The Impact of Digital MSK on Providers of Rehab Therapy
In 2016, a physical therapy patient approached Todd Norwood, DPT, with multiple questions about the ways he used technology and whether Norwood used digital tools to connect with and treat his patients.
“We were chatting, and [the patient] said, ‘Well, could you see patients over Facetime? Could you do your job like that?’” recalled Norwood, now the Senior Director of Clinical Services for Omata Health’s musculoskeletal (MSK) program. “Honestly, I wasn’t sure.”
It so happened the injured patient, a former Facebook employee, was interested in developing an early version of what we’ve come to know as a telehealth application. In Norwood, he found someone eager to embrace technology in his practice of physical therapy. This included a willingness to experiment in remote care using the beta version of this new app.
“The first time I did it, it was hard,” Norwood said. “It was really a challenge for me to think through all the things that I needed to do, how I was going to do it, how I was going to communicate over a screen when I’m used to being in-person. But then, this patient got better.”
Today, an increasing number of rehab therapists are experiencing a similar journey through digital trial and error. Some, like Norwood, are thrilled to expand their clinical repertoire into digital MSK care, while others are doing so cautiously and reluctantly, fearful of the potential long-term consequences on the profession.
Both attitudes are valid, said Andrew (Drew) Contreras, PT, DPT, Vice President of Clinical Integration and Innovation for the American Physical Therapy Association (APTA). But while it’s generally agreed that more research needs to be done on the use of digital tools and services in rehab therapy, the industry continues to shift toward digital innovation.
In the meantime, clinicians who have implemented digital MSK within their practices are finding these tools provide clinical benefits – aspects outlined throughout this chapter – that far outweigh most fears practitioners have about digital “taking over” the profession.
“Digital tools won’t replace a clinician, but a digitally savvy clinician will replace one who’s not,” Contreras said. “Physical therapists are kind of brought up in this world where one of the most valuable tools is right here – the hands. And when you tell people the hands are no longer the most valuable tools you have – it’s between your ears – that’s a huge shift that goes against what we’re taught.”
“I think the most important thing to think about,” he continued, “is that the profession needs to understand [digital MSK] and leverage it so that the profession can rise to serve at the highest level it can.”
The Benefits of Digital MSK in the Clinical Setting
To “rise to serve at this highest level,” rehab therapy clinicians will need to overcome a familiar list of challenges that have long plateaued the growth trajectory of the profession. Perhaps the greatest of these challenges is closing the gap between those with musculoskeletal pain and limitations (e.g., half of the country1) and those who seek rehab therapy for relief (only about 10% to 20%2).
Shortfalls in consumer education are often cited as a culprit whenever this issue arises, but that remains only part of the equation. Not all neighborhoods, communities, or regions are created equal, so even the most educated consumer within these spaces may still encounter hurdles with access, mobility, physical commitments, and costs that negatively impact the value of rehab therapy.
From a clinical standpoint, this is where rehab therapists have found some of the greatest success when implementing digital MSK. Consider the following clinical benefits of these tools and services:
Provide More Care with Digital MSK
By only offering in-person rehab therapy services, clinicians can help patients who walk through their doors, or those who they’re willing to visit. This may seem like a perfectly reasonable limitation to clinicians who believe their hands are their most important tools, but Norwood challenges rehab therapists to think differently.
“From my perspective, our identity isn’t necessarily about what we do with our hands, but what we do with our minds,” he said. “So much of the information diagnostically comes from your subjective exam … whether you do it face to face or over a [virtual] call.”
For a patient who is injured, has limited mobility or transportation, or may not have close access to a rehab therapist, online appointments and/or check-ins (i.e., remote therapeutic monitoring) may be the difference between seeking care or suffering through pain. This includes both the financial and time commitments patients may make when opting for a rehab therapy-based plan of care.
Digital MSK Helps Maintain a Consistent Plan of Care
It’s not unusual for patients to miss their appointments. One recent study found that an average of one in every four patients miss medical appointments.3 In addition, patients with just a single missed appointment are twice as likely to prematurely self-discharge,4 which can disrupt revenue, efficiency, and patient success.
So, why do patients miss appointments? Simply forgetting is the main culprit,5 one that can be prevented using automated digital reminders. Another 6.9% of patients miss appointments due to transportation issues, a roadblock that can be bypassed if given the option to connect remotely.
Beyond offering another choice in how they see rehab therapists, digital MSK can also offer patients a broader selection of clinicians to see. This can apply to instances when a patient may seek a specialist (i.e., women’s health, sports medicine, etc.) or simply a clinician with a common identity or background (i.e., race, ethnicity, gender, orientation, preferred language) as their own.
Missed visits, however, are not the only culprits that may interrupt a patient’s full rehab therapy journey. Misaligned expectations and/or the perceived lack of progress can frustrate patients, causing them to become disillusioned with the rehab therapy process.
Digital MSK solutions such as patient-reported outcome management tools help clinicians track the data they need to establish appropriate patient milestones, goals, and expectations prior to treatment, then track progress throughout the plan of care. Charting and regularly discussing such progress can enhance patient dedication and buy-in, enabling them to celebrate smaller successes throughout the plan of care.
