The need is there, the opportunities are there, and the technology is, well, almost there, but when it comes to assessment of low back pain (LBP), the current reality of telerehabilitation (TR) is that more work is needed before a remote approach becomes a fully reliable substitute for in-person interaction. That's the conclusion reached by Australian researchers who compared face-to-face and remote LBP assessments and found that while "important components" of the assessments can be valid when obtained through TR, "some areas of the assessment require further testing and development."
The study, published in the February 2014 edition of Telemedicine and e-Health (abstract only available for free) focuses on LBP assessments conducted on 26 adult residents of a rural area in Queensland, Australia. The participants reported experiencing LBP currently or within the past 2 years, but not at severe levels nor accompanied by severe neurological symptoms. All participants could mobilize independently, were capable of participating in a safe physical examination, and possessed adequate communication and cognitive function.
Researchers divided the participants into 2 groups, assigning half to undergo a face-to-face LBP assessment followed by a TR assessment, and half to go through the process in reverse order. Outcome measures were then compared relative to disability, pain, posture, active movement, and the straight leg raise (SLR) test. Participants also filled out a questionnaire about their own satisfaction with the TR approach.
Before the study could be conducted, however, researchers needed to create a viable TR system capable of facilitating a LBP assessment—and under realistic conditions. They set up the study in a rural hospital, to be conducted "by rural clinicians, with a group of local participants who have experience with limited access to health services." The technology selected reflected a similar real-world approach, using a 640x480-pixel digital camera that could record moving and still images, a 300mm calibration index, a plinth, and an audio hookup. "The TR assessment was pragmatically designed to require the minimum amount of equipment and setup at the remote end," the authors wrote. Clinicians used "features" of eHAB, a medical videoconferencing system developed by the Telerehabilitation Research Unit at the University of Queensland.
As for the actual conduct of the assessments, participants were instructed to stand on a reference line on the floor of the TR room and move according to the physical therapist's (PT) instructions. Participants were also told to bring a friend with them to the TR room to help with the SLR test. In cases where the participants didn't bring a friend, researchers recruited an "untrained nonclinical assistant" from the hospital staff.
At the end of the study, researchers found strong correlation between face-to-face and TR assessments when it came to some but not all measures.
"We found high levels of agreement with establishing if a lumbar spine movement was painful, detecting pain, eliciting symptoms, and sensitizing the SLR," the authors wrote. "Moderate agreement was found in identifying the limitation to an active lumbar spine movement, identifying the worst lumbar spine movement direction, SLR range of motion, and active lumbar spine range of motion. Poor agreement was found in all elements of the postural analysis."
Researchers believe the problems with the postural analyses were partly technical and partly related to individual participants. According to the study, the keystoning effect of the wide-angle lens "made it difficult to analyze coronal posture," while the resolution of the images obtained was "insufficient to discriminate physical landmarks and hence allow postural assessment." Adding to the difficulties, researchers reported that 4 participants were unwilling to disrobe for the postural analysis—"not an unusual occurrence in this physiotherapy clinic," and something that happened in both the TR and face-to-face sessions.
The study shows how—at least for now—these kinds of difficulties can tip the balance away from telehealth solutions, according to Alan Chong W. Lee, PT, PhD, DPT, CSW, GCS, associate professor at the Mount St Mary's College (California) doctor of physical therapy program. In the US, HIPAA regulations require legally compliant technologies, but even beyond a technological baseline, "patient and provider relationship and patient preference trumps any ability to provide best practice with value," he said. "For example, if the patient doesn't want to disrobe for a posture assessment because of privacy issues, it limits examination and evaluation." Lee agreed with the study's finding that image distortion can affect the assessment, saying that "the image projected on the frontal plane can be larger on the top versus the bottom."
Lee also believes that the study's target participants—patients with no mobility issues or neurological symptoms—says something about the current status of telehealth assessments when it comes to LBP. "Patient selection is key," he said. "Minors, patients with mobility and safety issues, and patients with severe irritability with LBP were excluded from this study."
"This is another example of how clinical decision making plays such a crucial role," said Matt Elrod, PT, DPT, MEd, NCS, senior practice associate at the American Physical Therapy Association (APTA). Elrod pointed out that APTA supports telehealth models, but only "when provided in ways consistent with APTA positions, guidelines, policies, standards of practice, ethical principles, and the Guide to Physical Therapist Practice."
"As physical therapists, we must use our professional judgment to identify when this technology is safe and appropriate by using the best available evidence, understanding the patients' wants and needs, and applying the physical therapist skills," Elrod said.
As for the patients themselves, the study found moderate-to-high satisfaction with the TR assessment, save for 1 area: whether they believed the remote approach was as good as a traditional face-to-face assessment. Authors write that satisfaction "was similar to ratings taken during earlier urban studies."
The key to moving forward with a telehealth assessment program, according to the study, is the development of a "clinically robust" TR assessment for LBP, and the investigation of multidisciplinary treatment.
Lee agrees, and believes that the "multidisciplinary" label needs to be applied to approaches within the practice of physical therapy. "Access to timely care and use of appropriate clinical and nonclinical staff can be best determined by musculoskeletal specialists in telehealth as well as usual care," he said.
Meet Trevor Russell, one of the lead authors of this study, at this year's APTA NEXT conference and exposition, June 11–14 in Charlotte, North Carolina.
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