Introduction
The musculoskeletal (MSK) system, composed of the bones, muscles, tendons, and ligaments in the body, provides structural support and enables movement. An injury to this intricate system may result in decreased strength, immobility, and/or pain. Therefore when a patient presents with an MSK injury, performing a thorough physical examination and prescribing therapeutic exercises are pillars of clinical care.
As the implementation of telemedicine has increased, so has telerehabilitation. Through information and communication technologies, the conventional practices of patient interviews, consultations, and physical therapy (PT) can be provided remotely. Since the 1990s, the use of different modalities to provide synchronous (real-time communication) and asynchronous (communication with a time lag) telerehabilitation has been explored. Initially implemented as a means for providing care to patients unable to attend in-person appointments due to access or resource limitations, the need for remote care increased drastically in the wake of the COVID-19 global pandemic. This development highlighted the lack of widespread understanding of how to implement telemedicine—a vulnerability within the health care system. For these reasons, it is essential to understand the previously assessed methodologies for providing telerehabilitation for MSK injuries, as well as the current suggestions for implementation, in order to provide optimal MSK care.
Telerehabilitation in Treating MSK Conditions
Telerehabilitation may be most applicable to the diagnosis of MSK injuries that do not require extensive physical examination for diagnosis, or for management of previously diagnosed conditions. Studies reported that 36% to 67% of diagnoses were in agreement, and 73% to 89% were similar to the diagnoses made in-person when utilizing synchronous telerehabilitation, with the lower range reported for telerehabilitation guiding a remote practitioner, and the upper range representing telerehabilitation provided to patients in their own homes. Moreover the pain generator identified was found to be in agreement in 94% of cases for patients with knee pain who participated in telerehabilitation from home compared with those who received traditional in-person assessments. A systematic review and metaanalysis on synchronous telerehabilitation for MSK conditions by Cottrell et al. concluded that when compared with conventional care, telerehabilitation may yield superior outcomes for improvement on physical function, reduced disability, and similar improvement of pain. Specifically, there is strong evidence in support of the diagnosis and management of conditions including osteoarthritis (OA) of the hand, knee, and hip as well as pathologies of the shoulder and spine through telerehabilitation provided to patients at home and remote facilities.
OA is the leading cause of disability in the United States, and it is estimated that four million people in the United States have symptomatic knee OA. Management of OA is largely focused on optimizing patients’ quality of life, and telerehabilitation designed for this pathology has been shown to result in a greater improvement in quality of life compared with clinic-based treatment. Patient education on lifestyle factors including regular exercise, weight loss, and the role of interventions can be easily communicated through the use of telehealth. Moreover, telerehabilitation programs are as effective as office-based PT in improving the function of patients with knee OA. In fact, a review on telerehabilitation for OA by Pietrak et al. indicated that, besides patients reporting high satisfaction and perceived improved communication with their health care professionals both virtually and in person, telerehabilitation for OA successfully improved health distress, activity limitation, self-reported global health, fatigue, and pain in report of patient numbers that ranged from 121 to 855.
Shoulder pain (e.g., rotator cuff injuries) has also been shown to improve through virtual care, with outcomes similar to conventional in-person care (sample sizes of patient populations n = 11–145). For patients with rotator cuff injuries, telerehabilitation allowed for significantly decreased pain and improved movement, function, and muscular strength. Equally important to the clinical improvement is the perception of the treatment modality, and in a study conducted by Macías-Hernández et al., all participating patients stated that they would recommend this platform to others. Moreover, for patients with nonspecific shoulder or spine pain, the incorporation of telerehabilitation with virtually provided myofeedback-based treatment resulted in decreased pain intensity and disability after 4 weeks, and remained after 3 months.
Similar to OA, low back pain and neck pain are highly prevalent and are among the leading contributors to years lived with disability in the United States. Nonspecific neck and low back pain have also been shown to improve through the use of telerehabilitation. Previous studies assessing telerehabilitation conducted by physical therapists and orthopedic surgeons to a patient’s home or general health clinic, respectively, have illustrated outcomes at least comparable to conventional in-person care. A study by Iles et al. reported that patients with nonchronic low back pain who received telerehabilitation in addition to in-person care improved significantly more than those receiving in-person care alone when assessing activity and recovery expectation.
