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.

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.

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.

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.

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.

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.

Evaluation of a teleaudiology service in regional Australia

OBJECTIVE

Evaluate accessibility, effectiveness, acceptability and efficiency of a student- assisted teleaudiology model of care in a regional hospital in Queensland, Australia.

DESIGN

Prospective mixed method service evaluation study.

STUDY SAMPLE

Demographic, service and satisfaction data were collected from 233 patients (children aged ≥5 and adults) who received teleaudiology assessment. Satisfaction data was collected from 27 hospital clinic staff (medical, nursing and clinic assistants) and 28 university audiology clinical educator participants. Experience and satisfaction data were collected from 16 teleaudiology clinic university students. Quantitative data was analysed using SPSS software. Qualitative data were analysed using inductive content analysis.

RESULTS

Following introduction of the teleaudiology service in 2017 and evaluation during the first 6 months, 95% of patients were able to access audiology assessments on the same day as their Ear, Nose and Throat appointments. New referrals to the service were seen within a month. The audiology assessment battery was completed 95% of the time within an average of 33 minutes by the end of the study period. Patients, hospital and university staff and students reported high satisfaction with their experiences of teleaudiology, including its convenience and efficiency.

CONCLUSIONS

A student-assisted teleaudiology model of care can deliver accessible, effective, and efficient services with high levels of satisfaction by participants.

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.

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.

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.

A shared accretion instability for black holes and neutron stars

Accretion disks around compact objects are expected to enter an unstable phase at high luminosity1. One instability may occur when the radiation pressure generated by accretion modifies the disk viscosity, resulting in the cyclic depletion and refilling of the inner disk on short timescales2. Such a scenario, however, has only been quantitatively verified for a single stellar-mass black hole3-5. Although there are hints of these cycles in a few isolated cases6-10, their apparent absence in the variable emission of most bright accreting neutron stars and black holes has been a continuing puzzle11. Here we report the presence of the same multiwavelength instability around an accreting neutron star. Moreover, we show that the variability across the electromagnetic spectrum-from radio to X-ray-of both black holes and neutron stars at high accretion rates can be explained consistently if the accretion disks are unstable, producing relativistic ejections during transitions that deplete or refill the inner disk. Such a new association allows us to identify the main physical components responsible for the fast multiwavelength variability of highly accreting compact objects.

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.

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.

Staff perspectives on the key elements to successful rapid uptake of telerehabilitation in medium-sized public hospital physiotherapy departments

BACKGROUND AND PURPOSE

During the COVID-19 pandemic, hospital physiotherapy departments transitioned to telerehabilitation to ensure continuity of care for patients. The purpose of this study is to determine the key elements to successful, rapid uptake of telerehabilitation in medium-sized public hospital physiotherapy departments in response to COVID-19.

METHODS

This study used a qualitative design. Physiotherapists who delivered telerehabilitation consultations during the COVID-19 restriction period in two Brisbane public hospital physiotherapy departments were eligible to participate in semi-structured interviews. Data were analysed thematically.

RESULTS

Twenty-five physiotherapists (22-60 years of age; 68% female) with 1-40 years of clinical experience provided insights into their perceptions of the rapid uptake of telerehabilitation in the provision of clinical care. Physiotherapists worked across musculoskeletal outpatient (72%), inpatient, community, paediatrics and pelvic health departments. Qualitative analyses in relation to the physiotherapist perceptions of the key elements of rapid transition to telerehabilitation, revealed four key themes underpinning success: (1) 'it requires a whole team approach', (2) 'technology issues will be encountered and can be overcome', (3) 'optimise the situation while understanding the differences' and (4) 'modifying your approach doesn't imply inferior quality of care'.

CONCLUSION

Rapid implementation of telerehabilitation in a hospital setting is possible, and is facilitated by organisational, administrative and management support, willingness of physiotherapists to adopt, shared learning experience, quality software and connection, availability of equipment and space and optimised systems and processes. Key factors facilitating successful telerehabilitation consultations include effective communication, demonstration, involving a third party to help, and clients who are well prepared and willing to engage.

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.

Integration intrapreneurship: implementing innovation in a public healthcare organization

AIM

As global events impact the way organizations operate and innovate in response to regional, workforce and consumer needs, the concept of intrapreneurism is attracting growing interest from policymakers and executives, particularly within the healthcare sector. The aim of this study was to capture the key learnings from the implementation of a telementoring pilot, to understand how intrapreneurship can embed innovation within an established organization to effect more integrated healthcare.

PURPOSE

A qualitative approach was used with a phenomenological lens to explore the key learnings of the Project ECHO^® (Extension for Community Healthcare Outcomes) pilot implementation to provide an understanding of what the project team's strategies and tactics were during the process of embedding a new business innovation. The implementation and piloting of Project ECHO^®, a telementoring model, in a large-scale public healthcare organization in Queensland, Australia, was investigated as an exemplar of integration intrapreneurship.

