Real-time video telerehabilitation shows comparable satisfaction and similar or better attendance and adherence compared with in-person physiotherapy: a systematic review.

QUESTION: How does physiotherapy delivered by real-time, video-based telerehabilitation compare with in-person delivery for the outcomes of attendance, adherence and satisfaction? DESIGN: Systematic review of randomised control trials indexed in PubMed, CINAHL, Embase, Cochrane and PEDro on 12 March 2024. PARTICIPANTS: Adults aged > 18 years. INTERVENTION: Physiotherapy delivered via real-time video telerehabilitation. OUTCOME MEASURES: Attendance, adherence and satisfaction. RESULTS: Eight studies were included for attendance (n = 1,110), nine studies for adherence (n = 1,190) and 12 studies for satisfaction (n = 1,247). Telerehabilitation resulted in attendance at treatment sessions that was 8% higher (95% CI -1 to 18) and adherence to exercise programs that was 9% higher (95% CI 2 to 16) when compared with in-person physiotherapy. Satisfaction was similar with both modes of delivery (SMD 0.03 in favour of telerehabilitation, 95% CI -0.23 to 0.28). The level of certainty assessed by GRADE ranged from very low to low, primarily due to inconsistency and high risk of bias. DISCUSSION: Attendance at appointments among participants assigned to telerehabilitation was somewhere between similar to and considerably higher than among control participants. Adherence to self-management with telerehabilitation was better than with in-person delivery, although with some uncertainty about the magnitude of the effect. Reported satisfaction levels were similar between the two modes of treatment delivery. Given the significance of attendance, adherence and satisfaction for successful outcomes, telerehabilitation offers a valuable alternative mode for physiotherapy delivery. CONCLUSION: Real-time telerehabilitation has potentially favourable effects on attendance at treatment appointments and adherence to exercise programs, with similar satisfaction when compared with traditional in-person physiotherapy. REGISTRATION: PROSPERO CRD42022329906.

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals with Persistent Low Back Pain.

OBJECTIVES: To evaluate the effect of combining pain education and virtual reality exposure therapy using a cognitive behavioural therapy-informed approach (VR-CBT) on pain intensity, fear of movement, and trunk movement, in individuals with persistent low back pain. METHODS: Thirty-seven participants were recruited in a single cohort repeated measures study, attending three sessions one week apart. The VR-CBT intervention included standardised pain education (Session 1), and virtual reality exposure therapy (Session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (Pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude, peak velocity) were collected at baseline (Session1), and one week following education (Session 2) and virtual reality exposure therapy (Session 3). One-way repeated measures ANOVAs evaluated change in outcomes from baseline to completion. Post-hoc contrasts evaluated effect sizes for the education and virtual reality components of VR-CBT. RESULTS: Thirty-four participants completed all sessions. Significant (P<0.001) reductions were observed in Mean(SD) pain (baseline 5.9(1.5); completion 4.3(2.1)) and fear of movement (baseline 42.6(6.4); completion 34.3(7.4)). Large effect sizes (Cohen's d) were observed for education (pain intensity 0.85; fear of movement 1.28) while the addition of virtual reality exposure therapy demonstrated very small insignificant effect sizes, (pain intensity 0.10; fear of movement 0.18). Peak trunk velocity, but not amplitude, increased significantly (P<0.05) across trunk movement tasks. DISCUSSION: A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

Project ECHO®: a global cross-sectional examination of implementation success.

