Telehealth for Low Back Pain

Introduction

Telehealth is defined as the provision of healthcare remotely through the form of telecommunications, such as telephones or laptops. The primary aim of Telehealth is to improve patient's health through education and service provision while reducing healthcare costs and overcoming geographical barriers [1][2].

Telehealth in other conditions has promoted adherence. A study on hospital readmittance reported that 49% of participants who received Telehealth were likely to be readmitted to the hospital compared with 67% of those who did not receive the Telehealth treatment [3]. In other areas such as Psychology, there is evidence that using video to carry out assessment can work well though there are limitations that can create inaccuracies, including feeling distant to patients and that some patients may not be able to use technology well [4].

What is Telehealth?

 http://2.bp.blogspot.com/--szGmCEUsJU/Vo8IjEZaqiI/AAAAAAAAc3s/ffCzwHxM4eg/s1600/VoIP%2BDr.jpg
Figure 1: Video consultation

Telehealth is a modality in which a healthcare professional such as a Physiotherapist, Nurse, or Doctor can consult with a patient through video or audio call utilizing a telephone, laptop, mobile phone, or tablet. Telehealth is a term which is used interchangeably with ‘telemed,’ ‘telemedicine,’ ‘telerehabilitation,’ ‘physiodirect,’ and ‘teleconsultation.’ Ultimately, this service allows a healthcare professional and a patient to consult when they are not able to gather face to face for a variance of reasons [5].

As technology has progressed, the feasibility for Telehealth has progressed too, resulting in some cross-disciplinary behavior theories and models being used to guide the implementation of Telehealth [6]. These behavior theories help clinicians to understand the patient’s motivation, efficacy, and goals, and allow the clinician to deliver telehealth interventions that meet the patient’s individual needs, complement the patient’s behavior and characteristics, and suits the patient’s unique social environment  [7].

The two primary underlying theories that underpin Telehealth are the self-determination theory and the self-efficacy theory [8][9]. The self-determination theory has been used in health behavior intervention by identifying an individual's motivational blocks and distinguishing between autonomous and controlled motivations [8]. This theory identifies that incorporating engagement, usability, and acceptance helps to improve self-motivation and engagement in Telehealth [10]. When there is a low initial motivation to use Telehealth, it is vitally important to evaluate the delivery and ensure individual training and education to increase motivation to engage with telehealth services [10].

From this, the concept of self-efficacy and one's ability to meet the challenges of self-management and succeed directly impacts Telehealth. Within low back pain patients, self-management is particularly essential. Barriers to self-efficacy include health literacy access and support, which Telehealth directly provides solutions for, thus increasing the patient’s belief and motivation to work towards a successful recovery [11].

History of Telehealth

Figure 2[5] Reasons for Teleconsultations.

The term Telehealth originated in the mid-20th century when healthcare professionals would attend to infectious disease patients from a distance using bells and signs. In the 1970s Telehealth developed into what we know it to be today. Initially, NASA needed to solve being able to monitor astronaut’s health while in space. There developed Telehealth through means of video calls. In the 1980s militants on large vessels and workers on oil rigs in the surroundings of the USA would consult with healthcare professionals at the LA medical center through telephone and video call. As it was unrealistic for them to see someone face to face, Telehealth became their best option to get immediate advice.

Fast forward to the 1990s, the USA become the largest consumer of telephone consultations, surpassing Norway. In 1996, figure (2) demonstrates what areas these types of consultations were being used for [5].

Validity and Reliability of Telehealth in Physiotherapy

Validity is the ability of a measure or modality to achieve what it is intended to achieve. When a modality has high validity, the results can be more trusted or believed [12]. A randomised control trial conducted in 2014 investigated the validity of Telehealth in lower back pain compared to face-to-face appointments. It found that Telehealth’s validity was varied dependant on the specific element of the assessment, as shown below:

Specific Validity Element Telehealth Validity
Detection of pain with specific movements High validity
Identifying the quality lumbar movement Moderate validity
Postural analysis Poor validity
Identifying reasons for limitations Poor validity

The study concludes that ‘Important components of the standard musculoskeletal assessment of LBP are valid via telerehabilitation in a clinical setting.’ [13]

Reliability is the ability of a measure or modality to achieve the same results when the measure is repeated [12] [14].