FINDINGS

Through an inductive approach, this qualitative study found the implementation of the Project ECHO^® pilot had specific dimensions and strategies/tactics which were exemplars of intrapreneurism. The organizational context and workforce characteristics described in this study presented new knowledge of how intrapreneurs implemented an innovation to address fragmentation of healthcare service delivery, professional isolation and instances of low-value care. This research contributes to a better understanding of the strategic and tactical approaches to implementing intrapreneurial innovations within a public healthcare organization, with learnings that can be adapted by intrapreneurs in other contexts.

Supervising Students During a Global Pandemic: Clinical Educators’ Perceptions of a Student-Led Telerehabilitation Service During COVID-19

Scope: In March 2020, COVID-19 restrictions prompted services delivered by student-led clinics in the university sector to transition to telehealth. This provided a unique opportunity to explore the challenges and opportunities faced by clinical educators when supervising students to deliver telehealth. Methodology: Semi-structured interviews were conducted with allied health clinical educators who supervised students on clinical placement who were required to provide services via telehealth. Clinical educators across the disciplines of audiology, occupational therapy, physiotherapy, and speech pathology were asked to reflect on their experiences and perceptions of the rapid transition to a telehealth model for student clinical placements. A content analysis approach was used to analyse qualitative data. Conclusions: From the perspective of clinical educators, student-led telehealth services can effectively meet client needs while achieving student learning outcomes. This study highlights many opportunities for student learning via telehealth in the clinical education environment and the role of the clinical educator in the learning experience.

An international core capability framework for physiotherapists delivering telephone-based care

QUESTION

What are the core capabilities that physiotherapists need in order to deliver quality telephone-based care?

DESIGN

Three-round modified e-Delphi survey.

PARTICIPANTS

An international Delphi panel comprising experts in the field, including consumers, physiotherapy researchers, physiotherapy clinicians and representatives of physiotherapy organisations.

METHODS

A modified e-Delphi survey was conducted. A draft framework was adapted from a previously developed core capability framework for physiotherapists delivering care via videoconferencing. The panel considered the draft framework of 39 individual capabilities across six domains. Over three rounds, panellists rated their agreement (via Likert or 0-to-10 numerical rating scales) on whether each capability was essential (core) for physiotherapists to deliver telephone-based care. Capabilities achieving consensus, defined as 75% of the panel rating the item at least 7 out of 10 in Round 3, were retained.

RESULTS

Seventy-one panellists from 17 countries participated in Round 1, with retention of 89% in Round 2 and 82% in Round 3. The final framework comprised 44 capabilities across six domains: compliance (n = 7 capabilities); patient privacy and confidentiality (n = 4); patient safety (n = 7); telehealth delivery (n = 9); assessment and diagnosis (n = 7); and care planning and management (n = 10).

CONCLUSION

This framework outlines the core capabilities that physiotherapists need to provide telephone-based care. It can help inform content of physiotherapy curricula and professional development initiatives in telehealth delivery and provide guidance for physiotherapists providing care over the telephone.

46 Primary Care Practitioners Have A High Level of Satisfaction with The Current Breast Referral Pathway but The Majority Would Support A Change to Patient Self-Referral

Aim

Currently, patients must consult with a primary care practitioner (PCP) prior to being referred to secondary care breast services. A change to patient self-referral would arguably reduce primary care workload, improve access for patients, and allow breast units to allocate resources more appropriately; no data currently supports this. This study aims to explore PCP's views on breast referral, evaluate the community breast workload, and to investigate the impact of COVID-19 on referral rates.

Method

An electronic survey was designed on SurveyMonkey.com which aimed to collect both quantitative and qualitative data. The weblink to the survey was sent out via two electronic newsletters. Participants were asked: their role and gender, their level of confidence surrounding breast care, details surrounding their breast workload, how they felt COVID-19 had affected their referral rates, their level of satisfaction with the current pathway, and their opinions on a potential change to patient self-referral.

Results

79 responses were received. PCPs estimated that 7.0% (median) of their total consultations were regarding a breast-related issue and that COVID-19 had not had a significant impact on the rate of referral to breast units (P = 0.75). 84.8% of PCPs were satisfied with the current referral pathway. Whilst 74.5% felt a change to patient self-referral would benefit patients and primary care services, their free text comments highlighted some of their reservations.

Conclusions

PCPs have a high level of satisfaction with the current breast referral pathway, but the majority would be open to a change to patient self-referral to specialist breast units.

