Musculoskeletal (MSK) conditions affect 25% of people worldwide, and they cost the western world billions of dollars in GDP through loss of productivity and healthcare expenditures.(2) With the high prevalence and extensive costs of these conditions, maximizing access to effective and efficient clinical treatments becomes crucial. But, clinicians’ ability to provide these treatments has been severely restricted since the global spread of the SARS-CoV-2 virus, resulting in the 2020 COVID-19 pandemic. Necessary social distancing, combined with shifting allocation of healthcare resources toward high-intensity levels of care (e.g. ICU’s), poses significant barriers to clinicians treating MSK conditions, who rely on administering close-proximity, low-intensity care.(6)
While it complicates treatment of MSK conditions, coronavirus disease may also magnify the need for treatments. Some severe cases of the disease lead to MSK complications. When the SARS-CoV-2 virus infects a cell, the viral proteins affect several fundamental cell functions, causing deep disruption of the host cell’s function and leading eventually cellular apoptosis (or cellular death). Apoptotic cells can contribute to tissue-level dysfunction and local inflammation that may impact, among other systems, the MSK system. Complicating matters further, some methods of treating the COVID-19 disease may interact with the immune system in ways that disrupt proper function and recovery of the MSK system.(3) The cellular burdens of infection with SARS-CoV-2, then, have potential to cause dysfunction in the MSK system. Research on the MSK consequences of SARS-CoV-1 (the coronavirus that spread globally in the 2002 to 2004 SARS pandemic) support these findings, documenting disease and death of muscle and bone tissues in some acute cases of SARS.(4),(5) This earlier evidence is used to predict similar short and long-term MSK complications resulting from SARS-CoV-2 infection because the viruses are very biologically similar and experimental studies show highly similar pathological responses to them.(3) These studies showing the cellular and systemic damage to the MSK system caused or worsened by some coronavirus infections point to a pressing need for MSK care both during and after the COVID-19 pandemic.
To meet this need under isolation-imposed barriers to treatment, clinicians have to work in new and creative ways. Many are looking towards telehealth services (treatments offered over phone or video call) as an alternative to close-proximity care.(1) As this method of administering treatments grows during the COVID-19 pandemic, it becomes increasingly important to understand its strengths and limitations. Research into the effectiveness of telehealth services has been conducted both prior to and as a result of the COVID-19 pandemic. In 2016, Cottrell et al. reviewed 14 separate trials in which real-time telerehabilitation was studied in comparison to in-person treatment of MSK conditions. They found that telerehabilitation was as effective – if not more effective to a small or moderate degree (P < 0.001) – than in-person treatment methods at improving physical function, reducing disability related to MSK conditions, and quality of life.(2) Lending further support to Cottrell’s findings is a 2020 study by Turolla et al. of the plausibility and challenges of integrating telehealth into clinical treatments during the COVID-19 pandemic. They reviewed previous studies on the efficacy of telehealth and found that substituting in-person treatment with telerehabilitation for MSK conditions is effective for reducing pain, improving physical function and daily life activities, and boosting quality of life.(6) These studies lend confidence to those looking to telehealth services as a viable way to treat MSK conditions under social isolation protocols in place during the COVID-19 pandemic.
However, it is important to evaluate these studies from Turolla et al. and Cottrell et al. in light of their findings as well as their limitations. The studies did not analyze the economic, insurance, and cost dimensions of administering telerehabilitation, and none of the trials they referenced considered these factors either.(6),(2) Further research in this area would be of large importance to clinicians who need to bill these services to support their practices during the financial crisis caused by the pandemic. More research would also benefit insurance agencies that struggle with how to best cover increasingly popular virtual and phone treatments. Turolla et al. also note several methodological weaknesses in the trials they referenced in their paper. These include small participant sample sizes, short follow-up periods, missed evaluation of barriers and facilitators, and lack of blinding in the study design.(6) Similarly, Cottrell et al. also note that the trials they reviewed had a lack of blind design, and no trials analyzed patient/clinician satisfaction with telerehabilitation services or compliance to rehabilitation programs.(2) These deficits in research quality leave room for potential bias in the trials or incomplete portrayal of the factors affecting the efficacy of telehealth services, and they remind us that there remains much to learn about the virtual healthcare world.
