Abstract
Background
Little is known about lived experience of synchronous telehealth in patients with musculoskeletal (MSK) disorders.
Objective
We conducted a rapid systematic review to answer: (1) what are the lived experiences and/or perspectives of people with MSK disorders receiving non-pharmacological interventions delivered through synchronous telehealth; and (2) what clinical implications can be inferred from qualitative studies focusing on lived experiences for how telehealth is delivered in the management of MSK disorders?
Data sources
A comprehensive search of MEDLINE, CINAHL, PsycINFO, ProQuest, and Google Scholar from June 2010 to July 2023. Eligible qualitative and mixed methods studies capturing lived experiences of adults with MSK disorders receiving non-pharmacological interventions via synchronous telehealth were included.
Study methods
Systematic rapid review conducted according to WHO guidelines. Titles and abstracts screened by reviewers independently, eligible studies critically appraised, and data was extracted. Themes summarized using the Consolidated Framework for Implementation Research (CFIR). GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) used to assess confidence in synthesis findings.
Results
We identified 9782 references, screened 8029, and critically appraised 22, and included 17 studies. There is evidence to suggest that the experience of telehealth prior to and during the pandemic was shaped by (1) patient perception of telehealth, (2) existing relationships with practitioners, (3) availability and accessibility of telehealth technologies, and (4) perceptions about the importance of the role of the physical exam in assessing and treating MSK disorders.
Conclusion
The five identified implications could be used to inform future research, policy, and strategy development.
Introduction
In the wake of the COVID-19 pandemic, we saw a dramatic uptake in the use of digital health technologies, including telehealth. The global pandemic instantiated a significant shift toward the use of telehealth in the non-pharmacological management of musculoskeletal (MSK) conditions.1–4 Over the past decade, evidence-based guidelines have advocated for the role of non-pharmacological interventions for the management of MSK conditions.2,5–8 We understand these interventions include but are not limited to education and reassurance, exercise-based rehabilitation, manual therapy, physical therapies, cognitive behavioral therapy, and other conservative interventions focused on reducing pain and improving function and quality of life. Previous reviews on the role of telehealth in the non-pharmacological management of MSK conditions have astutely noted that many of these guidelines recommended in-person and clinic-based interventions. 9 To this end, the use of telehealth in MSK care has raised several concerns regarding the adaptability of such hands-on and in-person practices to this emerging paradigm of remote care.10–12 Nonetheless, research efforts during the pandemic have demonstrated encouraging results regarding the efficacy and safety of telehealth for the management of MSK disorders, which have been summarized in recent reviews.9,13 Despite these studies, less is known about the lived experience of synchronous telehealth from the perspective of patients with MSK disorders and how these experiences shifted during the pandemic.
Against growing evidence supporting the use of telehealth in MSK care,2,4,9,14–17 further understanding of the emotional, psychosocial, political, economic, and cultural experiences of patients is required. To date, much of the scholarship on the use of telehealth in MSK care has focused on barriers and enablers encountered by users of telehealth,12,18 questions of patient satisfaction,
19
and the experiences of healthcare providers using this approach to care.3,20 For the purposes of our review, we are concerned with the nature of the experience of using synchronous telehealth interventions from the perspectives of patients, and the broader experiential context in which telehealth as method of MSK care delivery is situated. This knowledge is needed in order to meaningfully implement telehealth as a person-centered practice thereby expanding the reach of MSK care, rather than being a tool that substitutes for in-person care in emergency and extenuating circumstances.
15
To this end, our review investigates two intertwined questions:
what are the lived experiences and/or perspectives of people with MSK disorders receiving non-pharmacological interventions delivered through synchronous telehealth? and what clinical implications can be inferred from qualitative studies that focus on lived experiences for how telehealth is delivered in the management of MSK disorders?
Methods
Protocol and registration
Our systematic rapid review was conducted in accordance with WHO guidelines.