296 Case Report: Pacemaker Lead-Induced Fibrosis Resulting in Right Atrial and Tricuspid Stenosis Managed with An Open Surgical Approach

Pacemaker leads can result in localised inflammation and, over time, fibrosis. Rarely, this can significantly alter the anatomy of the heart and impair cardiac function. In this case, a fifty-year-old female had undergone pacemaker placement in her teens having experienced symptomatic bradycardia. Due to pacemaker pocket erosion, she had undergone a lead extraction where lead fragments had been left in-situ. Years after a new generator and leads were placed, she presented with symptoms of proximal venous congestion and superior vena cava (SVC) syndrome. A venogram demonstrated completely occluded brachiocephalic and innominate veins with significant adjacent venous collateralization. Computed tomography showed partial obstruction of the SVC and tricuspid stenosis. Initially, a decision was made not to intervene.

After developing abdominal distension, she was diagnosed with hepatic congestion and cirrhosis secondary to elevated right sided pressures and right atrial congestion due to tricuspid stenosis. It was concluded that the patient’s symptoms were the result of occluded proximal veins, SVC syndrome, and functional tricuspid stenosis, all of which were likely the result of fibrotic tissue secondary to pacemaker lead-induced inflammation. Due to the severity of her symptoms, the patient accepted the risks associated with surgical management. Intra-operatively, electrocautery was used to debride the fibrotic tissue inhibiting the leaflets of the tricuspid valve. This worked to great effect and additional valve repair/replacement was not necessary. Whilst the patient has been left with SVC syndrome, her tricuspid stenosis symptoms are greatly improved. To our knowledge, such a case has not been previously described.

Higher quality of care in emergency departments with physiotherapy service models

OBJECTIVE

To investigate the quality of care provided by EDs with physiotherapy services compared to those without, using established musculoskeletal process and outcome quality indicators (QIs).

METHODS

An analysis was undertaken of prospective observational and chart audit data collected from 628 patients who presented with a musculoskeletal injury in any of the eight participating EDs in Queensland in 2016-2017. The care provided was scored against 46 musculoskeletal QIs. Quality of care was first compared between EDs with physiotherapists to EDs with a limited physiotherapy service, and second between EDs with primary contact physiotherapists to EDs without. χ² and Fisher's exact tests were used to identify significant results.

RESULTS

In the first comparison, EDs with physiotherapists performed significantly higher on 15 QIs and EDs with only limited physiotherapy performed higher on two QIs. In the second comparison, EDs with primary contact physiotherapists performed significantly higher on 17 QIs when compared to EDs without and three QIs demonstrated significance in favour of EDs without primary contact physiotherapists. Performance differences occurred across both process and outcome QIs, including musculoskeletal assessment, diagnostics, pain assessment and management, fracture management, medication safety, mobility, patient information, referrals and follow-up, re-presentations and patient experience.

CONCLUSIONS

EDs with physiotherapists provide at least equivalent or higher quality of care for patients with musculoskeletal injuries than those EDs with limited access to physiotherapists. This may be because of their specialised training in musculoskeletal diagnosis and treatment, as well as the impact of teaching and mentoring for other ED clinicians.

New-graduate physiotherapists' training needs and readiness for telehealth

INTRODUCTION

The COVID-19 pandemic has necessitated a rapid transition to telehealth for the delivery of many Australian physiotherapy services. Little is known about new-graduate training needs in this method of service delivery.Aim.

To explore the readiness and specific training needs of new-graduate physiotherapists for telehealth service delivery in Australia.

METHODS

Qualitative individual telephone interviews of new-graduate physiotherapists (n = 16) and two videoconference focus groups of supervisors of new-graduate physiotherapists (n = 7) were undertaken. Thematic analysis was used.

RESULTS

Two global themes each with three organizing themes were generated. The two global themes were "support needs for novice practitioners" and "how to best prepare for telehealth."

DISCUSSION AND CONCLUSION

New-graduate physiotherapists and supervisors perceive that pre-professional exposure to, and practical skills training for, telehealth is essential. Elements such as undertaking physical assessments via telehealth, verbal communication, and effective clinical reasoning in telehealth assessment and treatment were highlighted as areas of need. Both stakeholder groups perceived that the rapid transition to telehealth challenged the self-efficacy of new-graduates as they did not have clinical experience to rely on. The preparation, and ongoing support of new-graduates to adopt telehealth in the workplace is considered critical given the shift in Australian healthcare to online platforms.

Physiotherapists and patients report positive experiences overall with telehealth during the COVID-19 pandemic: a mixed-methods study

QUESTION

What were the experiences of physiotherapists and patients who consulted via videoconference during the COVID-19 pandemic and how was it implemented?

DESIGN

Mixed methods study with cross-sectional national online surveys and qualitative analysis of free-text responses.

PARTICIPANTS

A total of 207 physiotherapists in private practice or community settings and 401 patients aged ≥ 18 years who consulted (individual and/or group) via videoconference from April to November 2020.