Specific Reliability Element Telehealth Reliability
Inter-rater reliability 0.92-0.96 very good
Intra-rater reliability 0.92-0.96 very good

Telehealth as a Tool for Assessing Low Back Pain

Telehealth can be and has been used in the assessment and management of Low Back Pain recently. There are certain critical aspects of Telehealth that drive success in this area, including that it can encourage early intervention, patient participation, and good communication between clinician and patient [3].

Tools for Assessments

The main tools used to perform Telehealth assessments and managements are mobile or device applications, websites, online chats or group discussions, email discussions, phone calls, or a combination of a number of these [15]. Telehealth has been commonly used in remote populations as these do not have easy access to clinics [16].

A 2014 study was investigating whether Telerehabilitation is a viable alternative to face-face assessment for patients with low back pain. Twenty-six participants were involved. The study found that there was an agreement in both approaches to identifying pain eliciting movements but poor agreement in identifying reasons for limitation in movement [16].

There have been several trials investigating the cost-effectiveness of Telehealth triage [17]. One such study investigating the use of Telehealth when implementing the McKenzie method for assessing and managing low back pain found Telehealth was significantly more clinically effective, and approximately 50% more cost-effective than the clinical based McKenzie treatment [15]. The main challenge facing the implementation of Telehealth is the limited existence of effective internet service facilities, and the initial engagement from patients is dependant on the adequate technological literacy of the patients [18].

Another way in which Telehealth aids in assessments is in its use in remote monitoring. Devices can collect physiological data from a distance and rapidly transfer that data to the patient’s cardiologist. Hospitals can have semi-autonomous monitoring of selected patients without the need for nurses to go over to the patient, leading to a 40% reduction in admissions and a significant drop in cost [3].

A new musculoskeletal assessment framework published in Cureus provides pre-consultation guidance and step-by-step remote examination instructions to musculoskeletal clinicians working in primary care to adapt their assessments based on published evidence, and community-sourced best practice; it also includes patient and clinician resources (patient information leaflet and photographs of examinations)[19].

Future Improvements to Telehealth Assessments

The majority of Telehealth facilities are implemented in areas where geographical location greatly restricts the patient’s ability to attend face-to-face consultations. However, very little research has been conducted in metropolitan cities, such as in the UK, where the population is not so sparsely populated. Hence it would be good to see more work carried out in the UK.

Furthermore, the majority of the assessment techniques used by clinicians for investigating low back pain are designed for face-to-face environments. This reduces the same assessment techniques reliability when completed in a telehealth setting. More research into the adaption of these techniques into Telehealth appropriate ones, as well as trials to see whether these are effective is needed.

There have not been any published studies showing how carrying out a subjective assessment would work using TeleHealth. This is a concern with the patient’s safety and data security affected if a subjective assessment is not entirely feasible within Telehealth.

Still, further research needs to be carried out to assess more closely the economic benefits to Telehealth [17],  as well as further advancements in technology to increase the accuracy of telehealth assessment consultation, as even with video consultations, the prefered form of Telehealth for assessing posture, it can still be challenging to discriminate physical landmarks on a video call [20].

Using Telehealth is a good alternative, but more work needs to be done to improve postural assessments, and further research is needed to see how devices utilising remote monitoring can be applied to LBP patients.

Telehealth as a Tool for Management Low Back Pain

With the advancements of online technology websites and applications have created a new frontier for research into patient’s self-managing their own physical conditions in their home environments. As compliance research shows that between 45-70% of patients are noncompliant with their physiotherapy prescriptions, This new field of Telehealth management promises to increase patient exercise adherence while offering physiotherapists a method to support patient self-management between face-to-face sessions [21].

The current practice guidelines for managing low back pain can be broken into three major categories: patient education, behavioral therapy, exercise prescription [22]. All of these could be delivered through telehealth rehabilitation [23].