Without adequate management, acute MSK injuries may become chronic conditions. Globally, chronic MSK injuries affect over 25% of the population, are the leading cause of pain and disability, and account for 21.3% of morbidity. Similar to acute MSK conditions, the evaluation of telerehabilitation for chronic MSK pain revealed promising results. For patients with chronic MSK pain, the addition of telerehabilitation appointments to a prescribed home exercise program reduced chronic neck pain symptoms and disability at 6 months, and increased compliance with their home exercise program. Telecare may also play an important role in the pharmaceutical management of chronic MSK pain. Kroenke et al. illustrated that the addition of automated symptom monitoring and as-needed telephone calls with a pain-specialist nurse resulted in improved pain scores by 12 months for patients with chronic MSK pain. As evidenced by the literature, appropriate implementation of telerehabilitation may bring benefits to patients otherwise inaccessible.
Practice
In practice, rehabilitation for MSK injuries often requires a collaborative approach that involves a variety of specialized therapists and health care professionals. Beyond enabling clinical care, telerehabilitation has the benefit of supporting multidisciplinary care and communication amongst care team members. This aspect of telerehabilitation is evidenced through a study by Careau et al. that found videoconferences dedicated to interprofessional care plan development have a mean productivity level of 96% with the most common advantage noted being good eye-contact.
Clinical Role in Outpatient MSK Care
For outpatient care, telemedicine for MSK injuries may be used for initial evaluation, to monitor response to treatment, or a combination of both. The initial outpatient MSK encounter traditionally begins with a visit to evaluate the injury and continues with follow-up appointments to assess treatment efficacy and recovery progress. Telemedicine may be used as an alternative to any of these interactions. Synchronous teleconferencing is the form of telerehabilitation that most resembles the traditional clinic interaction, and a study evaluating this type of telerehabilitation for an outpatient PM&R-based MSK and Sports Medicine clinic found that overall, 91.6% to 95.0% patients (in the various measures, ( Fig. 14.1 ) and 92% of physicians rated their experiences as “excellent” or “very good”. Synchronous videoconferencing has been shown to be a valid alternative to traditional outpatient MSK care, but where it is best incorporated may vary by MSK condition.
As an accurate diagnosis is essential for proper care and often requires an extensive physical examination, the initial evaluation should be conducted in person if possible. Additionally, patients and physicians prefer this initial in-person appointment to aid in establishing a strong physician-patient relationship. However, for patients in remote areas with limited access to specialized MSK care or with conditions requiring less extensive physical examinations for diagnosis, telemedicine may be a valid alternative to the initial consultation and used to determine if an in-person appointment is needed. Once a diagnosis has been made, telerehabilitation may also be incorporated into conventional care with proven benefit of decreasing need for in-person visits.
Clinical Evaluation
When evaluating a patient remotely, the physical examination relies on the clear transmission of visual, audio, and/or haptic data (data obtained from patient contact with technology). To enable effective communication, a patient participating in video-based telerehabilitation should be instructed to be in a well-lit, private area with room to perform full-body movements and dressed in a manner conducive to the examination of their injury (e.g., for a knee injury, shorts should be worn and socks and shoes removed). Patients should also be told ahead of their appointments that the camera used must be stable without being held and positioned so that the physician can view the body part being evaluated. In synchronous telemedicine, the physician may demonstrate the physical examination maneuver for the patient to perform on himself or herself, or may have others assist the patient with performing the physical examination testing. In accordance with the standards of in-person medicine, a clear understanding of which examinations should be performed and how best to document them is key in telemedicine ( Tables 14.1 and 14.2 ).