21
It builds on a recently conducted rapid quantitative evidence synthesis
9
which sought to determine whether non-pharmacological interventions delivered through synchronous telehealth are as effective and safe as clinic-based in-person interventions for improving outcomes, such as pain, functioning, self-reported recovery for the management of patients with MSK conditions. Our original protocol was registered on the Open Science Framework (OSF) on 8 August 2021 (
Ethics statement
No research ethics review was sought for this review as our analysis of patient experiences utilizes published and publicly reported qualitative literature.
Information sources
A health science librarian developed a comprehensive search strategy (see Appendix A). Three concept groups were used: (1) MSK disorders, (2) telehealth, and (3) qualitative research. Search terms included subject headings specific to each database (e.g. MeSH in MEDLINE) and free text words relevant to our objectives and eligible study designs. We systematically searched MEDLINE (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid), as well as ProQuest Dissertations & Theses Global and Google Scholar from June 2010 to June 2023. The date range of our search reflects technological and digital advancements impacting telehealth delivery in the past decade, most notably the emergence of smartphones and tablets to global markets in 2010. Prior to the COVID-19 pandemic, telehealth was primarily deployed in the context of emergency situations, including its use in military crisis managed by The North Atlantic Treaty Alliance (NATO) in 2000, and later during several environmental disasters in the United States and Australia in 2017 and 2019. 23 This date range thus reflects important technological and historical events shaping telehealth.
Eligibility criteria
Eligibility criteria was organized using the Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) Tool for Qualitative Evidence Synthesis.24,25
Sample
We included studies of adult populations with MSK disorders receiving non-pharmacological interventions offered via synchronous telehealth. We define MSK disorders as conditions that affect the locomotor system including injuries or disorders of the muscles, nerves, tendons, joints, cartilages, and supporting structures.26,27 We excluded conditions such as stroke, post-operative rehabilitation, fracture, or inflammatory arthropathies which require specific rehabilitation equipment, programs, or co-management with medical teams.
Phenomenon of interest
We investigated the lived experience of patients receiving non-pharmacological interventions offered via synchronous telehealth to treat MSK disorders. We define telehealth as the delivery of healthcare services, where patients and providers are separated by distance and exchange information regarding the diagnosis and treatment of diseases and injuries, research and evaluation, and education. Synchronous telehealth involves the delivery of healthcare services in real-time (e.g. through videoconferencing or telephone). 28 Asynchronous telehealth interventions (e.g. apps, text-based services, web portals, virtual reality, or pre-recorded video demonstrations) were excluded.
Design
We included qualitative studies of a range of qualitative methodologies. Studies were required to be experientially descriptive, and include quotes or illustrative passages describing the emotional, psychological, social, historical, political, economic dimensions of telehealth.
Evaluation
Our review focused on understanding the experience of telehealth from the perspective of patients. We defined lived experience as both the quotidian moments, decisions, and actions that shape a person's everyday life, and the forms of meaning that a person makes or collects about these experiences. We acknowledge that lived experience is shaped by formations of race, ethnicity, class, gender, and sex and their intersections; and that lived experience has emotional, psychological, sociocultural, historical, political, economic dimensions that are both tangible and intangible, articulable and inarticulable.
Research type
We included empirical studies published in English, in peer-reviewed journals representative of a range of qualitative methodologies. As well as studies using semi-structured interviews with individuals and groups conducted in-person, over the phone, and virtually. Mixed method studies were considered when the qualitative components could be extracted for appraisal and appropriately evaluated for adherence to quality criteria of its tradition following Mixed Methods Appraisal Tool (MMAT) guidance. 29 We also searched reference lists of all eligible articles for additional relevant studies. A grey literature search which included Google Scholar was conducted.
Study selection
We utilized EPPI-Reviewer software to conduct all screening and critical appraisal efforts. 30 In keeping with rapid review methodology,21,22 the lead author, a chiropractor in training with a doctorate in social anthropology, screened all the records and full texts. A second experienced clinician and researcher screened a random sample of 10% of the records to ensure that the selection was conducted appropriately.
Screening was based on our inclusion criteria, and citations were labeled relevant or possibly relevant. Full text screening was conducted by reviewing full texts of all relevant and possibly relevant articles. Disagreements regarding study eligibility were resolved through discussion. Unresolved disagreements were discussed, and consensus reached with a third author.
