TELEMEDICINE FOR PATIENTS WITH MUSCULOSKELETAL PAIN: AN OVERVIEW OF EVIDENCE GAPS TO ADDRESS BEFORE IT BECOMES USUAL CARE

S. Kaczorowski^1,2, L. Donath², P.J. Owen³, T. Saueressig⁴, N.L. Mundell³, M. Topp¹, C.L. Samanna³, R. Döding¹, D.L. Belavy¹

¹Hochschule für Gesundheit [University of Applied Sciences], Department of Applied Health Sciences, Division of Physiotherapy, Bochum, Germany, ²German Sports University, Department of Intervention Research in Exercise Training, Cologne, Germany, ³Deakin University, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Geelong, Australia, ⁴Physio Meets Science, Leimen, Germany

Background: Musculoskeletal (MSK) pain is one of the leading causes for patients seeking primary care worldwide. The COVID-19 pandemic has led to unprecedented challenges for healthcare systems and has contributed to a marked shift towards telemedicine delivery. Although this delivery approach might offer benefits for patients (e.g., enhanced flexibility and better access to therapy) and is in generally accepted by patients with MSK pain, its effectiveness for different subgroups of patients with MSK pain is unclear.

Purpose: The aim of this umbrella review was to identify evidence gaps regarding telemedicine interventions and modes of delivery in order to provide recommendations for future research. A second aim was to summarize the extant systematic review literature on the effectiveness of telemedicine interventions on several clinical outcomes (pain intensity, disability, psychological functioning, quality of life, and self-efficacy) for different diagnostic subgroups of patients with MSK pain.

Methods: This umbrella review followed a prospectively registered protocol (CRD42022298047). PubMed, SPORTDiscus, Cochrane Library, EMBASE, and CINAHL were searched from inception to 9 August 2022 for systematic reviews with meta-analysis that evaluated the effectiveness of exercise, education, and psychological interventions delivered by telemedicine. Screening and extraction were conducted by two independent reviewers. AMSTAR-2 was used to assess methodological quality.

Results: Of 1,135 records, we identified 20 eligible systematic reviews with meta-analysis containing 94 unique randomized controlled trials (N=15,423 participants). Included reviews investigated the following MSK pain conditions: low back (N=5), knee (N=1), osteoarthritis (N=4), fibromyalgia (N=1), mixed (N=5), and chronic conditions (N=4). In the primary trials, telemedicine-interventions were compared to in-person intervention (N=15[16%]), usual care (N=40[43%]), minimal intervention (N=17[18%]), waiting list (N=16[17%]), or no intervention (N=6[6%]). The majority of trials investigated exercise training (N=31[33%]) or psychological treatments (N=29[31%]), and the most frequently examined delivery pathways were telephone (N=22[23%]) and web-based (N=39[42%]). Web-based interventions were delivered both synchronously and asynchronously. Standardized mean differences ranged from -0.66 to 0.10 for pain intensity and from -0.56 to 0.10 for disability in favor of telemedicine. A similar tendency toward telemedicine was found for the improvement of psychological functioning (SMD -0.77 to 0.11), quality of life (SMD -0.58 to 0.30), and self-efficacy (SMD -0.65 to -0.19). Methodological quality was rated ‘critically low’ in 17/20 reviews, with the remaining three being ‘low’ and ‘moderate’ quality.

Conclusions: Telemedicine appears effective for pain intensity, disability, psychological functioning, quality of life, and self-efficacy in patients with MSK pain, but results should be interpreted with caution owing to the poor methodological quality in the included reviews. Current evidence gaps include primary RCTs that compare telemedicine interventions with in-person delivery of similar intervention approaches, RCTs for videoconferencing, and investigations combining different treatment approaches. Further research is needed on safety and factors influencing adherence.

Implications: Telemedicine is becoming increasingly important in the rehabilitation of patients with MSK pain, but its use in clinical care is still limited. Providing treatment for patients with MSK pain could be sought as an alternative treatment to usual care delivered in-person. Individual patient preferences towards the treatment should also be considered, in order to optimize patient outcomes.

Funding acknowledgements: No funding was received for this research.

Keywords:
Digital Health
Telerehabilitation
Telehealth

Topics:
Musculoskeletal
Pain & pain management
Disability & rehabilitation

Did this work require ethics approval? No

Reason: Umbrella reviews involve the synthesis of information from systematic reviews without the involvement of human participants in the research process. Hence, ethical approval was not needed for this review.