BACKGROUND: Organizations implement innovations to disrupt the status quo and create value. Within sectors such as healthcare, innovations need to navigate large scale system and organizational factors to succeed. This research explores the implementation of a global innovation- Project ECHO®. Project ECHO® is a validated virtual communities of practice model organizational teams implement to build workforce capacity and capability. Project ECHO® has experienced broad global adoption, particularly within the healthcare sector, and is experiencing growth across other sectors. This study sought to examine the state of implementation success for Project ECHO® globally, to understand how these implementations compare across geographic and sectoral contexts, and understand what enablers/barriers exist for organizational teams implementing the innovation. METHODS: An empirical study was conducted to collect data on 54 Project ECHO® implementation success indicators across an international sample. An online survey questionnaire was developed and distributed to all Project ECHO® hub organizations globally to collect data. Data was analyzed using descriptive statistics. RESULTS: The 54 implementation success indicators measured in this survey revealed that the adoption of Project ECHO® across 13 organizations varied on a case-by-case basis, with a strong rate of adoption within the healthcare sector. Implementation teams from these organizations successfully implemented Project ECHO® within 12-18 months after completing Immersion partner launch training and operated 51 ECHO® Networks at the time of data collection. Implementation teams which liaised more regularly with ECHO® Superhub mentors often went on to launch a higher number of ECHO® Networks that were sustained over the longer term. This suggests that these implementation teams better aligned and consolidated their Project ECHO® pilots as new innovations within the local context and strategic organizational priorities. Access to research and evaluation capability, and a more automated digital client relationship management system were key limitations to showcasing implementation success outcomes experienced by the majority of implementation teams. CONCLUSIONS: These findings make a valuable contribution to address a knowledge gap regarding how a global sample of organizations adopting Project ECHO® measured and reported their implementation successes. Key successes included pre-launch experimentation and expansion, Superhub mentorship, stakeholder engagement, and alignment to strategic priorities.

Telerehabilitation in Physical Therapist Practice: A Clinical Practice Guideline From the American Physical Therapy Association.

A clinical practice guideline on telerehabilitation was developed by an American Physical Therapy Association volunteer guideline development group consisting of international physical therapists and physiotherapists, a physician, and a consumer. The guideline was based on systematic reviews of current scientific literature, clinical information, and accepted approaches to telerehabilitation in physical therapist practice. Seven recommendations address the impact of, preparation for, and implementation of telerehabilitation in physical therapist practice. Research recommendations identify current gaps in knowledge. Overall, with shared decision-making between clinicians and patients to inform patients of service delivery options, direct and indirect costs, barriers, and facilitators of telerehabilitation, the evidence supports the use of telerehabilitation by physical therapists for both examination and intervention. The Spanish and Chinese versions of this clinical practice guideline, as well as the French version of the recommendations, are available as supplementary material (Suppl. Materials).

Assessing a GPS-Based 6-Minute Walk Test for People With Persistent Pain: Validation Study.

BACKGROUND: The 6-minute walk test (6MWT) is a commonly used method to assess the exercise capacity of people with many health conditions, including persistent pain. However, it is conventionally performed with in-person supervision in a hospital or clinic, therefore requiring staff resources. It may also be difficult when in-person supervision is unavailable, such as during the COVID-19 pandemic, or when the person is geographically remote. A potential solution to these issues could be to use GPS to measure walking distance. OBJECTIVE: The primary aim of this study was to assess the validity of a GPS-based smartphone app to measure walking distance as an alternative to the conventional 6MWT in a population with persistent pain. The secondary aim of this study was to estimate the difference between the pain evoked by the 2 test methods. METHODS: People with persistent pain (N=36) were recruited to complete a conventional 6MWT on a 30-m shuttle track and a 6MWT assessed by a smartphone app using GPS, performed on outdoor walking circuits. Tests were performed in random order, separated by a 15-minute rest. The 95% limits of agreement were calculated using the Bland-Altman method, with a specified maximum allowable difference of 100 m. Pain was assessed using an 11-point numerical rating scale before and after each walk test. RESULTS: The mean 6-minute walk distance measured by the GPS-based smartphone app was 13.2 (SD 46; 95% CI -2.7 to 29.1) m higher than that assessed in the conventional manner. The 95% limits of agreement were 103.9 (95% CI 87.4-134.1) m and -77.6 (95% CI -107.7 to -61) m, which exceeded the maximum allowable difference. Pain increased in the conventional walk test by 1.1 (SD 1.0) points, whereas pain increased in the app test by 0.8 (SD 1.4) points. CONCLUSIONS: In individuals with persistent pain, the 2 methods of assessing the 6MWT may not be interchangeable due to limited validity. Potential reasons for the differences between the 2 methods might be attributed to the variation in track layout (shuttle track vs continuous circuit); poor GPS accuracy; deviations from the 30-m shuttle track; human variability in walking speed; and the potential impact of a first test on the second test due to fatigue, pain provocation, or a learning effect. Future research is needed to improve the accuracy of the GPS-based approach. Despite its limitations, the GPS-based 6MWT may still have value as a tool for remote monitoring that could allow individuals with persistent pain to self-administer frequent assessments of their functional capacity in their home environment.