Critical appraisal
Critical appraisal was conducted on eligible studies by two experienced clinicians and researchers using the Critical Appraisals Skills Program (CASP) tool 31 or the MMAT tool 29 (Table 1a and b). No relevant gray literature was identified for critical appraisal. Appraisal rating disagreements were resolved through team discussions.
Critical appraisal results.
Data extraction
Data extraction was conducted by the lead author. We utilized guidance from the National Institute for Health and Care Excellence (NICE) to construct our evidence table 49 capturing data on study research questions, participant characteristics, setting, sample size, and identified themes (Table 2). Themes and subthemes discussed in each of the included articles were numbered for organizational clarity. The extracted data was reviewed and verified by the research team.
Qualitative evidence summary tablea.
Adapted following NICE guidance on evidence tables for qualitative studies.
Quality scores: ++ All or most of the checklist criteria fulfilled, where they have not been fulfilled the conclusions are very unlikely to alter; + Some of the checklist criteria fulfilled, where they have not been fulfilled, or not adequately described, the conclusions are unlikely to alter; – Few or no checklist criteria have been fulfilled and the conclusions are likely or very likely to alter. 49
Analysis
The analysis of the included studies was guided by the Consolidated Framework for Implementation Research (CFIR) using deductive thematic synthesis 30 . The CFIR is a tool developed to direct researchers in systematically assessing, evaluating, explaining, and developing the process of integrating evidence-based interventions into health systems and care practices. As a “meta-theoretical” tool, the CFIR distills prevailing concepts and theories from the broader field of implementation science into 5 comprehensive domains and 37 constructs nestled within each domain 50 . These constructs reflect the manifolded factors influencing effective implementation practices and strategies. Importantly, these constructs do not delimit the conditions or interactions required for effective implementation; rather, this tool enables researchers to “select constructs from the CFIR that are most relevant for their particular study setting and use these to guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings in research studies or quality improvement initiatives.” 50
To enhance the transparency of qualitative synthesis, 51 we focused our analysis on the results sections and relevant tables of the included studies. Themes and patient quotes providing insight into the lived experiences of telehealth were categorized under the CFIR domains and constructs. As we proceeded with the thematic analysis, the data from the included studies condensed around 4 domains and 8 constructs of CFIR (Table 3). We then proceeded to thematically analyze the data captured from the included studies in relation to the meanings of CFIR domains and constructs. This facilitated analysis incorporating the evidence on the patient experience of telehealth in, and the current state knowledge about factors affecting the implementation of health services.16–18 In this sense, our analysis considers how the lived experience of telehealth is shaped by individual, systemic, and cultural factors.
The CFIR and data extraction.
Given the intentional and intrinsic flexibility of CFIR, 52 we modified the grammar of the relevant domains to better suit the scale and focus of the studies we analyzed (please see Appendix B).
We used GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) to assess confidence in the synthesis findings 53 . The assessment is based on four key components: (1) methodological limitations of included studies; (2) coherence of the review finding; (3) adequacy of the data contributing to a review finding; and (4) relevance of the included studies to the review question. The included articles were reviewed by the authors, reaching consensus as required.
Results
Study selection
We identified 9782 references, screened 8029 references, and critically appraised 22 articles (Figure 1). A total of 5 articles were excluded on critical appraisal, resulting in the inclusion of 17 studies in our review. Twelve of the included studies were assessed using the CASP tool32–37,39–43 and five using the MMAT tool44–48. During the screening process a 98% absolute agreement was met, with a Kappa score of 0.99 based on a 10% sample.
PRISMA diagram summarizing flow of included studies.