METHODS

Separate customised online surveys were developed for physiotherapists and patients. Data were collected regarding the implementation of videoconferencing (cost, software used) and experience with videoconferencing (perceived effectiveness, safety, ease of use and comfort communicating, each scored on a 4-point ordinal scale). Qualitative content analysis was performed of physiotherapists' free-text responses about perceived facilitators, barriers and safety issues.

RESULTS

Physiotherapists gave moderate-to-high ratings for the effectiveness of and their satisfaction with videoconferencing. Most intended to continue to offer individual consultations (81%) and group classes (60%) via videoconferencing beyond the pandemic. For individual consultations and group classes, respectively, most patients had moderately or extremely positive perceptions about ease of technology use (94%, 91%), comfort communicating (96%, 86%), satisfaction with management (92%, 93%), satisfaction with privacy/security (98%, 95%), safety (99% both) and effectiveness (83%, 89%). Compared with 68% for group classes, 47% of patients indicated they were moderately or extremely likely to choose videoconferencing for individual consultations in the future. Technology was predominant as both a facilitator and barrier. Falls risk was the main safety factor.

CONCLUSION

Patients and physiotherapists had overall positive experiences using videoconferencing for individual consultations and group classes. The results suggest that videoconferencing is a viable option for the delivery of physiotherapy care in the future.

48 Chyle Leak Following Pancreaticoduodenectomy: A Tertiary HPB Unit 14-year Experience and a Proposed Management Algorithm

Introduction

Chyle leak (CL) is an uncommon complication of pancreaticoduodenectomy (PD). Its incidence, risk factors, and effect on prognosis are not well described and optimum management remains debated. This study aims to calculate the incidence of CL, identify risk factors, consider effect on patient outcome, and propose a simple management algorithm.

Method

This is a retrospective review of all patients who developed CL following PD between January 2006 and April 2020. The following details were obtained from a prospectively maintained database: age, ASA grade, BMI, details of operation, tumour histology, length of stay, and mortality.

Results

A total of 560 patients underwent PD and 17 (3.04%) developed CL. These patients had significantly higher BMI (P &lt; 0.01) and significantly longer operation times (P &lt; 0.05). CL patients had a higher rate of portal vein (PV) tumour adherence, PV resection, and intra-operative blood transfusion although this was not statistically significant. Sixteen CL patients (94.1%) were managed successfully with a non-operative approach.

Conclusions

3.04% of patients who underwent PD developed CL. CL was associated with higher BMI and longer operation time. CL did not affect length of stay. The vast majority of CL cases can be managed successfully with a non-operative approach.

Evaluation of a Novel e-Learning Program for Physiotherapists to Manage Knee Osteoarthritis via Telehealth: Qualitative Study Nested in the PEAK (Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis) Randomized Controlled Trial

BACKGROUND

The delivery of physiotherapy via telehealth could provide more equitable access to services for patients. Videoconference-based telehealth has been shown to be an effective and acceptable mode of service delivery for exercise-based interventions for chronic knee pain; however, specific training in telehealth is required for physiotherapists to effectively and consistently deliver care using telehealth. The development and evaluation of training programs to upskill health care professionals in the management of osteoarthritis (OA) has also been identified as an important priority to improve OA care delivery.

OBJECTIVE

This study aims to explore physiotherapists' experiences with and perceptions of an e-learning program about best practice knee OA management (focused on a structured program of education, exercise, and physical activity) that includes telehealth delivery via videoconferencing.

METHODS

We conducted a qualitative study using individual semistructured telephone interviews, nested within the Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis randomized controlled trial, referred to as the PEAK trial. A total of 15 Australian physiotherapists from metropolitan and regional private practices were interviewed following the completion of an e-learning program. The PEAK trial e-learning program involved self-directed learning modules, a mock video consultation with a researcher (simulated patient), and 4 audited practice video consultations with pilot patients with chronic knee pain. Interviews were audio recorded and transcribed verbatim. Data were thematically analyzed.

RESULTS

A total of five themes (with associated subthemes) were identified: the experience of self-directed e-learning (physiotherapists were more familiar with in-person learning; however, they valued the comprehensive, self-paced web-based modules. Unwieldy technological features could be frustrating); practice makes perfect (physiotherapists benefited from the mock consultation with the researcher and practice sessions with pilot patients alongside individualized performance feedback, resulting in confidence and preparedness to implement new skills); the telehealth journey (although inexperienced with telehealth before training, physiotherapists were confident and able to deliver remote care following training; however, they still experienced some technological challenges); the whole package (the combination of self-directed learning modules, mock consultation, and practice consultations with pilot patients was felt to be an effective learning approach, and patient information booklets supported the training package); and impact on broader clinical practice (training consolidated and refined existing OA management skills and enabled a switch to telehealth when the COVID-19 pandemic affected in-person clinical care).