Telehealth Cognitive Behavior Therapy to Reduce Anxiety in People Living with Cognitive Impairment: A Randomized Feasibility Pilot Study.

OBJECTIVES: To evaluate the feasibility of telehealth-based cognitive behavior therapy for people living with cognitive impairment experiencing anxiety (Tele-CBT), and to assess whether this leads to improvements in anxiety, depression, and quality of life post-intervention. METHODS: This was a single-blind randomized feasibility pilot trial of the Tele-CBT versus usual care. People living with mild cognitive impairment or dementia experiencing anxiety were recruited and randomized to receive Tele-CBT (n = 5) or continue usual care (n = 5). Feasibility data comprised recruitment uptake and retention, adherence, and ease of use. Outcomes of anxiety (primary outcome - Rating Anxiety in Dementia; RAID), depression, stress, and quality of life were measured pre- and post-intervention. RESULTS: Intervention feasibility was demonstrated through minimal attrition, acceptability, and ease of use via videoconferencing. Both groups showed a decrease of anxiety symptoms (RAID) from baseline to post-assessment. CONCLUSIONS: The Tele-CBT program was acceptable to use via videoconferencing. Reduced anxiety symptoms were observed in both groups at post-. An RCT with a larger sample is required to determine the efficacy and implementation of the intervention. CLINICAL IMPLICATIONS: This study indicates the feasibility of videoconference CBT to address anxiety experienced by people living with cognitive impairment with minimal assistance from support persons.

Telerehabilitation consultations with a physiotherapist for chronic knee pain versus in-person consultations in Australia: the PEAK non-inferiority randomised controlled trial.

BACKGROUND: Telerehabilitation whether perceived as less effective than in-person care for musculoskeletal problems. We aimed to determine if physiotherapy video conferencing consultations were non-inferior to in-person consultations for chronic knee pain. METHODS: In this non-inferiority randomised controlled trial, we recruited primary care physiotherapists from 27 Australian clinics. Using computer-generated blocks, participants with chronic knee pain consistent with osteoarthritis were randomly assigned (1:1, stratified by physiotherapist and clinic) in-person or telerehabilitation (ie, video conferencing) physiotherapist consultations. Participants and physiotherapists were unmasked to group assignment. Both groups had five consultations over 3 months for strengthening, physical activity, and education. Primary outcomes were knee pain (on a numerical rating scale of 0-10) and physical function (using the Western Ontario and McMaster Universities osteoarthritis index of 0-68) at 3 months after randomisation. Primary analysis was by modified intention-to-treat using all available data. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12619001240134. FINDINGS: Between Dec 10, 2019, and June 17, 2022, 394 adults were enrolled, with 204 allocated to in-person care and 190 to telerehabilitation. 15 primary care physiotherapists were recruited. At 3 months, 383 (97%) participants provided information for primary outcomes and both groups reported improved pain (mean change 2·98, SD 2·23 for in-person care and 3·14, 1·87 for telerehabilitation) and function (10·20, 11·63 and 10·75, 9·62, respectively). Telerehabilitation was non-inferior for pain (mean difference 0·16, 95% CI -0·26 to 0·57) and function (1·65, -0·23 to 3·53). The number of participants reporting adverse events was similar between groups (40 [21%] for in-person care and 35 [19%] for telerehabilitation) and none were serious. INTERPRETATION: Telerehabilitation with a physiotherapist is non-inferior to in-person care for chronic knee pain. FUNDING: National Health and Medical Research Council.

Evaluation framework for conversational agents with artificial intelligence in health interventions: a systematic scoping review.