Study characteristics
Eight of the included studies were conducted before the declaration of the global COVID-19 pandemic in March 2020,35,36,39–42,46,47 and nine studies afterwards.32–34,37,38,44,45,48 One study was conducted in Norway, 47 one in Ireland, 43 one in South Africa, 34 three in the United States,32,46,48 five in the United Kingdom,33,36–38,42 and six studies were conducted in Australia.35,39–41,44,45 Nine of the included studies recruited participants from a previous or ongoing clinical trials.35,36,39–43,46,47
Practitioners represented in these studies included mental health professionals, occupational therapists, physicians, and physiotherapists. Non-pharmacological interventions for MSK disorders were delivered via telephone conferencing36,40,42,44,46,47 and videoconferencing using applications such as Zoom, Skype, and Microsoft teams.32,33,37,39,41,45 Six studies reflected the use of telehealth within publicly funded hospitals,33,36–38,42,45,47 four from academic hospitals,34,35,43,48 two from private physiotherapy practices,40,44 one from both private and public physiotherapy practices, 39 one from a private medical practice, 32 and one study reflected the use of telehealth in both a not-for-profit hospital and within a veterans healthcare system. 46
CFIR domains and constructs
We identified four domains and their respective constructs from the CFIR that were most relevant for both synthesizing and analyzing the data about the patient experience with telehealth. We summarize these results, organized by each of the four CFIR domains and their respective constructs (see Table 3 for full definitions of each domain and construct).
Domain I: Interventional characteristics
This domain refers to the features of an intervention that might influence implementation including its adaptability and its costs as experienced by patients with MSK disorders.
Construct I.I: Relative advantage
Across the included studies there was consistent reporting that patients appreciated the convenience, efficiency, flexibility, and reduced travel times associated with telehealth.32–35,37,39,41,42,45,46,48 Not having to schedule childcare or take time away from work was seen as an advantage by many of the patients involved in the included studies. Studies conducted during the pandemic highlighted the advantage of telehealth in preventing the transmission of COVID-19, and in ensuring continuity of care during lockdowns.32,44,45
In terms of the experience of pain, patients who participated in the Hinman et al. 41 study made the poignant observation that telehealth is particularly advantageous for those in acute pain. With telehealth, patients did not have to travel in pain, navigate parking lots and clinical buildings, or dwell uncomfortably in waiting rooms. Similarly, several studies examining virtual chronic pain management programs found that telehealth offers high-quality care to people living with chronic pain whose symptoms such as fatigue and anxiety have prevented them from participating in in-person appointments.33,48
Indeed, prior to the pandemic, Gilbert et al. 37 found that some patients felt that videoconferencing relieved the anxiety associated with face-to-face interactions in an orthopedic rehabilitation setting. These sentiments were echoed in the work of Fraser et al. 36 and Booth et al., 33 with both studies finding that patients liked telehealth-based interventions because it enhanced feelings of anonymity, reduced stigma, and created conditions for communication without judgment.
Construct I.II: Adaptability
The experience of adapting to the remote delivery of MSK care was varied throughout the included studies. Several studies conducted before the pandemic reported that patients considered exercise instruction, coaching, and pain focused counseling interventions adaptable to telehealth.32,39,44,45 As Ezzat et al. 40 describe, patients felt telehealth was acceptable and adaptable to their MSK health needs once they had been exposed to and experienced this form of care. Nevertheless, patients in all of these studies posited that telehealth was not adaptable for urgent complaints, complex cases, or MSK issues they believed necessitate an in-person exam.32,44,45
Limitations in adapting MSK care to telehealth were also articulated in studies conducted during the pandemic. Bell et al. 32 found that patients did not want to receive serious news via telehealth. Other studies reported that patients had difficulty adapting to the telehealth format because of distractions in their home-environment 34 . Barton et al. 44 identified that patients were better able to adapt to telehealth at home provided they had an existing relationship with their physiotherapist.
Critically, Gilbert et al.37,38 and Booth et al. 33 point to the specific set of challenges experienced by people with disabilities when adapting to telehealth, which include sensory issues, communication and literacy barriers, and access to and use of specialized equipment and technology to facilitate in-home care.
These findings suggest that it is not only a matter of exposure to telehealth that aids in its adoption in the non-pharmacological management of MSK disorders; rather, it is the conditions in which one is exposed to telehealth that matter for how this format is perceived as adaptable.
