physical therapy

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Physical Therapy Teleassessment for Lower Quarter Musculoskeletal Conditions

Posted by Alena Mokrzycki on October 25, 2016
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Background Information

  • Current gold standard: face-to-face assessment
  • Teleassessment involves the use of video to complete an assessment in real-time led by a remote physical therapist
  • Telehealth for PT treatment has been researched, but typically involves a face-to-face PT assessment first
  • PT teleassessment is a more recent topic being researched

Case Scenario

  • Outpatient physical therapy facility
    • Currently has a waiting list
    • Recently implemented the use of teleassessment
  • 32 y/o female calls to schedule an initial evaluation
    • Diagnosis of L ankle sprain
  • Patient is given the following options:
    • Teleassessment
    • Traditional face-to-face assessment (put on the waitling list)

Outcome Measures: validity, reliability (intra-rater and inter-rater), patient satisfaction

PICO Question

Is teleassessment for patients with lower quarter musculoskeletal pain as valid and reliable as traditional face-to-face assessment?

Type: Diagnostic

Included Articles

  1. Cabana F, Boissy P, Tousignant M, et al. Interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty. Telemed J E Health 2010; 16: 293–298.
  2. Richardson BR, Truter P, Blumke R, Russell TG.Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation. J Telemed Telecare. 2016 Mar 15. pii: 1357633X15627237. [Epub ahead of print] PubMed PMID: 26985005.
  3. Russell T, Truter P, Blumke R, et al. The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders. Telemed J E Health 2010; 16: 585–594.
  4. Russell TG, Blumke R, Richardson B, et al. Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother Res Int 2010; 15: 167–175.
  5. Truter P, Russell T and Fary R. The validity of physical therapy assessment of low back pain via telerehabilitation in a clinical setting. Telemed J E Health 2014; 20: 161–167.

 Search Strategy and Results

PICO Question: Is teleassessment for patients with lower quarter musculoskeletal pain as valid and reliable as traditional face-to-face assessment?

Methods

Inclusion Criteria, Article must include:

  • Subjects that have a diagnosis of musculoskeletal origin (lower quarter).
  • At least one intervention group that received teleassessment for physical therapy.
  • At least one intervention group that received traditional face-to-face assessment for physical therapy.
  • Assessment of at least one of the following outcome measures:
    • Validity
    • Reliability
    • Patient satisfaction

 Exclusion Criteria, Article cannot include:

  • Subjects that do not have a diagnosis of musculoskeletal origin.
  • Subjects that have a diagnosis of musculoskeletal origin (upper quarter).
  • Interventions where telerehabilitation was delivered (as treatment), but traditional face-to-face assessment was used.

Search Strategy:

Databases searched:

  • PubMed
  • OVID
  • CINAHL

Terms searched: “physical therapy” AND “assessment” AND “telemedicine”

Levels of Evidence

picture2TH: telehealth; FtoF: face-to-face

Analysis of Results

  • Weighted kappa (k) statistics
    • –Discounts the proportion of agreement expected by chance
  • Strength of agreement 0 to 1
    • –Slight agreement: k=0.00-0.20
    • –Fair agreement: k=0.21-0.40
    • –Moderate agreement: k=0.41-0.60
    • –Substantial agreement: k=0.61-0.80
    • –Almost perfect agreement: k=0.81-1.00
  • Values of k>0.40 were considered to be clinically acceptable
  • Statistical significance was set at p<0.05 for all tests

Summary Statement

There is limited, high-level evidence that suggests that physical therapy teleassessment of lower quarter musculoskeletal pain is feasible and results in overall good validity and excellent reliability when compared to traditional face-to-face physical therapy assessment.  Although research on implementation of telehealth is highly prevalent in other healthcare fields, teleassessment is a more recent area of research for physical therapy.  This resulted in a higher prevalence of low quality evidence, although high quality evidence is also available upon a more in-depth review of the available evidence.  Currently most of the available evidence comes from Australia, where physical therapists are finding roles in primary care related to the assessment and treatment of musculoskeletal conditions.  However, in the United States, physical therapists as primary care providers is a more recent area of research.  This could explain why research performed in the United States on this topic is currently lacking.