OBJECTIVES: Conversational agents (CAs) with emerging artificial intelligence present new opportunities to assist in health interventions but are difficult to evaluate, deterring their applications in the real world. We aimed to synthesize existing evidence and knowledge and outline an evaluation framework for CA interventions. MATERIALS AND METHODS: We conducted a systematic scoping review to investigate designs and outcome measures used in the studies that evaluated CAs for health interventions. We then nested the results into an overarching digital health framework proposed by the World Health Organization (WHO). RESULTS: The review included 81 studies evaluating CAs in experimental (n = 59), observational (n = 15) trials, and other research designs (n = 7). Most studies (n = 72, 89%) were published in the past 5 years. The proposed CA-evaluation framework includes 4 evaluation stages: (1) feasibility/usability, (2) efficacy, (3) effectiveness, and (4) implementation, aligning with WHO's stepwise evaluation strategy. Across these stages, this article presents the essential evidence of different study designs (n = 8), sample sizes, and main evaluation categories (n = 7) with subcategories (n = 40). The main evaluation categories included (1) functionality, (2) safety and information quality, (3) user experience, (4) clinical and health outcomes, (5) costs and cost benefits, (6) usage, adherence, and uptake, and (7) user characteristics for implementation research. Furthermore, the framework highlighted the essential evaluation areas (potential primary outcomes) and gaps across the evaluation stages. DISCUSSION AND CONCLUSION: This review presents a new framework with practical design details to support the evaluation of CA interventions in healthcare research. PROTOCOL REGISTRATION: The Open Science Framework (https://osf.io/9hq2v) on March 22, 2021.

Performance of key physical tests for temporomandibular disorder via telehealth: Establishing validity and reliability.

BACKGROUND: During the COVID-19 pandemic, many individuals sought healthcare virtually. Physiotherapy is integral in managing temporomandibular disorders (TMDs); therefore, establishing how key physical tests can be appropriately adapted to telehealth is paramount. OBJECTIVES: To establish the validity and reliability of telehealth (specifically videoconferencing) assessments against in-person assessments on a battery of TMD physical tests. METHOD: A repeated-measures study design was undertaken. Thirty-six adult participants (19 healthy and 17 TMD) underwent concurrent temporomandibular joint (TMJ) physiological movement measurements via videoconferencing and in-person as per standard clinical practice. Inclusion criteria included the presence of central incisors and no significant comorbidities precluding a safe telehealth examination. Participants with TMD completed seven additional pain provocation physical tests. RESULTS: Agreement between telehealth and in-person physiological movement measures was excellent (ICC >0.90, 95% CI: 0.53 to >0.99). Inter- and intra-rater reliability for telehealth measures indicated excellent reliability (ICC >0.97, 95% CI: 0.91 to >0.99). Exact agreement between telehealth and in-person for provocation tests ranged between 58.8% and 94.1%. Fourteen of the twenty-six individual measures produced substantial to near perfect agreement (PABAK = 0.65-0.88), seven produced moderate agreement (PABAK = 0.53), while five produced poor to fair agreement (PABAK = 0.18-0.29). CONCLUSION: There is high level of agreement between telehealth and in-person measurements of TMJ physiological movement and pain provocation tests.

Co-development and evaluation of the Musculoskeletal Telehealth Toolkit for physiotherapists.

