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 .
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 . 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 .
What is Telehealth?
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 .
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 . 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 .
The two primary underlying theories that underpin Telehealth are the self-determination theory and the self-efficacy theory . 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 . This theory identifies that incorporating engagement, usability, and acceptance helps to improve self-motivation and engagement in Telehealth . 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 .
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 .
History of Telehealth
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 .
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 . A randomised control trial conducted in 2014 investigated the validity of Telehealth in lower back pain compared to face-to-face appointments
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 patien
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 . Telehealth has been commonly used in remote populations as these do not have easy access to clinics .
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 .
There have been several trials investigating the cost-effectiveness of Telehealth triage . 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 . 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 .
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 .
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).
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 , 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 .
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 .
The current practice guidelines for managing low back pain can be broken into three major categories: patient education, behavioral therapy, exercise prescription . All of these could be delivered through telehealth rehabilitation .
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 . 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) . 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 . 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) . 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 ,
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 . 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 . 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 . 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.
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.
Source: physio-pedia