The included articles of this CAT (5 articles; 4 articles CEBM 2, 1 article CEBM 3) reported on the validity, intra-rater reliability, inter-rater reliability, and participant satisfaction of physical therapy teleassessment when compared to the current gold standard, which is traditional face-to-face physical therapy assessment.

VALIDITY: 4 out of 5 articles reported on validity.  All 4 articles (CEBM 2) showed consistent findings that teleassessment was valid (ranging from slight to almost perfect).

  • Total n = 78
  • 4 out of 5 articles reported on this
  • All 4 articles were CEBM 2
  • Showed consistent findings that teleassessment was valid
    • Ranging from slight (k=0.00-0.20) to almost perfect (k=0.81-1.00)
      • Slight agreement (k=0.00-0.20) for postural assessment (lumbar spine)
      • Fair (k=0.21-0.40) to moderate (k=0.41-0.60) agreement for determining the movement limitation and identifying the worst direction of movement (lumbar spine)

INTRA-RATER RELIABILITY: 3 out of 5 articles reported on intra-rater reliability.  All 3 articles (CEBM 2) showed consistent findings that teleassessment was reliable (almost perfect).

  • Total n = 52
  • 3 out of 5 articles reported on this
  • All 3 articles were CEBM 2
  • Showed consistent findings that teleassessment was reliable
    • –Almost perfect (k=0.81-1.00)

INTER-RATER RELIABILITY: 4 out of 5 articles reported on inter-rater reliability.  All 4 articles (3 articles CEBM 2, 1 article CEBM 3) showed consistent findings that teleassessment was reliable (ranging from fair to almost perfect).

  • Total n = 67
  • 4 out of 5 articles reported on this
  • 3 articles were CEBM 2 and 1 article was CEBM 3
  • Showed consistent findings that teleassessment was reliable
    • Ranging from fair (k=0.21-0.40) to almost perfect (k=0.81-1.00)
      • Fair (k=0.21-0.40) agreement for scar assessment

PARTICIPANT SATISFACTION: 4 out of 5 articles reported on participant satisfaction.  All 4 articles (CEBM 2) showed consistent findings that participants indicated a high level of satisfaction with teleassessment (5 out of 6 questions) except for 1 question (question 3: whether they thought teleassessment was as good as face-to-face assessment).

  • Total n = 78
  • 4 out of 5 articles reported on this
    • Visual Analog Scale (VAS)
  • All 4 articles were CEBM 2
  • Showed consistent findings that participants indicated a high level of satisfaction with teleassessment
    • 5 out of 6 questions
    • Except question 3
      • Whether they thought teleassessment was “as good as face-to-face assessment”

Participant Satisfaction (cont.)

picture3

Russell T, 2010

 

picture4

Truter P, 2014

picture5

Richardson, 2016

picture6

Russell TG, 2010

Implications to Clinical Practice

  • PT teleassessment could present a valuable role in reaching specific patient populations
    • Individuals who live in rural or underserved areas
  • Insurance: billing and reimbursement for telehealth services
    • There are no telehealth-specific CPT codes for PT
    • Medicare’s current list of approved providers does not include PTs, OTs, or SLPs
    • Medicaid has reimbursed for this since 2002, but not in all states
    • Reimbursement from private third-party payers depends on your contract with your payer

Clinical Bottom Line

  • There is limited, high-level evidence that suggests that physical therapy teleassessment of lower quarter musculoskeletal pain is feasible and results in overall good validity and excellent reliability when compared to traditional face-to-face physical therapy assessment.
  • Not all techniques (functional assessments) used in face-to-face assessment can be performed via teleassessment
    • Alternative techniques (functional testing) can be used during teleassessment
  • No adverse events were reported