INTRODUCTION: In-person physiotherapy services are not readily available to all individuals with musculoskeletal conditions, especially those in rural regions or with time-intensive responsibilities. The COVID-19 pandemic highlighted that telehealth may facilitate access to, and continuity of care, yet many physiotherapists lack telehealth confidence and training. This project co-developed and evaluated a web-based professional development toolkit supporting physiotherapists to provide telehealth services for musculoskeletal conditions. METHODS: A mixed-methods exploratory sequential design applied modified experience-based co-design methods (physiotherapists [n = 13], clinic administrators [n = 2], and people with musculoskeletal conditions [n = 7]) to develop an evidence-informed toolkit. Semi-structured workshops were conducted, recorded, transcribed, and thematically analysed, refining the toolkit prototype. Subsequently, the toolkit was promoted via webinars and social media. The usability of the toolkit was examined with pre-post surveys examining changes in confidence, knowledge, and perceived telehealth competence (19 statements modelled from the theoretical domains framework) between toolkit users (>30 min) and non-users (0 min) using chi-squared tests for independence. Website analytics were summarised. RESULTS: Twenty-two participants engaged in co-design workshops. Feedback led to the inclusion of more patient-facing resources, increased assessment-related visual content, streamlined toolkit organisation, and simplified, downloadable infographics. Three hundred and twenty-nine physiotherapists from 21 countries completed the baseline survey, with 172 (52%) completing the 3-month survey. Toolkit users had greater improvement in knowledge, confidence, and competence than non-users in 42% of statements. Seventy-two percentage of toolkit users said it changed their practice, and 95% would recommend the toolkit to colleagues. During the evaluation period, the toolkit received 5486 total views. DISCUSSION: The co-designed web-based Musculoskeletal Telehealth Toolkit is a professional development resource that may increase physiotherapist's confidence, knowledge, and competence in telehealth.

Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study.

BACKGROUND: Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders. OBJECTIVE: This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders. METHODS: Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes. RESULTS: The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology. CONCLUSIONS: Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities.

Content and Quality of Mobile Apps for the Monitoring of Musculoskeletal or Neuropathic Pain in Australia: Systematic Evaluation.

Background: Mobile apps offer a potential mechanism for people with persistent pain to monitor pain levels conveniently within their own environment and for clinicians to remotely monitor their patients' pain. However, the quality of currently available apps and the usefulness of included features from a clinical perspective are not known. Objective: The aim of this study was to examine the content and quality of currently available smartphone apps designed for monitoring the intensity or presence of musculoskeletal or neuropathic pain. Methods: A systematic search was performed in the Australian Apple and Google Play stores. Apps were included if they were designed to monitor the intensity or presence of musculoskeletal or neuropathic pain and were available in the English language within the Australian app stores. Data pertaining to the intended use of the app and clinical population were extracted by using a custom-designed data extraction form, and app quality was assessed by using the 23-item Mobile App Rating Scale. Results: Of the 2190 apps screened, 49 met the inclusion criteria. Apps were primarily designed for adult users (36/49, 73%) with nonspecific musculoskeletal or neuropathic pain conditions, arthritis, and joint pain. All apps monitored pain intensity, with almost half (23/49, 47%) also specifying pain location. Overall, the mean quality scores from the Mobile App Rating Scale ranged from 1.5 to 4.4 (out of 5.0). Between 20% (10/49) and 22% (11/49) of apps involved clinicians, consumers, or both in their development, and 20% (10/49) had published literature related to the development or use of the app in clinical scenarios. Although 71% (35/49) had data sharing features, only 5 apps enabled client-clinician communication through the app. Conclusions: The overall quality of mobile apps that are currently available for monitoring pain intensity is acceptable. Presently, mobile apps for remote pain monitoring lack functionality for clinicians to view data between consults. Both users and clinicians should be aware of the limitations of these apps and make informed choices in using or recommending apps that best suit the clinical need.

Bringing researchers to the consumer table: The process and outcomes of a consumer roundtable on telehealth.

INTRODUCTION: Despite the significant expansion and rapid uptake of telehealth services as a COVID-19 response, the pandemic restricted opportunities to involve health consumers in telehealth research. Authentic consumer and community involvement in research begins with engagement in priority-setting. We report here on the process and outcomes of a consumer-led event intended to support involvement of consumers, from early in the research process. METHODS: In 2022, The University of Queensland's Consumer and Community Network hosted a Consumer Roundtable to 'bring researchers to the consumer table' and explore emerging issues and priorities for future research. The event used World Café Method, with three 20-min rounds of small group discussion centred on questions about telehealth experiences, followed by a facilitated harvest discussion about future research directions. Participants' notes from small group discussions were subjected to conventional inductive content analysis, and a visual record was created in real-time by a graphic artist. RESULTS: Twenty-eight consumers and 22 researchers took part. Content analysis identified three main foci from discussions: person-centred care, better access to better care, the (unrealised) potential of telehealth. Research questions prioritised by consumer vote focussed on marginalised groups and stigmatised conditions; differences between telehealth and face-to-face healthcare delivery; and the experience of conveying and receiving compassion via telehealth. DISCUSSION: The Consumer Roundtable created early engagement between health consumer representatives and telehealth researchers, which has yielded ongoing partnerships. World Café method proved particularly useful for seeding relationships between researchers and consumers. However, there was limited opportunity to generate consensus about research priorities.