Construct I.III: Cost
One salient issue identified was a perceived pricing disparity between telehealth and in-person care. Barton et al. 44 found that some patients thought telehealth should cost the same or less than in-person care. These patients expressed concerns about the accuracy of telehealth as a format for assessing and diagnosing MSK disorders and did not feel that telehealth encounters had the same value as in-person appointments. 44 Other studies noted the financial and energetic advantages of telehealth, including not having to spend money on travel expenses and not losing income to accommodate for appointments, were valued by patients.34,37,39,45,48
Domain II: Outer setting
This domain concerns the external contexts and conditions in which patients experience telehealth and the effects of those situations on the telehealth experience.
Construct II.I Patient Needs and Resources
Across the included studies, patients consistently described a set of interconnected needs that point to broader structural issues and resource constraints affecting the experience of telehealth. Those needs were primarily related to the access to smartphones, devices, or computer for telehealth appointments, and the availability of reliable, affordable, and secure internet.32–35,37–39,41,44–46
Several studies raised concerns about digital literacy34,35 and the educational needs that must be addressed for all patients to meaningfully engage with telehealth. Dharmasri et al. 46 found that many older African American adults included in their study on telehealth interventions for osteoarthritis either did not own a computer or did not believe they had the skills to manage a telehealth appointment. Hasani et al. 39 found that many patients needed guidance on camera set-up during supervised exercise training via telehealth. Cottrell et al. 45 and Barton et al. 44 suggest the need for adequate appointment preparation and support for telehealth including help with setting expectations and payment. 25 Indeed, Ezzat et al. 40 found that technological barriers to telehealth were overcome with planned time for training and practice, further gesturing the importance of assessing for the technological and infrastructural barriers patients face before engaging in telehealth based care.
Domain III: Inner setting
In this domain we explore how the cultural values, meanings, and norms associated with MSK care are contested and renegotiated through the experience of telehealth.
Construct III.I: Culture
The implementation of telehealth in the treatment of MSK disorders prior to and during the pandemic challenged beliefs that patients hold closely about how care ought to be delivered. Across the included studies, patients described the in-person physical exam as playing a critical role in assessing and treating MSK disorders. Patients expressed concern regarding the validity of telehealth assessments, wondering openly if their practitioners could diagnose without physical touch.32,33,36–40,44,48 Several studies noted that patients struggled to explain their experience of pain or their MSK complaints during a telehealth encounter.32,42,44
These feelings of distance and disconnect were especially acute in several studies conducted during the pandemic.32,33,37,44,45,48 As one patient in the Barton et al.’s 44 study put it, “But now, all I feel like is I’m talking to a screen. You don’t get to feel the energy in the room, you don’t get to feel that person's energy (P14).” Bell et al. 32 suggested the removal of the physical exam during the turn to telehealth represented a profound “Alteration in the ritual of medicine” that left many patients feeling as though “Something [was] missing” from their appointments. In discussing their findings, these researchers suggested that the change in the expected and familiar practices of consultation left patients feeling less fulfilled with their telehealth encounters. These results question the lasting effects of the implementation of telehealth during the pandemic on the rituals of medical encounters and how patients may have been affected by this disruption to the ceremonial practices they value so deeply. Many patients also expressed a desire for a hybrid model of care, envisioned as including an in-person initial evaluation, followed by telehealth appointments.34,48
Some studies also reported that patients were concerned about how telehealth would impact their ability to develop a relationship with a new practitioner. 40 In contrast, one study reported that some patients felt “A subtle shift in power” when consulting with their providers remotely. This was felt in situations where patients received undivided attention from their physical therapist because of telehealth, thereby feeling they were the focus of the encounter. 41
Domain IV: Characteristics of individuals
This domain elucidates how patient attitudes, beliefs, and experiences influence the implementation of telehealth into MSK care.