CONCLUSIONS

Findings provide evidence for the perceived effectiveness and acceptability of an e-learning program to train physiotherapists (in the context of a clinical trial) on best practice knee OA management, including telehealth delivery via videoconferencing. The implementation of e-learning programs to upskill physiotherapists in telehealth appears to be warranted, given the increasing adoption of telehealth service models for the delivery of clinical care.

"It's really exciting to think where it could go": a mixed-method investigation of clinician acceptance, barriers and enablers of virtual reality technology in communication rehabilitation

PURPOSE

Acquired communication disorders can result in significant barriers to everyday life activities, and commonly require long-term rehabilitation. This research aimed to investigate usability, acceptance, barriers and enablers to the use of immersive virtual reality (VR) technology for communication rehabilitation from the perspective of speech-language pathologists (SLPs).

METHODS

Semi-structured interviews and surveys (system usability and motion sickness) were carried out with 15 SLPs following their participation in communication activities typical of daily life, experienced within an immersive VR kitchen environment.

RESULTS

The system usability scores were average. In addition, motion sickness symptoms were low after interaction with the VR system. The main findings from semi-structured interviews are discussed across five main themes: (i) attitude towards the use of VR in communication rehabilitation (ii) perceived usefulness of VR (iii) perceived ease of use of VR (iv) intention to use VR, and (v) clinical adoption barriers and enablers.

CONCLUSIONS

Overall, participants were positive about VR and its potential applications to communication rehabilitation. This study provides a foundation to inform the design, development, and implementation of a VR system to be used in the rehabilitation of individuals with acquired communication disorders.IMPLICATIONS FOR REHABILITATIONVirtual Reality applications could simulate social communication situations within the clinic.VR could be used as a rehabilitation tool for communication assessment and/or outcome measure.VR requires customisation to the specific communication rehabilitation needs of the client.Participants identified barriers and enablers to adoption of VR by speech-language pathologists.

A survey analysis of farmer practices and perceptions of zero-grazing on Irish dairy farms

Zero-grazing (ZG; the mechanical harvesting and feeding of fresh grass) is increasingly used in grass-based milk production systems alongside conventional grazing. It allows farmers to supply fresh grass from land parcels that are outside of the main grazing block during seasonal shortages and periods when climatic conditions limit animal grazing opportunities. The objective of this study was to establish an understanding of current ZG practices on Irish dairy farms, to capture farmer perceptions on the implementation of this management practice, and to identify farmer knowledge requirements on ZG. An online survey was distributed and completed by 130 dairy farmers who use or have used ZG. Zero-grazing was used alongside conventional grazing by 92% of respondents. These farms were particularly fragmented, with between 1 and 14 separate land blocks. Respondents felt ZG helped them overcome fragmentation, increase grass use, and extend grass feeding in spring and autumn. However, extra cost and time input associated with ZG were recognized as key challenges. The majority of respondents rated current technical information available on ZG in the Republic of Ireland as "poor" or "very poor," and knowledge deficits were identified in the areas of cost analysis, grass management and productivity, cow productivity, cow health and nutrition, and soil fertility.

Communication and swallowing changes, everyday impacts and access to speech-language pathology services for people with Parkinson's disease: An Australian survey

PURPOSE

To investigate people with Parkinson's disease (PwPD): 1) self-reported communication and swallowing difficulties due to Parkinson's disease (PD), 2) participation and psychosocial impacts of these difficulties and 3) experience with and access to speech-language pathology (SLP) services.

METHOD

A cross-sectional mix-methods survey was conducted using nonprobability, purposive sampling for recruitment. An inclusion criterion was that participants needed to have self-reported communication and/or swallowing changes due to PD. Descriptive statistics and thematic analysis were utilised.

RESULT

All of the 78 PwPD who participated reported changes to their communication (97%) and/or swallowing (93%). A diverse range of participation restrictions was found in social, recreational, vocational and everyday living activities. Adverse emotional impacts including frustration, loss of self-confidence, depression and isolation were reported due to these changes. Only 59% of our sample had accessed SLP services. The most common reason for PwPD not accessing services was that neither their general practitioner nor neurologist had referred them to SLP. The majority of PwPD wanted to access SLP at some point in the future. Wide variability in the SLP services provided was evident. Most of the PwPD who had received SLP support wanted further ongoing management.

CONCLUSION

This study provided insight into the everyday impacts of communication and swallowing changes experienced by PwPD, and the gap between service supply and demand.

Perspectives of older adults with chronic disease on the use of wearable technology and video games for physical activity

BACKGROUND

There is increasing interest in technology to deliver physical rehabilitation and allow clinicians to monitor progress. Examples include wearable activity trackers and active video games (AVGs), where physical activity is required to play the game. However, few studies have explored what may influence the effectiveness of these as technology-based physical activity interventions in older adults with chronic diseases.