Technical issues occur but are infrequent and have little impact on physiotherapist-delivered videoconferencing consultations for knee osteoarthritis: A descriptive study.

INTRODUCTION: Clinicians often report technical issues as a barrier to adopting videoconferencing service models. This descriptive study nested within a randomised controlled trial investigated the frequency, nature and impact of technical issues during video consultations. METHODS: Physiotherapists (n = 15) underwent training to deliver knee osteoarthritis care focussed on education, strengthening and physical activity. In the randomised controlled trial, participants received five physiotherapy consultations either in-person or via videoconferencing (via Zoom) over 3-months; consultations were recorded and physiotherapists documented technical difficulties. In this study, available notes were audited (n = 169 initial and n = 147 final consultations) and nature and frequency of technical issues coded. Based on whether the clinician reported technical difficulties, three subgroups were created for analysis 1) in-person, 2) videoconferencing without technical issues, 3) videoconferencing with technical issues. Forty participants were randomly selected for each subgroup (n = 120). Duration of consultation components (set-up and introduction, assessment, exercise, physical activity, education and wrap-up), total consultation duration and duration of technical issues were compared across subgroups using one-way multivariate analyses of variance with mean differences (MD) and 95% confidence intervals (CIs). RESULTS: Technical issues were documented in 37% (initial) and 19% (final) of video consultations. Problems with audio/video were most frequent, occurring in 36-21% (initial) and 18-24% (final) consultations. Audio/video problems were predominantly experienced during set-up, but did not significantly increase videoconferencing consultation duration compared to in-person consultation duration (MD (95% CI) 0.72 (-3.57 to 5.01) minutes). DISCUSSION: While technical issues with videoconferencing consultations frequently occur, they are typically minor, transient and resolved quickly.

Facilitators and barriers to implementing electronic patient-reported outcome and experience measures in a health care setting: a systematic review.

OBJECTIVE: This systematic literature review aimed to identify factors that influence the implementation of electronic patient-reported outcome measures (ePROMs) and patient-reported experience measures (ePREMs) in healthcare settings. INTRODUCTION: Improvements in health care through increased patient engagement have gained traction in recent years. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are tools used to improve the quality of care from the patient perspective. The influence of implementing PROMs and PREMs using electronic information systems (ePROMs and ePREMs) is not well understood. INCLUSION CRITERIA: Studies with information related to the implementation of ePROMs and/or ePREMs with a focus on health-related services, irrespective of provider type, were included. METHODS: A literature search of peer-reviewed databases was conducted on the 24th of January 2022 for articles about barriers and facilitators of the implementation of ePROMs/ePREMs in healthcare settings. Two reviewers independently extracted relevant findings from the included studies and performed a descriptive code-based synthesis before collaboratively creating a final consensus set of code categories, which were then mapped to the consolidated framework of implementation research (CFIR). Study quality was appraised using a mixed-methods appraisal tool (MMAT). RESULTS: 24 studies were eligible for inclusion in the screening of 626 nonduplicate studies. Quality assessment using the MMAT revealed that 20/24 studies met at least 60% of the MMAT criteria. Ninety-six code categories were identified and mapped to the constructs across all CFIR domains. CONCLUSION: To guide the effective implementation of ePROMs/ePREMs in healthcare settings, factors shown to influence their implementation have been summarised as an implementation checklist for adoption and use by clinicians, organisations, and policymakers.