Construct IV.I: Knowledge and beliefs about the intervention
In the included studies, we find immense variance in patients’ knowledge and beliefs about the use and value of telehealth. Gilbert et al.37,38 offered the important reminder that patients arrived into the telehealth encounter with a set of “relational expectations” which reflected “normative conventions” around how patients and providers related to one another in the context of MSK care. In their study on the PhysioDirect service in the NHS, Pearson et al. 42 reported that some patients perceived the telephone-based intervention as an impersonal format that made it difficult to forge a connection with their practitioner. Pearson et al. describe that this experience contributed to the perception of the service as being less valuable than face-to-face consultations. 42
Several of the included studies described that patients’ perception of telehealth is influenced by the quality of the therapeutic alliance they have with their MSK health provider. These studies elucidate that if a patient feels supported by this relationship, and if patients are collaboratively engaged in their care, they will think favorably of telehealth.34,37,38,43
Construct IV.II: Self-efficacy
Research conducted before the pandemic suggests that the home environment plays a role in how connected patients feel in their telehealth encounters. 39 Some of the included studies reported that patients experienced enhanced feelings of comfort working with their practitioners at home which in turn facilitated increased adherence to home exercise programs, changed perceptions of the value of exercise, and self-reported improvements in pain and function.35,38,41,43 On the other hand, some studies described the difficulties patients had in learning exercises remotely, suggesting hands on exercise correction was needed. 48
Several studies described competing demands on patients while at home, including work and caregiving responsibilities, making it difficult for patients to be present for a telehealth appointment or adhere to their prescribed exercises.32,37 Further, Gilbert et al. 37 identified that virtual consultations can provoke anxiety and diminish the experience of the intervention because the format exposes the private sphere of the home. These barriers to self-efficacy and adherence cast the relative advantages of telehealth in a new light. While telehealth may relieve patients of the labor of travel, and allows for easier scheduling, it also brings the encounter of MSK management in the home—a social space not always designed to hold for such medical consultations.
Amplifying results about the importance of the patient–practitioner relationships, studies demonstrated that patients experience deeper feelings of engagement with their care when they have an existing relationship with their practitioner.39–41 With a secure therapeutic alliance in place, telehealth encounters become motivating for patients, enabling commitments to exercise prescription and self-management.39–41 When this alliance is not in place, patients lack accountability and support, 40 and face emotional barriers to committing to their plan of management. 47
Similarly, the emergence of supportive relationships between patients was reported in studies that involved group-based telehealth interventions for chronic and persistent pain. Studies by Ernstzen et al., 34 and Booth et al., 33 report that the virtual setting propagated forms of peer support and relationships that patients maintained beyond the intervention sessions, suggesting that telehealth interventions have the potential to positively impact the rehabilitation experiences of individual and communities.
Confidence in review findings
We assessed the findings arising from collected data against each of CFIR domains and constructs using GRADE-CERQual 54 and assigned a confidence rating of no or very minor concern, minor concern, moderate concern, or serious concern (Table 4). We identified minor concerns with each domain and construct, except for Construct I.I Relative Advantage which posed moderate concern. Moderate concern was expressed because of methodological issues pertaining to three mixed methods studies included did not clearly report on the integration of their qualitative and quantitative data44,45,48 and one study did not provide adequate consideration of the patient–researcher relationship. 35 The remaining identified minor concerns reflect issues with appropriate research design,32,46 and with results sections of studies focused more heavily on program delivery than patient experience.36,40,42,46 We recognize that some of the concerns we identified may reflect challenges pertaining to the publication of qualitative and mixed methods health research, and constraints faced by teams conducting research during the COVID-19 pandemic. We believe our findings reasonably represent our phenomena of interest, 54 and have assigned an overall confidence rating of moderate for the findings of our review.
GRADE CERQual confidence in review findings.
Discussion
Our review adapted the CFIR to examine the contextual and experiential factors shaping the implementation of synchronous telehealth in the non-pharmacological management of MSK disorders. Using CFIR, we identified four key domains shaping the lived experience of telehealth from the patients’ perspective: (1) Interventional Characteristics, (2) Outer Setting, (3) Inner Setting, and (4) Characteristics of Individuals. Each of these domains and their associated constructs have bearing on how we understand the ongoing implementation of telehealth. Broadly, our findings demonstrate that the experience of telehealth is influenced by access and comfort with technology, the environments in which telehealth is lived, and existing patient attitudes, beliefs, values, and experiential knowledge about what constitutes good care in the broader field of MSK Health. These findings are also consistent with recent commentaries on the use of telehealth in manual therapy practice. 15 Using GRADE CERQual we assigned a moderate level of confidence in our findings.