Over time, such outcome measures can also be used by clinicians to optimize patient success, specifically when developing digital programs around services like telehealth, RTM, digital home exercise programs, and so on.
Better Engage with Patients Between Appointments
With payers actively charting a movement toward value-based care, nearly any additional touchpoint a clinician can provide for patients will enhance the perceived value of their rehab therapy care.
As clinicians explore the best ways to utilize emerging digital innovations, most digital MSK tools and solutions could contribute to driving better engagement with patients, especially between visits.
“In my mind, the best tools that we can have from a digital standpoint are the ones that are going to improve our communication with our patients,” Norwood said. “For me, very early on in my journey of doing digital was the ability to send secure chat messages back and forth to my patients between visits. It was a super low barrier … and we could have this interaction where I give them the information they need.”
Beyond offering secure patient messaging, engagement tools under the digital MSK umbrella can include appointment reminders, virtual home exercise program (HEP) apps, patient portals, and the implementation of remote therapeutic monitoring (RTM).
Such a boost in communication empowers patients to be truly hands-on in their healthcare journeys. More importantly, it enables clinicians to better oversee and monitor patient progress, leading to greater personalization and flexibility for patients.
Enrich Patient Interactions in Familiar, Rehab-Friendly Spaces
Reach more people, offer some digital flexibility, ensure patients remain active participants in their treatment plans, and create opportunities to connect between appointments. These are all key ingredients in utilizing digital MSK to drive better overall patient outcomes.
This is supported by a 2021 report by McKinsey, which lists improved care models and outcomes as one of three main core benefits that define value proposition around digital and telehealth services.6 (The other benefits are increased convenience and improved access.)
In addition, each of the above key ingredients offers incremental opportunities to affect outcomes in personal ways. When using telehealth, for example, patients essentially invite you into their homes, which has its benefits.
“You’re in their personal space, so there’s all these personal things – a wedding picture in the background, their dog walks by, their kids come into the frame,” Norwood said. “So, you actually get to have what in many ways is a richer interaction with the person.”
Clinicians can also see where the patient does their home exercise programs, enabling them to troubleshoot potential problems, as well as opportunities, on the fly.
“The transfer is one-to-one, right?” Norwood added. “You can say, ‘Hey, I need you to do this exercise, and I see you have this great door frame you can use back there, or you have a machine that will work’ … whatever it is that they have in their space. And they can do it right there. It’s already set up for them, with none of the translation from the clinic to the home.”
Abundant Data Helps Guide Digital MSK Programs
As with any industry that trends toward digital solutions, the potential to collect data via virtual interactions, engagement, compliance, and so on can supply rehab therapy clinicians and operators with an abundance of data. When analyzed and understood, this data can be used to fine-tune the effectiveness of both digital MSK services and related treatments, driving clinicians toward delivering even better outcomes.
“For me, it’s all centered around data,” Norwood said. “You can collect all your information about your subjective, all your information about your objective, all the patient demographics. You can know how often they did their home exercise program and if they had any feedback on it. You could have videos of them performing movements that you could analyze at some point in time.”
This information, along with pain scores and outcome measure, can be central in enabling clinicians to draw correlations related to patient success.
“So, if we do this, what is more likely to happen?” Norwood added. “What frequency of appointments impacts outcomes? What cadence of update home exercise programs, which exercises tend to lead to better outcomes for plantar fasciitis in females over the age of 40? You can start to ask all those questions of your data and get really, really specific.”
In addition to improving care and efficiency, the answers to these and other questions can offer rehab therapy operations insight into opportunities for mentorship, training, and marketing.
3 Tips for First-Time Telehealth Clinicians
Whether assessing, treating, or simply checking in with patients during a remote therapeutic monitoring session, the number of rehab therapists and assistants engaging with patients via real-time video connections is likely to keep increasing. As they do, clinicians new to virtual care are bound to quickly realize one thing:
Success in in-person care does not automatically translate to success in digital care.
This aligns with the experience of Todd Norwood, DPT. When attempting his first telehealth appointment back in 2016, for instance, it didn’t take him long to learn that simply communicating with patients was quite different.
Because of this and other potential obstacles, digital care can feel a little clunky at first, at least from the clinician perspective. To help ease the process, Norwood suggests new digital practitioners consider the following steps.
1. Set Your Expectations
Don’t expect a telehealth session to be just like an in-person appointment, minus the hands-on work. Having a successful remote appointment will feel a little trickier at first, and that’s OK. It’s expected.
To help temper any frustrations you have, pick one or two specific ailments you’re most comfortable treating – say, chronic low back pain. Develop a level of comfort and success treating patients who fit this category, all while developing your own virtual treatment style, before moving forward with other ailments. Progressively taking on more complicated cases will help make virtual care a positive experience for you as well as the patient.