Absence of Improvement With Exercise in Some Patients With Knee Osteoarthritis: A Qualitative Study of Responders and Nonresponders.

OBJECTIVE: To compare the perceptions of patients about why they did, or did not, respond to a physical therapist-supported exercise and physical activity program. METHODS: This was a qualitative study within a randomized controlled trial. Twenty-six participants (of 40 invited) with knee osteoarthritis sampled according to response (n = 12 responders, and 14 nonresponders based on changes in both pain and physical function at 3 and 9 months after baseline) to an exercise and physical activity intervention. Semistructured individual interviews were conducted. Inductive thematic analysis was undertaken within each subgroup using grounded theory principles. A deductive approach compared themes and subthemes across subgroups. Findings were triangulated with quantitative data. RESULTS: (Sub)themes common to responders and nonresponders included the intervention components that facilitated engagement, personal attitudes and expectations, beliefs about osteoarthritis and exercise role, importance of adherence, and perceived strength gains with exercise. In contrast to responders who felt empowered to self-manage, nonresponders accepted responsibility for lack of improvement in pain and function with exercise, acknowledging that their adherence to the intervention was suboptimal (confirmed by quantitative adherence data). Nonresponders believed that their excess body weight (supported by quantitative data) contributed to their outcomes, encountered exercise barriers (comorbidities, stressors, and life events), and perceived that the trial measurement tools did not adequately capture their response to exercise. CONCLUSION: Responders and nonresponders shared some similar perceptions of exercise. However, along with perceived limitations in trial outcome measurements, nonresponders encountered challenges with excess weight, comorbidities, stressors, and life events that led to suboptimal adherence and collectively were perceived to contribute to nonresponse.

Psychological therapy using virtual reality for treatment of driving phobia: a systematic review.

PURPOSE: Driving phobia is prevalent in injured individuals following motor vehicle crashes (MVCs). The evidence for virtual reality (VR) based psychological treatments for driving phobia is unknown. This systematic review synthesized the available evidence on the effectiveness, feasibility, and user experience of psychological treatments for driving phobia using VR. METHODS: Three databases (PsycINFO, SCOPUS, and PubMed) were searched. Eligibility criteria included adults with clinical or sub-clinical levels of driving phobia manifesting as part of an anxiety disorder or post-traumatic stress disorder (PTSD). Primary outcomes were driving-related anxiety/fear or avoidance, PTSD symptoms and driving frequency/intensity, as well as treatment feasibility including recruitment, treatment completion and retention rates, user experience and immersion/presence in the VR program. Secondary outcomes were other health outcomes (e.g., depression) and VR technological features. RESULTS: The 14 included studies were of low methodological quality. Clinical and methodological heterogeneity prevented quantitative pooling of data. The evidence provided in this review is limited by trials with small sample sizes, and lack of diagnostic clarity, controlled designs, and long-term assessment. The evidence did suggest that VR-based psychological interventions could be feasible and acceptable in this population. CONCLUSIONS: For VR-based psychological interventions to be recommended for driving phobia, more high-quality trials are needed. Implications for rehabilitationVirtual reality (VR) based psychological treatments may be feasible and acceptable to patients with driving phobia.There is potential to increase accessibility to psychological therapies in patients with driving phobia following motor vehicle crashes through the use of digital psychiatry such as VR.

Physiotherapy students' empathy towards Australians living in rural settings: A pre-test post-test evaluation of a stand-alone rural simulation activity.