Application to Case

  • This patient was appropriate for PT teleassessment
    • Diagnosis of musculoskeletal origin (lower quarter)
    • She was willing to use this option of assessment
  • Patient received an initial evaluation for PT via teleassessment
    • NPRS: best: 2/10, worst: 6/10, average: 4/10
    • LEFS: 56/80
  • Plan of care was developed at the end of the session
    • Patient will participate in a daily HEP and have check-in sessions via telephone and/or video 1-2x/week
    • Reassessments will occur via video every 2-3 weeks
    • Based on the check-in sessions and reassessments, the patient’s POC will be progressed

Limitations

  • Small sample sizes
  • Majority of participants were young
  • Repeated measures study design
  • All of the research was performed outside of the United States
    • Four of the studies were performed in the same facility in Australia and by the same group of researchers
  • No inclusion of cost effectiveness as an outcome measure

Suggestions for Future Research

  • Studies should focus on cost effectiveness
  • Studies should measure the effectiveness of PTs in screening for red flags via teleassessment
  • More high quality studies need to explore the validity of teleassessment of the lumbar spine
  • Studies need to be performed in the US
  • More research is needed on policy within the US

References

1.Cabana F, Boissy P, Tousignant M, et al. Interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty. Telemed J E Health 2010; 16: 293–298.

2.Richardson BR, Truter P, Blumke R, Russell TG. Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation. J Telemed Telecare. 2016 Mar 15. pii: 1357633X15627237. [Epub ahead of print] PubMed PMID: 26985005.

3.Russell T, Truter P, Blumke R, et al. The diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders. Telemed J E Health 2010; 16: 585–594.

4.Russell TG, Blumke R, Richardson B, et al. Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother Res Int 2010; 15: 167–175.

5.Truter P, Russell T and Fary R. The validity of physical therapy assessment of low back pain via telerehabilitation in a clinical setting. Telemed J E Health 2014; 20: 161–167.

 

Presentation: mokrzycki_final-cat-presentation

Vestibular Rehabilitation vs. Rest in Treatment of Persistent, Post-Concussion Symptoms

Posted by Gabrielle Zdunkiewicz on October 25, 2016
Posted in: Uncategorized. Tagged: , , . Leave a Comment

Clinical Scenario:

Patient is a 19-year-old female, collegiate ice hockey goaltender who sustained a concussion during a game ~3 weeks prior when she was run into by an opposing player and subsequently hit her head on the ice. Her chief complaint at time of evaluation was persistent symptoms of dizziness, headache and neck pain, all of which had prevented her from performing daily academic and personal responsibilities. Patient denied loss of consciousness at the time of injury and reports imaging revealed no fractures.

Key Exam Findings:

DHI: 36/100

NPRS: headache 2/10, dizziness 3/10, neck pain 3/10; pt reports all increase with activity

PCSS: 36

Oculomotor Exam: Pupils are reactive and symmetrical, with full visual fields. Pt demo normal smooth pursuit however was unable to perform >5 rapid alternating eye movements before exacerbation of symptoms. Pt demo 3-line difference during Dynamic Visual Acuity test, with c/o dizziness with head movement horizontally > vertically.

Gait and Balance: Pt demo increased sway with tandem stance as well as increased sway and reduced time bilaterally during single leg balance on firm surface with eyes closed. Romberg test negative. Pt demo normal gait pattern however was unsteady during tandem gait backwards > forwards. Tandem gait worse with eyes closed.

Palpation: TTP at C/S paraspinals

Other: Head thrust, Dix-Hallpike and Roll tests all negative. No dysmetria observed in upper or lower extremities. Strength and sensation WNL throughout.

PICO Question:

In adolescent and young adults (ages 13-25) with reports of dizziness and headache following a sport-related concussion, does cervical and vestibular rehabilitation have a greater impact on symptom reduction than rest alone?

Search Strategy:

A literature search was performed to identify all eligible articles, including randomized controlled trials, cohort studies, and case studies. Electronic searches of MEDLINE (January 2002-August 2016), Pedro, and CINAHL (2006-2016) were performed, using keywords ‘concussion’, ‘brain concussion’, ‘physical therapy’, ‘vestibular’, ‘rest’, ‘physical therapy modalities’, and ‘sport-related concussion’. Only full reports in English, peer reviewed, and human trials were included. Initial search strategy was to included on randomized controlled trials investigating concussions with physical therapy treatment aimed at comparing cervicovestibular treatment to rest or standard treatment protocols in the adolescent and young adult population; however, due to lack of current/emerging research for this topic, the level of study as well as age range was expanded to include adolescent and adult populations. Articles were excluded if they did not specify or include reference to physical therapy treatment following concussion or mild traumatic brain injury for acute and/or persistent post-concussion symptoms including headache, dizziness, and/or neck pain.