2. Practice with a Friend
Before trying it out with a real patient, practice a telehealth visit with a friend or family member. Avoid colleagues, if you can, or anyone who has more than a layperson’s experience with rehab therapy. You will learn quickly that using precise language and setting proper camera angles can be key to the appointment’s success.
“When you’re in a clinic and you’re right next to somebody, if you say something [and] they don’t interpret it as you intended, it’s pretty easy to correct by placing your hand on them or giving a visual cue,” Norwood said. “But when it’s over a Zoom or a FaceTime sort of video interaction, that’s not the case. It can be challenging.”
3. Prepare for All Virtual Appointments
Your ability to see and communicate is of prime importance in remote care. So, before you log on, plan for what you will need from the patient and how you will communicate this to them. What exercises are important, and how will you teach them? Where should the camera be set up to analyze movement, range of motion, proper exercise form, etc.? Be prepared.
“I’d say that upfront, one should think, well, if I want to see this movement, what do I need to ask of my patient?” Norwood said. “How do I need to have them positioned so I can see what I need to see in order to make the decisions I need to make? It’s important to have a plan for this before starting the session.”
Potential Hurdles for Implementing Digital MSK
While digital MSK solutions provide clinicians with powerful tools for reaffirming and boosting the value of rehab therapy in today’s healthcare market, no innovation is without its flaws and digital MSK comes with several caveats.
For one, patients must utilize updated computer and/or smartphone technology with reliable access to the internet. This can exclude those who lack economic means or live in isolated areas.
Other possible clinical hurdles of implementing digital MSK services include:
Effective Telehealth Takes Practice
Assessing and treating a patient in-person does not automatically translate to doing the same online. Successfully providing digital MSK care takes practice, the ability to articulate movements and instructions, and a willingness to ease into the process. As rehab therapists generally agree that education has yet to fully catch up with digital best practices (research using randomized clinical trials are in short supply, Norwood said), some trial and error will likely be necessary.
Telehealth Won’t Work for Every Ailment
This should be great news for practitioners – remember, digital MSK will not replace a clinician. But for patients with ailments that require regular hands-on assessments and interventions – for example, injuries that can benefit from treatments like myofascial rerelease, the Graston technique, and others – the flexibility provided through digital tools could be minimal or nonexistent. In this respect, you will likely need to refer some patients to fully in-person care.
Digital Training Takes Time and Buy-In
Beyond simply knowing how to effectively work with a patient remotely, clinicians must also know how to use the tools in front of them. This includes applications for telehealth, virtual HEP, remote therapeutic monitoring, outcomes software, and more. It also helps if all clinicians fully buy into the need and how these tools complement in-person, hands-on care. Unfortunately, both training and buy-in can take some time.
Technology Can Fail
The internet can go out. Computers can crash. Application updates can sometimes introduce new bugs. Occasionally a storm, a fallen tree, or an unfortunate squirrel can knock out power for hours at a time. When leaning on technology, great and unexpected things can happen in an instant. Offering a hybrid model for rehab therapy – both digital and in-person solutions – can help clinicians overcome such challenges.
A Shortage of Supporting Evidence
While a handful of studies have been done around the use of digital tools in rehab therapy, more randomized clinical trials are needed. Despite this, Norwood says plenty of clinical and outcome data collected since the start of the pandemic supports moving forward with digital MSK. These studies cover various MSK ailments, from low back pain7 to total knee arthroplasty.8
In addition, Norwood suggests clinicians continue tracking and reviewing their own data.
“If you’re looking at your data the whole time – if you’re monitoring your data and looking at your outcomes – you’re actually investing in understanding the potential for digital MSK in your clinic,” he said. “I think that can be really powerful.”
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“Digital tools won’t replace a clinician, but a digitally savvy clinician will replace one who’s not,”
“In my mind, the best tools that we can have from a digital standpoint are the ones that are going to improve our communication with our patients,”
Let’s Talk About Digital MSK
 Bone and Joint Initiative USA, “The Burden of Musculoskeletal Diseases in the United States,” 2015
2 Centers for Disease Control and Prevention, “Physical, Speech, Rehabilitative, or Occupational Therapy Use Among Adults Aged 25-64, by Veteran Status,” August 2022
3 National Library of Medicine, “Data Analytics and Modeling for Appointment No-Shows in Community Health Centers,” Nov. 17, 2018
4 Healthcare Innovation, “Missed Appointments Cost the U.S. Healthcare System $150B Each Year,” April 26, 2017
5 Journal of Family Medicine and Disease Prevention, “Why Do Patients Miss Their Appointments at Primary Care Clinics?” Sept. 28, 2018
6 McKinsey & Company, “Telehealth: A Quarter-Trillion-Dollar Post-COVID-19 Reality?” July 9, 2021
7 Physical Therapy & Rehabilitation Journal, “Is Telerehabilitation a Viable Option for People with Low Back Pain? Associations Between Telerehabilitation and Outcomes During the COVID-19 Pandemic,” Feb. 23, 2022
8 National Library of Medicine, “Role of telerehabilitation in patients following total knee arthroplasty: Evidence from a systematic literature review and meta-analysis,” July 9, 2016