OBJECTIVE: To investigate how a rural simulation activity influenced physiotherapy students' rural empathy, and to explore students' perception of the activity. SETTING: A metropolitan university in Queensland, Australia. PARTICIPANTS: Second year undergraduate physiotherapy students. DESIGN: A single cohort pre-test post-test evaluation was undertaken to evaluate a rural simulation activity. Participants received the rural simulation activity, featuring an immersive video and telehealth simulation with a standardised patient portrayed by an actor. Participants undertook a structured debrief and guided reflection following the simulation. Outcome measures included the Rural Comprehensive State Empathy Scale (R-CSES) and the Satisfaction with Simulation Experience Scale. Group interviews were undertaken regarding participant perceptions of the activity. Wilcoxon Rank-Sum tests were used to analyse survey data, and group interview data were subject to thematic analyses. RESULTS: A total of 102 students undertook the activity, with an outcome measure response rate of 92.2% (94/102). Intra-personal rural empathy increased following the activity as demonstrated by the overall R-CSES score [pre-test: 101.5 (90-110.75) vs post-test 107 (100-120); p = <0.001; r = 0.39]. There was high satisfaction with the experience [mean SSES score = 18/21]. Two themes were generated from the group interview data: (1) effect on perceptions of rural practice and (2) feedback regarding the simulation. CONCLUSION: A rural simulation activity using an immersive video, standardised patient, and a structured debrief increased physiotherapy students' empathy towards Australians living in rural settings. Students were satisfied with the activity and felt that it improved their understanding of the challenges of rural healthcare.

Telehealth education and training in entry-to-practice physiotherapy programs in Australian universities: A qualitative study with university educators.

BACKGROUND: To explore attitudes to telehealth education and experiences incorporating telehealth education into entry-to-practice physiotherapy programs in Australia, from the perspective of university educators. METHODS: Qualitative design based on a constructivist paradigm and a phenomenological approach. Sixteen university educators (who had a responsibility for telehealth curriculum or oversight of the broader curriculum in an entry-to-practice physiotherapy programme at an Australian university) were recruited. Individual semi-structured interviews were conducted via Zoom. Interviews were recorded, transcribed verbatim, and analysed thematically using an inductive approach. RESULTS: Three themes (with associated subthemes) were identified: (i) telehealth education has a role in contemporary physiotherapy practice (COVID-19 pandemic was a driver for telehealth education, acknowledgement that telehealth is here to stay and identified areas of focus for telehealth education and training); (ii) telehealth education and training vary substantially (content delivered and assessment of telehealth competency is ad hoc and student exposure to telehealth on clinical placements is inconsistent); (iii) challenges in telehealth education (finding space and time in the curriculum, as well as insufficient knowledge and expertise of staff, are challenges for implementation of telehealth education, however, course and subject development and/or reviews provide opportunities for implementing telehealth education and training). CONCLUSION: Current content and volume of telehealth education and training in entry-to-practice physiotherapy programs across Australia varies substantially. Although educators believe telehealth is an important component of contemporary physiotherapy practice, many barriers exist for including telehealth training into the curriculum.

A comparison of prospective observations and chart audits for measuring quality of care of musculoskeletal injuries in the emergency department.

BACKGROUND: Accurate and efficient data collection is crucial for effective evaluation of quality of care. The objective of this study is to compare two methods of data collection used to score quality indicators for musculoskeletal injury management in Emergency departments: prospective observation, and chart audit. METHODS: An analysis was undertaken of data collected from 633 patients who presented with a musculoskeletal injury to eight emergency departments in Queensland, Australia in 2016-17. Twenty-two quality indicators were scored using both prospective observation and chart audit data for each occasion of service. Quality indicators were included if they were originally published with both collection methods. Analyses were performed to compare firstly, the quality indicator denominators, and secondly, the quality indicator trigger rates, scored using each collection method. Chi Square statistics were used to identify significant differences. RESULTS: Prospectively collected data scored quality indicator denominators significantly (p value<0.05) more often than chart audit data for five (22.7 %) of the 22 quality indicators. The remaining 17 quality indicators (77.3 %) showed no statistical differences. When comparing quality indicator trigger rates, 16 (72.7 %) had significantly different results between methods with 12 (54.5 %) scoring higher using prospective data and four (18.2 %) with chart audit data. The remaining six quality indicators (27.3 %) in this comparison showed no significant difference between chart and prospective data. CONCLUSION: Quality indicators including aspects of care associated with patient safety, and those relying on clinician written orders or forms were adequately scored using either prospective observation or chart audit data. Whereas quality indicators relying on time-sensitive information, elements of a social history, general physical exams and patient education and advice scored higher using prospective observation data collection.