| System | System Sub-Area | Adaptation to Virtual Care | Suggested Documentation for Normal Examination |
|---|---|---|---|
| Vital signs | Evaluate for tachypnea, cyanosis, orthostatic symptoms as applicable. May ask patient for height/weight. If patient has heart rate monitor (wrist or chest) and/or automatic blood pressure cuff, can have them provide values | Normal rate of breathing, appears well oxygenated without cyanosis, reports no dizziness or orthostatic changes when asked to stand for 5 minutes after sitting | |
| General | Practitioner’s observation, including alertness, general appearance | Alert, cooperative, well-appearing, no acute distress | |
| Respiratory | Practitioner’s observation, including labor of breathing, presence of cough, or wheezing | Non-labored breathing, no cough or wheezing | |
| Skin | Practitioner’s observation of patient’s skin for masses, lesions, or ulcers. Inspect and comment on any skin changes at anatomical site(s) postinjection | No lesions or ulcers visualized on exposed skin. No discharge, drainage, or redness at site(s) of prior Injection | |
| Psychiatric | Practitioner’s observation of patient’s mood and affect | Normal mood, congruent affect, answers questions appropriately | |
| Neurologic | Mental status | Level of alertness, orientation to visit, able to identify objects, and maintain attention to tasks | Alert and oriented to person, time and reason for visit. Able to identify objects including items of clothing, electronic devices in use, and ability to perform serial 7 s (or spell WORLD backward if fluent in English or more appropriate for education) |
| Speech | Rate of speech, word choice, and volume | Fluent and normal rate of speech, no word finding difficulties | |
| CN I | If patient accompanied, patient may be presented with familiar smell (coffee, bread) to identify with eyes closed | CN 1 confirmed intact as patient able to accurately identify presented odor | |
| CN II | Practitioner’s observation of pupils | Pupils equal and round | |
| CN III, IV, VI | Ask patient to gaze in different directions | Extraocular movements intact, no nystagmus, no ptosis | |
| CN V | Ask patient to clench and release jaw | Jaw movements intact and symmetric | |
| CN VII | Ask patient to smile, raise eyebrows | Symmetric facial movement and smile | |
| CN VIII | Practitioner’s observation of patient’s hearing ability | Hearing intact to normal voice | |
| CN IX/X | Practitioner’s observation of vocal quality | Normal vocal quality, no hoarseness | |
| CN XI | Ask patient to shrug shoulders, rotate neck | Symmetric shoulder shrug and neck rotation | |
| CN XII | Ask patient to stick out tongue | Tongue protrudes midline | |
| Motor | Practitioner’s observation of abnormal movement at rest including tremor, dystonia, clonus; instruct patient on rapid finger tapping, pronator | No tremor, dystonia, clonus observed. Rapid finger tapping intact. No pronator drift | |
| Tone | Practitioner’s observation on voluntary movement, co-contraction, posturing with position changes | Patient able to perform full active movements, no co-contraction, no posturing with position changes | |
| Coordination | Practitioner instructs patient on performing rapid alternating movements, finger-to-nose with alternating movements, finger-to-nose with available targets (e.g., edge of computer screen), heel-to-shin | Rapid alternating movements intact and symmetric; finger-to-nose and heel-to-shin intact bilaterally | |
| Proprioception | Practitioner instructs patient on performing Romberg and tandem walking tests | Negative Romberg; normal tandem walking | |
| Sensation | Practitioner asks patient or accompanying individual to gently touch appropriate dermatomal regions, simultaneously if possible and report any abnormal sensation. May also provide diagram of dermatomes to further instruct patient. Practitioner can also ask patient to use tip of pencil and eraser to test sharp/dull sensation | Sensation to light touch and sharp/dull subjectively intact | |
| Strength | Practitioner’s observation of whether patient can performing appropriate movements such as antigravity; heel and toe walking can provide additional information about dorsiflexion/plantarflexion strength | Strength at least antigravity in all four limbs. Able to walk on heels and toes without difficulty | |
| Musculoskeletal | Gait | Practitioner’s observation of patient’s gait | Symmetric, nonantalgic, heel-to-toe gait |
| Inspection | Practitioner’s observation of relevant body regions as directed by patient and clinical suspicion | No asymmetry; no discoloration, erythema, or swelling; no obvious deformity | |
| Palpation | Practitioner instructs patient to find area(s) of tenderness and guides patient to palpate relevant associated areas, sense temperature differences in adjacent region or contralateral side, and describes crepitus | No tenderness to palpation; no crepitus reported, equal warmth | |
| Range of motion | Practitioner guides patient in performing movements to observe active range of motion | Full symmetric, active range of motion in bilateral shoulders, elbows and knees | |
| Special testing | Practitioner guides patient as appropriate for patient’s chief complaint (see Table 14.2 ) |
| Performed Without Assistance | Performed With Assistance From Nonclinician | |
|---|---|---|
| Cervical spine |
| |
| Lumbar Spine |
| |
| Hip/SI joint |
|
|
| Knee |
|
|
| Ankle/Foot |
|
|
| Shoulder |
|
|
| Elbow | Tinel test over ulnar groove (ulnar neuropathy at the elbow) |
|
| Wrist/Hand |
| |
| Bone (General) | Palpation, direct and indirect percussion, hop test (bone stress injury) |
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