58 Articles Identified through Search => 44 Articles excluded after screening titles/abstracts => 14 Full Texts Reviewed => 9 Articles excluded (lack of treatment or relevant outcome measures, lower quality evidence) => 5 Articles Included

Results:

results-table

Clinical Bottom Line:

The current evidence available to address treatment for persistent symptoms of dizziness and headache following a sport-related concussion is minimal. In the studies reviewed to address the clinical question, there was inconclusive evidence to support the theory that cervical and vestibular rehabilitation are more beneficial than rest alone in reducing symptoms following a sport-related concussion. There were two studies available that addressed cervical and vestibular therapy as treatment for post-concussion symptoms (1 RCT and 1 retrospective analysis), and although there were positive findings as to the effectiveness of this type of treatment, limitations in sample size, treatment protocols and lack of analysis on the effects of covariates such as age, time, and dosage of treatment, impact the overall quality of the findings. Low-quality evidence does suggest that for symptoms persisting longer than 10 days, strict cognitive and physical rest may not be as beneficial in symptom reduction as beginning a low-level, multi-modal physical therapy treatment plan. However, these studies were retrospective in nature and lacked randomization and control or comparison groups. For patients with persistent post-concussion symptoms presenting with cervical and/or vestibular dysfunction, an early rest period followed by an impairment-based treatment program with gradual progression may help facilitate recovery.

Application to Case Scenario:

  • Patient is outside spontaneous recovery window (~7-10 days post-injury); study by Gibson et al. suggests additional cognitive rest not indicated
  • Studies by Schneider et al. and Alsalaheen et al. suggest individualized VR program may be beneficial in symptom reduction
  • Plan of care: 2x/week for 6-8 weeks
  • Intensity: Symptom exacerbation ≤ 15-30 min
  • Interventions: aerobic training, balance, adaptation and substitution exercises, C/S AROM and manual therapy

Limitations:

  • Lack of available high-quality evidence
  • 3 of 5 articles were retrospective studies and lacked control groups
  • Lack of long-term follow-up and formal vestibular function testing
  • Future Research: High-quality RCT’s with focus on short- and long-term effects of VR on PCS

 

References:

  1. Schneider K, Meeuwisse W, Emery C, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British Journal Of Sports Medicine [serial online]. September 2014;48(17):1294-1298.
  2. Thomas D, Apps J, Hoffmann R, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics [serial online]. February 2015;135(2):213-223. Available from: CINAHL, Ipswich, MA.
  3. Gibson S, Nigrovic L, O’Brien M, Meehan W. The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Injury [serial online]. July 2013;27(7/8):839-842. Available from: CINAHL, Ipswich, MA.
  4. Alsalaheen B, Mucha A, Sparto P, et al. Vestibular rehabilitation for dizziness and balance disorder after concussion. Journal Of Neurologic Physical Therapy [serial online]. June 2010;34(2):87-93. Available from: CINAHL, Ipswich, MA.
  5. Moser R, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. Journal Of Pediatrics [serial online]. November 2012;161(5):922-926. Available from: CINAHL, Ipswich, MA.
  6. Daneshvar D, Nowinski C, McKee A, Cantu R. The epidemiology of sport-related concussion. Clinics In Sports Medicine [serial online]. January 2011;30(1):1-17. Available from: CINAHL, Ipswich, MA.
  7. Ellis M, Cordingley D, Vis S, Reimer K, Leiter J, Russell K. Vestibulo-ocular dysfunction in pediatric sports-related concussion. JOURNAL OF NEUROSURGERY-PEDIATRICS. 2015;16(3):248-255. doi: 10.3171/2015.1.PEDS14524.