OBJECTIVE

This study aimed to explore: 1) perceptions about wearable physical activity trackers; 2) perceptions about using technology to share physical activity information with clinicians; 3) barriers and motivators to playing games, including AVGs for rehabilitation.

METHODS

Qualitative study based on semi-structured interviews with older adults (n = 19) with chronic obstructive pulmonary disease (COPD).

RESULTS

Wearable activity trackers were perceived as useful to quantify activity, facilitate goal-setting, visualize long-term improvements and provide reminders. Participants generally wished to share data with their clinicians to gain greater accountability, receive useful feedback and improve the quality of clinical care. Participants were motivated to play games (including AVGs) by seeking fun, social interaction and health benefits. Some felt that AVGs were of no benefit or were too difficult. Competition was both a motivator and a barrier.

CONCLUSIONS

The findings of the present study seek to inform the design of technology to encourage physical activity in older adults with chronic diseases.

Mobile Apps for Speech-Language Therapy in Adults With Communication Disorders: Review of Content and Quality

Background

Worldwide, more than 75% of people with acquired brain injury (ABI) experience communication disorders. Communication disorders are impairments in the ability to communicate effectively, that is, sending, receiving, processing, and comprehending verbal and nonverbal concepts and symbols. Such disorders may have enduring impacts on employment, social participation, and quality of life. Technology-enabled interventions such as mobile apps have the potential to increase the reach of speech-language therapy to treat communication disorders. However, ensuring that apps are evidence-based and of high quality is critical for facilitating safe and effective treatment for adults with communication disorders.

Objective

The aim of this review is to identify mobile apps that are currently widely available to adults with communication disorders for speech-language therapy and to assess their content and quality using the validated Mobile App Rating Scale (MARS).

Methods

Google Play Store, Apple App Store, and webpages were searched to identify mobile apps for speech-language therapy. Apps were included in the review if they were designed for the treatment of adult communication disorders after ABI, were in English, and were either free or for purchase. Certified speech-language pathologists used the MARS to assess the quality of the apps.

Results

From a total of 2680 apps identified from Google Play Store, Apple App Store, and web searches, 2.61% (70/2680) apps met the eligibility criteria for inclusion. Overall, 61% (43/70) were available for download on the iPhone Operating System (iOS) platform, 20% (14/70) on the Android platform, and 19% (13/70) on both iOS and Android platforms. A content analysis of the apps revealed 43 apps for language, 17 apps for speech, 8 apps for cognitive communication, 6 apps for voice, and 5 apps for oromotor function or numeracy. The overall MARS mean score was 3.7 out of 5, SD 0.6, ranging between 2.1 and 4.5, with functionality being the highest-scored subscale (4.3, SD 0.6), followed by aesthetics (3.8, SD 0.8), information (3.4, SD 0.6), and engagement (3.3, SD 0.6). The top 5 apps were Naming Therapy (4.6/5), Speech Flipbook Standard (4.6/5), Number Therapy (4.5/5), Answering Therapy, and Constant Therapy (4.4/5).

Conclusions

To our knowledge, this is the first study to systematically identify and evaluate a broad range of mobile apps for speech-language therapy for adults with communication disorders after sustaining ABI. We found a lack of interactive and engaging elements in the apps, a critical factor in sustaining self-managed speech-language therapy. More evidence-based apps with a focus on human factors, user experience, and a patient-led design approach are required to enhance effectiveness and long-term use.

Technology versus tradition: a non-inferiority trial comparing video to face-to-face consultations with a physiotherapist for people with knee osteoarthritis. Protocol for the PEAK randomised controlled trial

BACKGROUND

Knee osteoarthritis (OA) is a global problem that causes significant pain and physical dysfunction, substantially impacting on quality of life and imposing enormous cost to the healthcare system. Exercise is pivotal to OA management, yet uptake by people with knee OA is inadequate. Limited access to appropriately skilled health professionals, such as physiotherapists, for prescription of an exercise program and support with exercise is a major barrier to optimal care. Internet-enabled video consultations permit widespread reach. However, services offering video consultations with physiotherapists for musculoskeletal conditions are scant in Australia where there is typically no Government or private health insurer funding for such services. The paucity of robust evidence demonstrating video consultations with physiotherapists are clinically effective, safe and cost-effective for knee OA is hampering implementation of, and willingness of healthcare policymakers to pay for, these services.

