise such as the burdens of travel or time may hinder individuals' ability to participate in such training programs. Advancements in technology have allowed for remote, home-based exercise training to be utilized as a supplement or replacement to conventional exercise training programs. Individuals in these home-based exercise programs are able to do so under varying levels of supervision from trained professionals, with some programs having direct supervision, and others having little to no supervision at all. The purpose of this review is to examine the use of home-based, tele-exercise training programs for the treatment of different disease states and conditions, and how these programs compare to conventional clinic-based exercise training programs.

Use of pre-enrollment randomization and delayed consent to maximize participation in a clinical trial of opt-in versus opt-out tobacco treatment

Background: Enrollment in smoking cessation trials remain sub-optimal. The aim of this analysis was to determine the effectiveness of a modified Zelen's design in engaging hospitalized patients who smoke in a pragmatic OPT-IN versus OPT-OUT tobacco treatment trial. Methods: At bedside, clinical staff screened smokers for eligibility, randomized eligible into study arms, and delivered the appropriate treatment approach. Study staff called randomized patients at one-month post-discharge, debriefed patients on the study design, and collected consent to participate. We used frequencies and percentages for categorical variables and means and standard deviations for quantitative variables to describe the characteristics of those who consented and were enrolled versus those who did not enroll. We also compared the characteristics of participants who consented and those who were reached and explicitly refused consent at one-month follow-up. We used the Cohen's d measure of effect size to evaluate differences. Results: Of the 1,000 randomized, 741 (74.1%) consented to continue in the study at one-month follow-up. One hundred and twenty-seven (12.7%) refused consent and 132 (13.2%) were unreachable. Cohen's d effect size differences between those who consented/enrolled (n = 741) and those who were not enrolled (n = 259) were negligible (<0.2) for age, gender, race/ethnicity, and most forms of insurance. The effect size was small for Medicaid (0.36), and other public insurance (0.48). After excluding those unreached at 1 month (12.7%), there were medium Cohen's d effect size differences between those who consented to participate (n = 741) and those who explicitly refused (n = 127) with respect to age (0.55) and self-pay or no insurance (0.51). There were small to negligible effect size differences with respect to sex, race/ethnicity, and other forms of health insurance. Conclusions: The modified Zelen's design resulted in successful enrollment of most participants who were initially randomized into the trial, including those not motivated to quit.

The Utilization and Benefits of Telehealth Services by Health Care Professionals Managing Breast Cancer Patients during the COVID-19 Pandemic

Telehealth is the delivery of many health care services and technologies to individuals at different geographical areas and is categorized as asynchronously or synchronously. The coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions in health care delivery to breast cancer (BCa) patients and there is increasing demand for telehealth services. Globally, telehealth has become an essential means of communication between patient and health care provider. The application of telehealth to the treatment of BCa patients is evolving and increasingly research has demonstrated its feasibility and effectiveness in improving clinical, psychological and social outcomes. Two areas of telehealth that have significantly grown in the past decade and particularly since the beginning of the COVID-19 pandemic are telerehabilitation and teleoncology. These two technological systems provide opportunities at every stage of the cancer care continuum for BCa patients. We conducted a literature review that examined the use of telehealth services via its various modes of delivery among BCa patients particularly in areas of screening, diagnosis, treatment modalities, as well as satisfaction among patients and health care professionals. The advantages of telehealth models of service and delivery challenges to patients in remote areas are discussed.

Zelen design clinical trials: why, when, and how

BACKGROUND

In 1979, Marvin Zelen proposed a new design for randomized clinical trials intended to facilitate clinicians' and patients' participation. The defining innovation of Zelen's proposal was random assignment of treatment prior to patient or participant consent. Following randomization, a participant would receive information and asked to consent to the assigned treatment.

METHODS

This narrative review examined recent examples of Zelen design trials evaluating clinical and public health interventions.