Recent discussions on rapid reviews and evidence synthesis during the COVID-19 pandemic have gestured to the importance of developing practical implications that support how practitioners and decision makers grapple with information on emergent phenomena. 55 We have developed a set of implications which leverage social theory to understand how our findings may have been contoured by broader cultural, political, historical dimensions that also factor into experiences patients have with telehealth. These implications are meant to help appreciate the complexity of patient experiences while also provoking novel forms of inquiry and action in this emergent area of implementation.
Implication I: Relationships matter
Our review found that telehealth is experienced positively when adapted into situations where there is an existing patient–practitioner relationship. These findings suggest that the experience of telehealth is deeply influenced by the knowledge and beliefs patients hold about their relationships with their providers. When patients have positive telehealth experiences, it appears to be due to a felt sense of connection with their provider, or because their providers demonstrated an effort to forge a connection through the distance.39–41 This is an important consideration for the use of telehealth in the management of acute MSK conditions with no prior onset, or previous history of being treated by an allied health provider. The ongoing use of telehealth in MSK care must consider how these technologies can be used to create and sustain patient–provider relationships.
Implication II: Transforming the ritual of medicine
One of the studies included in this review contended that telehealth and the virtual physical exam poses an “alteration in the ritual of medicine.” 32 Bell et al. 32 suggest that the physical exam is a kind of ceremony—a way of making and demonstrating a shared commitment to care and rehabilitation. Hands-on care is thus critical for patients in developing relationships with their providers. Patients place immense value in being able to feel that their practitioner is attuning to their injury through the act of the physical exam. Our review also demonstrates that the absence of the physical exam negatively influences the patient experience of telehealth.32,36,37,40 When we think about the continued implementation of telehealth in MSK, especially in situations where physical exams cannot be performed, consideration should be given to what new rituals could be adapted to the encounter that might help to forge bonds of trust and connection.
Implication III: Technology continues to be barrier to telehealth
As demonstrated by our results, the continued implementation of telehealth in the broader field of MSK care should support how patients access and utilize telehealth technologies. Other reviews evaluating the implementation of telehealth technologies highlight how inequalities concerning internet and device access continue to influence the experience of telehealth.10,56 These reviews suggest that the potential of telehealth to expand the reach of medical services is contingent on investments in telecommunications infrastructure and on the broader recognition of the socioeconomic inequalities that shape how people access telehealth.57–59
Social scientists have identified that telehealth technologies have primarily imagined clinicians, not patients, as their primary users.60,61 There is an opportunity for patients, particularly persons with disabilities, to be involved as stakeholders in the continued implementation of telehealth, and be equipped with the necessary training and tools to determine how these technologies are used in their care.
Implication IV: Telehealth is work for patients
In their recent systematic review on the use of virtual consultation in orthopedic rehabilitation, Gilbert et al., 11 argue that “The use of virtual consultations changes the work of being a patient.” They contend that virtual consultations catalyze new forms of “self-management” for patients. We uncovered similar results in our review, with included studies reporting that patients using telehealth must learn to be their own educators and technical support staff37,44,45 and take on the work of transforming their home environments into spaces conducive to telehealth encounters.37,44
Furthermore, the movement of healthcare into the home has implications for the patient experience. Sociologists refer to this phenomenon as “deinstitutionalization”—a term which names the mobilization of technology to allow clinical encounters to occur outside of conventional medical environments. 62 Patients bear the brunt of the work associated with the deinstitutionalization of MSK care and, as Gilbert et al., 11 suggest, this may determine “patient preference for or against virtual consultations.” More research is needed to understand the role of the home and homelife in the experience of telehealth. Insight into housing security, perceptions of safety, and experiences of home-based violence will help us understand when, where, and how telehealth can be used or ought to be used.