Telehealth is a beneficial intervention, with the best outcomes, in trials investigating walking programs, cognitive-behavioral therapies, education, and group therapy sessions. A systematic review of 11 Randomised Controlled Trials has been conducted with a total of 2,280 participants looking to evaluate whether interventions delivered by Telehealth improve pain, disability, function, and quality of life in Non-Specific Low Back Pain [24]. The Telehealth interventions in the studies were delivered by telephone and online chats, websites, and emails. An important finding in the study was that those who participated in a tailored self-management web-based program involving education and behavior strategies were near two times less likely to experience LBP symptoms again two months after treatment (1.7 OR) [24]. Despite this, the only outcome that a significant difference favoring the use of Telehealth was quality of life. The results showed no significant improvement in pain or disability short term in any of the studies (WMD -2.61, 95% CI -5.23-0.01). There was no significant difference in disability.

Another randomized controlled trial investigating the effect a telehealth-based mobile application called Snapcare could have on chronic low back pain patient's pain and function. Of the 93 participants recruited, 45 received Snapcare in addition to a written prescription, and 48 received medicine and recommended physical exercise. The was a significant (P<0.05) reduction in pain and disability in both groups, and a significantly (P<0.001) greater decline in the Snapcare group compared to the control group [25]. The conclusion is that the telehealth application reminded and promoted the patients to be compliant with their physical activity program, thus facilitating the patient’s recovery by aiding the increase in physical activity.

Within the management of low back pain empowering the patient to feel able to self-manage effectively is vitally important to treatment success. Trials investigating the role of Telehealth as a unique intervention in the management of acute low back pain found an educational component that improves the patient’s knowledge of their condition and encourages an active lifestyle, as well as health tracking devices, such as a pedometer, is successful in reducing current pain intensity, depression, anxiety, stress, and duration of pain significantly (P=0.04) [26][27]. Implementing behavioral change approaches such as cognitive behavioral therapy and health coaching principles can be used successfully within Telehealth as well. Compared to usual care alone, combining telehealth strategies with usual care has a clinically significant reduction of pain, disability, and function in patients with subacute low back pain both short and medium-term [28][29],

There is conflicting evidence on the effect Telehealth has on chronic low back pain, with moderate-quality evidence reporting there is no significant difference between Telehealth and minimal interventions for reducing short term or medium term pain in chronic low back pain patients [28]. Some trials have found that Telehealth does not affect chronic low back pain patient's function short or medium term, as a sole intervention or combined with the minimal intervention [29]. However, when trials investigated telehealth effect on patient's quality of life, Telehealth was significantly superior in improving all patients' quality of life irrespective of the duration of low back pain symptoms or length of follow-up [24]. For chronic low back pain, Telehealth seems to be suitable when needed but not yet as an undisputed good alternative to face-to-face appointments.

Management Options

The three main Telehealth models for Physical Therapy are [30]:

  • Live Video (Synchronous): This uses real-time live consultation to treat patients.
  • Store and Forward (Asynchronous): This uses the secure transmission of pre-recorded materials to treat patients.
  • Remote Patient Monitoring: This uses technology to remotely get medical data on the patient’s treatment progress.

The various methods of telehealth attempt to comply with all three of these models to ensure the treatment provided are of the best quality, and accessible for all patients. For example, Reflexion Health Inc has developed a telehealth tool called VERA System, which combines all three Telehealth models. It walks patients through exercises, carries out an accurate analysis of movements, and gives real-time feedback. Though not used for treating LBP, it was shown to be of equal benefit as traditional physical therapy in Post Total Knee Replacements Rehab, with the additional benefits of having significantly lower health costs [31].

Future Improvements to Telehealth Managements

A major issue affecting the development of Telehealth is that it is as good as the technology is the most available technologies, such as SMS, Apps and Health Trackers, are the least investigated. These have shown some promise in some papers but not specifically enough with LBP. Therefore more research needs to be done to investigate the effects of app-based interventions and fitness trackers especially [3][25]. Also, as more technology has been developed specifically for health purposes, not many quality technologies exist that are transferable to physical therapy. Those that do exist require further testing to know their full clinical benefit.