Aside from limitations in research design and reliability, the distanced aspect of telehealth necessarily causes it to lack important contextual factors. Turolla et al. detailed the challenge of being unable to perform hands-on tests that screen for potential ‘red flags’ that can indicate serious medical conditions lurking beneath other symptoms. They also speak about the significance of reduced touch, eye-contact, and healing atmosphere that are known to impact treatment outcomes. Further, telerehabilitation leaves most patients without rehabilitation instruments available in clinics, and it rests in still-murky waters of the medicolegal system.(6) These results emphasize the importance of bringing social, practical, and ritualistic elements of treatments to the socially-distanced session – a task many are still not sure how to accomplish in safe, ethical, and legal ways.
Adopting remote treatment methods for MSK conditions is a complex decision leaving every party in the healthcare system a host of factors to consider. Even amidst this complexity, the American Physical Therapy Association reports that, as of July 2020, 47% of physical therapists (PTs) provided live video consults, which is a huge increase from the 2% offering live video consults before the pandemic.(1) This indicates that many PTs are finding telerehabilitation useful to their practice during the pandemic. But, even with increased use of telehealth services, 77% of the surveyed PTs were treating no more than 5 of their patients virtually.(1) This shows that though these services are increasingly used, they are not taking over as substitutes for normal in-person treatments. Because many practices still struggle with less access volume, lower weekly income, and higher unemployment,(1) it is clear that using telehealth services is not the only solution to the challenges the healthcare system faces in treating MSK conditions during the COVID-19 pandemic.
While treating MSK conditions occurs both virtually and in-person, the benefit of using scientifically-designed technology that is easy to use both in the clinic and by patients at home becomes magnified. Esurgi’s Biostabilizer, a Pressure Biofeedback Unit (PBU), gives real-time feedback on a digital interface to users performing rehabilitation tests. This device has a fast, one-button set up, and it enables physical therapists to help their patients relearn how to use core muscles to stabilize the spine. Based on the easy-to-understand auditory and visual feedback, users can easily use the device at home after consulting with their physician to know whether they are performing the exercises correctly. How could a PBU help you treat patients efficiently both during and after the pandemic?
1) American Psychological Association. (2020, August 17). APTA Report: Pandemic Continues to Disrupt Physical Therapy Profession. Retrieved August 21, 2020. https://www.apta.org/news/2020/08/17/apta-report-pandemic-continues-disrupt-profession.
2) Cottrell, M., Galea, O., O’Leary, S., Hill, A., Russell, T. (2016, May 2). Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Sage Journals 31(5), 625-638. https://doi.org/10.1177%2F0269215516645148.
3) Disser, Nathaniel et al. (2020, July 15). Musculoskeletal Consequences of COVID-19. The Journal of Bone and Joint Surgery 102(14), 1197-1204. doi: 10.2106/JBJS.20.00847.
4) Griffith, James. (2011, November 11). Musculoskeletal Complications of Severe Acute Respiratory Syndrome. Seminars in Musculoskeletal Radiology 15(5), 554-560. doi: 10.1055/s-0031-1293500.
5) Leung, Thomas et al. (2005, July). Myopathic changes associated with respiratory syndrome: a postmortem case series. Archives of Neurology 62(7), 1113-1117. https://doi.org/10.1001/archneur.62.7.1113.
6) Turolla, A., Rossettini, G., Viceconti, A., Palese, A., Geri, T. (2020, May 08). Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer? Physical Therapy 100(8), 1260-1264. https://doi.org/10.1093/ptj/pzaa093.