Is an online consultation for shoulder pain reliable and valid?

Ann Cools, New in / Monday, July 5th, 2021

This was the question the Master students Rehabilitation Sciences and Physiotherapy from Ghent University Léonie Lejon, Yao Lin, and Silke Schotte wanted to answer with their project.

The covid pandemic has forced us to examine, treat and guide patients with shoulder pain through internet communication as an alternative for the usual care in vivo. Many clinicians experimented with online tools, apps and programs in order to optimize their care during the lockdowns and restrictions for usual physiotherapeutic care.

Several research questions lead to this study:

1) Can 2 examiners reliably observe the basic clinical examination, provocative and symptom reduction tests of a patient, adapted for online application, on video?

2) Are the estimations of range of motion, made during the consultation valid compared to measurements of joint angles on the video?

3) Will the 2 examiners, after interpretation of the video, come to the same conclusion, in terms of a physiotherapeutic diagnosis?

4) Are patients satisfied with this online approach, and are therapists confident with the results?

For the project set-up, one student did the online consultation with a patient (general shoulder pain more than 4 weeks, no surgery or major trauma in the history), the second student assessed the patient only through watching the video afterwards, the third student measured ROM angles with kinovea. Shoulder assessment was adapted to a self-assessment, as an example, patient resisted external rotation with the healthy side and reported pain or a feeling of weakness. They also applied self-testing for provocative tests (for instance the Jobe test) and symptom reduction tests (for instance adding external rotation to an elevation task). After completion of the examination, patients were classified into 4 categories of shoulder diagnoses: 1/ subacromial pain syndrome (with subdivision for rotator cuff disorders, biceps related pathology, and scapular dysfunction), 2/ the stiff shoulder, 3/ shoulder instability, and 4/ other.

The good news is that the online consultation is reliable with respect to estimating ROM or pain during resistance tests, and that estimations were very close to the post-hoc measurements. However, with respect to the physiotherapeutic diagnosis, there was only 64% agreement when the sub-classification for SAPS was used, increasing up to 77% when categorizing all SAPS patients in one category.

Maybe even more important was the subjective feedback from the examiners as well as the patients. More than 80% of the patients was satisfied with the online consultation, but mentioned that an in vivo consultation gives them more confidence in the therapist’s skills and knowledge. The examiners attributed possible differences in diagnosis or interpretation of results to the communication rather than to difference in visual observation.

Bottomline: if we are forced to examine a patient online because of circumstances, a clear communication is extremely important. Make sure you have a standardized way to ask for a result of a test regarding the pain, discomfort, decreasing symptoms etc… and then probably the final physiotherapeutic conclusion will be more reliable and valid.

Reference: Léonie Lejon, Yao Lin & Silke Schotte: Reliability of teleconsultation as an alternative for a physiotherapeutic shoulder examination. Unpublished Master Thesis June 2021, Ghent University, Belgium

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