METHODS

This is an assessor- and participant-blinded, two-arm, pragmatic, comparative effectiveness non-inferiority randomised controlled trial (RCT) conducted in Australia. We are recruiting 394 people from the community with chronic knee pain consistent with a clinical diagnosis of knee OA. Participants are randomly allocated to receive physiotherapy care via i) video-conferencing or; ii) face-to-face consultations. Participants are provided five consultations (30-45 min each) with a physiotherapist over 3 months for prescription of a home-based strengthening exercise program (to be conducted independently at home) and physical activity plan, as well as OA education. Participants in both groups are provided with educational booklets and simple exercise equipment via post. The co-primary outcomes are change in self-reported i) knee pain on walking; and ii) physical function, with a primary end-point of 3 months and a secondary end-point of 9 months. Secondary outcomes include changes in other clinical outcomes (health-related quality of life; therapeutic relationship; global ratings of change; satisfaction with care; self-efficacy; physical activity levels), time and financial costs of attending consultations, healthcare usage and convenience. Non-inferiority will be assessed using the per-protocol dataset.

DISCUSSION

Findings will determine if video consultations with physiotherapists are non-inferior to traditional face-to-face consultations for management of people with knee OA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12619001240134. http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377672&isReview=true.

Speech-language pathologists' perceptions of the use of telepractice in the delivery of services to people with Parkinson's disease: A national pilot survey

Purpose: To explore the perceptions, use and interest to use telepractice by speech-language pathologists (SLPs) to deliver services to people with Parkinson's disease (PwPD).Method: A cross-sectional, mixed-methods online survey was conducted. Recruitment of SLPs with an active caseload of PwPD was conducted through non-probability, purposive sampling. Data were analysed using frequency distribution and thematic analysis.Result: A total of 63 SLPs responded. The majority (82.5%) were interested in telepractice, but only 23.1% provided services to PwPD online. Monitoring of motor speech function, and therapy were the primary services delivered online. Of those who did not currently offer online services to PwPD, 77.5% expressed interest to use telepractice. The development of telepractice guidelines and a comprehensive list of available software were the resources most requested to assist clinicians in offering such services. Most perceived telepractice as an appropriate delivery method for speech-language pathology services. However, views regarding the preference for face-to-face delivery were divided.Conclusion: SLPs view telepractice as a viable service delivery model for PwPD, but uptake of the model is variable. Several key barriers and resource limitations must be addressed to facilitate the implementation and sustainability of telepractice in clinical services.

SAT0356 THE ROLE OF IL-36 AS A POTENTIAL NOVEL THERAPEUTIC TARGET IN SPONDYLARTHROPATHY ASSOCIATED PATHOLOGY DUE TO ITS UPSTREAM INDUCTION OF IL-23/IL-17 PATHWAY CYTOKINES AND STROMAL ACTIVATION IN AN IN VITRO ENTHESITIS MODEL

Background:

Enthesitis, defined as inflammation of anchorage points of tendons, ligaments and joint capsules to bones, is now understood to be the cardinal pathogenic lesion in spondyloarhtopathies (SpA). Evidence from genetic studies, animal models, and therapeutic studies firmly implicates the IL-23/IL-17 axis in the pathogenesis of SpA. We have recently confirmed the presence of IL-23 myeloid cells and IL-17 producing T cells populations in the human enthesis (McGonagle, ARD 2019). The upstream drivers of these key cytokines in the enthesis is, however, not defined. Emerging evidence suggests that IL-36 may be critical in regulating the IL-23/IL-17 axis in various organs. Also IL-38 SNPs have been associated with SpA which is of interest given that IL-38 is an IL-36 antagonist. Further, IL-36α is upregulated in the joints of psoriatic arthritis patients and deficiency of the IL-36 receptor antagonist (DITRA) results in generalized pustular psoriasis with comorbid arthritis in at least third of patients. Thus, we hypothesised that IL-36 could be an upstream regulator of the IL23/17 axis at the enthesis.

Objectives:

To confirm the induction of IL-36 at the human enthesis and to test the effect of IL-36 on resident innate and adaptive immune cell populations and enthesis stromal cells.

Methods:

Entheseal spinous processes from patients undergoing elective orthopaedic surgeries was obtained and mechanically digested. Peri-entheseal bone (PEB), and entheseal soft tissue (EST) digests were stimulated with fungal and bacterial adjuvants and IL-36 measured by ELISA. Disease relevant compounds such as methotrexate and PDE4i were assessed for their ability to attenuate IL-36 secretion. IHC was used to confirm the presence of IL-36R+ cells in the enthesis. Digested PEB was stimulated with IL-36, and IL-6, IL-8, IL-23, and TNF-alpha were analysed by ELISA and Flow Cytometry. As the IL-36 cytokines require protease mediated post translational processing for full activation, these were measured in enthesis digests. Entheseal fibroblasts were isolated and stimulated with IL-36 and ICAM-1 measured by Flow Cytometry and genes by qPCR.