RESULTS

Zelen designs have often been applied to questions regarding real-world treatment or intervention effects under conditions of incomplete adherence. Examples include evaluating outreach or engagement interventions (especially for stigmatized conditions), evaluating treatments for which benefit may vary according to participant motivation, and situations when assignment to a control or usual care condition might prompt a disappointment effect. Specific practical considerations determine whether a Zelen design is scientifically appropriate or practicable. Zelen design trials usually depend on identifying participants automatically from existing records rather than by advertising, referral, or active recruitment. Assessments of baseline or prognostic characteristics usually depend on available records data rather than research-specific assessments. Because investigators must consider how exposure to treatments or interventions might bias ascertainment of outcomes, assessment of outcomes from routinely created records is often necessary. A Zelen design requires a waiver of the usual requirement for informed consent prior to random assignment of treatment. The Revised Common Rule includes specific criteria for such a waiver, and those criteria are most often met for evaluation of a low-risk and potentially beneficial intervention added to usual care. Investigators and Institutional Review Boards must also consider whether the scientific or public health benefit of a Zelen design trial outweighs the autonomy interests of potential participants. Analysis of Zelen trials compares outcomes according to original assignment, regardless of any refusal to accept or participate in the assigned treatment.

CONCLUSIONS

A Zelen design trial assesses the real-world consequences of a specific strategy to prompt or promote uptake of a specific treatment. While such trials are poorly suited to address explanatory or efficacy questions, they are often preferred for addressing pragmatic or policy questions.

Patient knowledge of rotator cuff related shoulder pain condition and treatment and validation of a patient-reported knowledge questionnaire

BACKGROUND

Rotator cuff related shoulder pain (RCRSP) knowledge is an important contributor to compliance with clinical practice guidelines and providing best practice care. However, there are no validated instruments for measuring health literacy levels among people with RCRSP. This study aimed to design a valid and reliable instrument to measure RCRSP health literacy and use it to evaluate an education intervention for people with RCRSP.

METHODS

Development of the patient knowledge questionnaire (PKQ-RCRSP) included three phases. Phase 1 was developed based on available literature and input from expert clinicians, researchers and patients. Face validity, pilot testing and readability assessment were also undertaken. In Phase 2, internal consistency and predictive validity were assessed in people with RCRSP and other shoulder pain diagnoses. In Phase 3, RCRSP health literacy was assessed.

RESULT

Face validity was acceptable and pilot testing identified minor accuracy issues that were corrected. Literacy level was rated as 'difficult to read' which reflects the medical terminology within the questionnaire. Internal consistency was very good and 81% of questions demonstrated acceptable predictive validity. Health literacy was heterogeneous depending on the question with less than 40% of respondents answering correctly for questions related to the indications, process and the known benefits of RCRSP surgery.

CONCLUSION

The PKQ-RCRSP demonstrated acceptable face validity, predictive validity and reliability (internal consistency) in assessing RCRSP health literacy. Health literacy among our small sample was poor for questions related to surgery for RCRSP.

The Efficacy of Tele-Rehabilitation Program for Improving Upper Limb Function among Adults Following Elbow Fractures: A Pilot Study

Background: Active mobilization post-elbow fractures reduces the incidence of complications. Occupational therapists use tele-rehabilitation, incorporating technology into their practices. There is a lack of evidence-based trials regarding the integration of tele-rehabilitation during treatment. We therefore aimed to compare tele-rehabilitation treatment outcomes with conventional rehabilitation in improving the upper limb function post-elbow fractures. Methods: Eighteen participants post-elbow surgery due to fracture were divided into two groups according to age and fracture type. The groups received one month of treatment: the tele-rehabilitation group (N = 9, median age 33.0 ± 27.9 years, range 18.5–61.0) received 1–2 tele-rehabilitation treatments per week via a biofeedback system of elbow motion (the ArmTutor and 3D Tutor systems, MediTouch Ltd., Netanya, Israel) and 1–2 treatments in an outpatient clinic, and the control group (N = 9, median age 60.0 ± 37.0 years, range 20.5–73.0) received 3–4 treatments per week in the clinic. Both groups were instructed to self-practice at home. Four evaluations were performed: before and after the intervention, and 3 months and 1 year from surgery. The outcome measures included the Jebsen–Taylor hand function test; the disabilities of the arm, shoulder, and hand questionnaire; the patient-rated elbow evaluation; satisfaction; passive and active range of motion (ROM); and strength measurements. Results: Findings demonstrated a significant improvement in the ROM and in functional assessments in both groups. No statistically significant differences were found between the groups. The subjects in the tele-rehabilitation group reported a higher level of satisfaction and needed less help from a family member during practice. Conclusions: Tele-rehabilitation programs could be incorporated in the framework of treatment following elbow fractures. Tele-rehabilitation is a cost-effective treatment, suitable for patients with accessibility difficulties or who have difficulty arriving at the clinic.