As video calls are the most frequently used telehealth tool more research into whether face to face video management enhances LBP management is required to support its use. There is also a need to investigate multimodal interventions within Telehealth, as the majority of telehealth methods attempt to incorporate the three main models. Trials investigating the relative success of these three models are needed.

As with assessment methodology, there is no specific management option with Telehealth and a lot of the studies investigated use such different means it is difficult to come to a clear conclusion [24]. Confounded upon this is the disagreement within the literature for managing low back pain using Telehealth, with most of the current telehealth-based interventions showing no significant clinically important benefits in the outcomes investigated, particularly for chronic Low back pain. In contrast, research on acute or subacute low back pain has shown promising significantly important benefits in the outcomes measured.

The significant benefits Telehealth has on all types of low back pain patient's quality of life, suggests that there is biopsychosocial benefits telehealth has on low back pain patients and demands further study.

Telehealth Pros and Cons

Within Telehealth, there are several pros et contras. One study investigating the use of a Telehealth based website to facilitate health coaching found that participants logged into the website only 38% of the recommended time [32]. Showing that adherence and compliance to the telehealth interventions were lower than recommended or expected. Within this study, there are some possible explanations to why the adherence to the telehealth treatment was lower than expected. Potentially the patients were becoming disheartened and disinterested as the effects of the treatment on their low back pain were smaller than they might have expected. Also, the technology itself may have been limited and a factor contributing to the higher level of non-compliance than expected.

Below is a break down of the most common advantages and disadvantages that Telehealth offers to physiotherapy, particularly in the management of low back pain.

Pros Cons
Telehealth provides an alternative solution for people who live in remote areas and are not always able to travel. Poor patient compliance is associated with using telehealth [33].
Telehealth makes healthcare accessible to everyone, as long as there is an internet connection, even during a global pandemic like 2020. Patients often decline to use Telehealth due to preferring face to face contact.
Telehealth provides a means to use new technology to enhance health services [24]. May lead to fragmentation of care amongst multiple providers.
Telehealth is effective in managing health conditions such as obesity and asthma. There may be a lower quality of the patient-clinician relationship
Telehealth reduces healthcare costs by improving efficiency and revenue. Patients may have a lack of access to the necessary technology.
Telehealth offers a better possibility of continuity of care. There is a high initial cost of acquiring the technical equipment.
Telehealth can ease the global burden of low back pain, which has a high prevalence rate of 39% worldwide [34]. Many argue its overall effectiveness for dealing with chronic Low Back Pain is limited.
Telehealth has been shown to significantly improve patients quality of life, particularly patients with chronic low back pain. Telehealth may be detrimental to clinicians establishing patient rapport.
Patients had increased compliance with their treatment exercises [25].

Conclusion

Telehealth has very high validity and reliability suggesting there is a clinical use. From a moderate amount of research, there is some benefit to using Telehealth to manage patients with low back pain, but there is still a need for more research. Within physiotherapy telehealth is a relatively new area of study, still requiring the development and testing of specific assessment and management approaches to treating certain conditions.

Within telehealth research, the patient satisfaction scores and patient quality of life scores are significantly higher within telehealth interventions groups. Despite this, there is still a public concern associated with Telehealth. Many patients may not fully understand the breadth of physiotherapy and what is included within physiotherapy treatment, assuming that physiotherapy requires physical contact.

With the COVID-19 pandemic, telehealth has played an essential role in enabling physiotherapy clinics to continue semi-functioning during global lockdowns. Telehealth has enabled infections to be avoided while still maintaining contact with patients ensuring exercises are being adhered to.

There is a vital role Telehealth plays in sparsely populated communities where the distance between clinical facilities and patients is too great or dangerous for either patient or clinician to traves. The research has shown that Telehealth can be an effective supplement to usual physiotherapy, rather than a replacement. The future of Telehealth seems promising, with the continual developments and improvements of current technologies, hopefully, followed by more researcher, from all areas of the world, taking an active interest in Telehealth biopsychosocial, hygienic, and economic benefits. Consequently, further clinical trials and systematic reviews will be carried out broadening and deepening the pool of research to base the management of low back pain using Telehealth.

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