Implication V: A new type of patient
The process of deinstitutionalizing MSK rehabilitation vis-a-vis the implementation of telehealth has far reaching effects beyond transforming peoples’ homes into makeshift clinical spaces. It also has an impact on how people relate to and enact the role of the patient. The studies included in our review evidence that telehealth is transforming the concept of “patienthood”—thus suggesting that being a patient is not a fixed identity category but rather an ongoing process of interactions with different types of medical providers in different medical environments that transform people into patients.63–66 How people take on and perform the patient identity reflects their expectations, behaviors, situated experiences, and formations of power that are shaped by interactions with medicine and medical providers. In this sense, we can consider that part of the strain described by patients reflects learning how to enact the patient role in the home environment where people with MSK disorders may not be used to acting as patients. The continued implementation of telehealth needs to consider that patients are actively navigating and negotiating these new challenges to their identity as they receive care at a distance.
Strengths and limitations
Strengths of our review include the use of consistent, transparent methods to screen, critically appraise, and extract data from included studies, and robust quality assurance processes. We also worked closely with an experienced health librarian to conduct our literature search.
There are limitations shaping our review. We only included studies published in English, and this may have excluded relevant studies. We believe this is an unlikely source of bias. 67 Our use of rapid review methodology meant that one reviewer was responsible for screening and data extraction; however, we implemented quality assurance processes to address this concern. Two reviewers screened a 10% sample of the records, arriving at a 98% agreement. We also used second and third reviewers to support the critical appraisal and GRADE CERQual analysis of our results.
For the purposes of our review, we did not search Embase because we did not have institutional access. Guidance from the Cochrane Rapid Reviews Methods Group on the rapid review of randomized control trial data indicates that Embase should be searched if access is available. 68 Noting the limitation in accessing this database, we followed best guidance and searched recommended specialized databases that were appropriate for the retrieval of qualitative studies, specifically CINAHL (EBSCO) and PsycINFO (Ovid).
Using the CFIR to guide data analysis also may have influenced the framing of our findings. Important findings may have been missed if they did not map onto existing domains and constructs in the CFIR. Several of the included studies recruited participants from ongoing randomized control trials on telemedicine; therefore, it is unclear whether these participants are a good reflection of those seen in clinical practice. Furthermore, our results are limited to those with MSK disorders treated by mental health professionals, occupational therapists, physicians, and physiotherapists; and therefore, may not be generalizable to the experiences of patients with other disorders treated by other healthcare professionals.
Finally, our review offers an overarching analysis of the lived experience of telehealth and does not offer specific considerations for how those experiences differ for people with varying MSK disorders. Future reviews, and indeed qualitative research, are needed to more substantively investigate the nuanced differences in how the experience of synchronous telehealth is lived by people with MSK disorders.
Conclusion
Our findings, as refracted through the CFIR and rated with moderate confidence according to GRADE CERQual criteria, suggest that the experience of telehealth both before and during the pandemic was shaped by many factors including but not limited to patient perceptions of telehealth, existing relationships with practitioners, availability and accessibility of telehealth technologies, and perceptions about the importance of the role of the physical exam in assessing and treating MSK disorders. We have identified five clinical implications arising from our review which we believe hold importance for endeavoring to improve the patient experience of telehealth in the non-pharmacological management of MSK disorders.
Footnotes
Contributorship
MAG, GB, CC, MC, SR, ADZ, SM: Made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of data. KM: Designed and executed the database search strategy; review of search strategy was provided by MAG, SM. MAG, GB, CC, MC, SR, ADZ, KM: Drafted the article or revised it critically for important intellectual content, approved the version to be published.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the College of Chiropractors of British Columbia but they were not involved in the design, conduct or interpretation of the research that informed the research. This research was undertaken, in part, thanks to funding from the Canadian Memorial Chiropractic College and funding from the Canadian Chiropractic Research Foundation to Carol Cancelliere who holds a Research Chair in Knowledge Translation in the Faculty of Health Sciences at Ontario Tech University.
Guarantor
SM.