Results:

TLR ligands induced the production of IL-36 at the enthesis. Further cell sorting, revealed CD11+ myeloid cells were the predominant entheseal producer of IL-36. Induced IL-36 could be significantly attenuated by PDE4i but not by methotrexate. IHC confirmed the presence of IL-36R+ in the enthesis. Stimulation of enthesis digest with IL-36 significantly upregulated the production of IL-6, IL-8, TNF-a, and IL-23. Stimulation of enthesis fibroblasts with IL-36 upregulated surface ICAM-1 and secretion of IL-6, CCL2 and CCL20. Enthesis digests showed high basal expression of IL-36 activating protease including cathepsin S and G.

Conclusion:

IL-36 is inducible from enthesis myeloid cells and IL-36R+ cells are present at the enthesis. Enthesis stimulation with IL-36 results in the upregulation of several disease relevant mediators such as TNF, IL-23 and CCL20 in both immune and stromal lineage cells. This is the first demonstration of IL-36 production in human enthesis. Given its pleiotropic effect and relation to IL-23/IL-17 axis, IL-36 is a potential novel therapeutic target in SpA.

Figure 1.

Expression and role of IL-36 at the enthesis. (A). IL-36 is induced by stimulation with lipopolysaccharide (LPS) and Mannan. (B) IL-36 is predominantly produced by CD11c+ cells. (C) IL-36 stimulation of PEB resulted in increased TNF-alpha production by CD14+ cells, and increased production of IL-23 (D) IL-36 stimulation of stromal cells increased ICAM-1 expression, and CCL2, CCL20, IL-6 and IL8 secretion

Figure 2.

Gene expression by qPCR following stromal cell stimulation by IL-36

Disclosure of Interests:

Kassem Sharif: None declared, Charlie Bridgewood: None declared, Tobias Russell Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Hannah Rowe Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Qaio Zhou: None declared, Abhay S Rao: None declared, Almas Khan: None declared, Robert Dunsmuir: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC

THU0028 AN EXPLANTION FOR HOW VIRAL INFECTION MAY TRIGGER SPONDYLOARTHROPATHY BASED ON TLR9 DRIVEN TNF RESPONSES FROM ENTHESEAL DERIVED PLASMACYTOID DENDRITIC CELLS

Background:

It is well known that viral infections may trigger psoriatic arthritis (PsA), a disease that typically has extensive pre-clinical entheseal abnormalites. Skin resident plasmacytoid dendritic cells (pDCs) produce IFNα that contribute to T cell expansion and the development of experimental psoriasis [1, 2]. IFN pathway SNPs have been reported in both PsA and psoriasis and we previously reported the presence of pDCs at the human enthesis [3].

Objectives:

To investigate whether the TLR9 agonist ODN that replicates viral infection activate a wide array of of entheseal derived pDCs molecular cascades including the TNF pathway that might provide a link between viral infection and PsA.

Methods:

pDCs were sorted from enthesis and blood and stimulated with ODN as previously described (n=16) [3, 4]. IFNα protein pre and post stimulation were detected by ELISA. Intracellular flow cytometry (IFC) of entheseal pDCs was used to detect TNF protein. RNA was extracted post-stimulation. The mRNA were hybridised and tagged by probes then measured on the nCounter platform. Data was analysed using nSolver 4.0. Log2 |fold change| >1 and P-value <0.05 were considered statistically significant. The gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) of differentially expressed genes (DEGs) were analyzed using DAVID. Protein-protein interaction (PPI) network was drawn by STRING.

Results:

Stimulated entheseal pDCs showed a strong DEGs pattern pointing towards increased TNF expression. There were 11 genes significantly upregulated including TNF. RIPK3 is involved in TNF signalling pathway. TNF, RIPK3 and ZBP1 are involved in necroptosis. TNF and ITGB2 are involved in IL-4 and IL-13 signaling pathway. TNF, HLA-DOA, ITGB2/TLR7 are involved in virus infection. Together it highlights extremely activated TNF pathway genes.

IFN protein was induced in sorted entheseal pDCs following stimulation (n=8). TNF protein was detected by IFC on stimulated entheseal pDCs (CD45+HLA-DR+CD123+CD303+ CD11c-) (n=3). We also compared entheseal and matched peripheral blood pDCs (n=8) following stimulation where no major differences in the TNF pathway were present between groups.

The KEGG analysis was mapped in Figure 1. GO analysis showed the most significant change in biological processes was enriched in the positive regulation of DNA binding transcription factor activity. The change in molecular function was mainly enriched in p53 binding.

Conclusion:

Entheseal pDCs, upon viral molecule stimulation, show several markers of activation. However, TNF pathway genes were highly activiated which provides a novel mechanistic link between viral infection and PsA as reported in epidemiological studies.

References:

[1]Nestle, F.O., et al.,Plasmacytoid predendritic cells initiate psoriasis through interferon-alpha production.J Exp Med, 2005.202(1): p. 135-43.

[2]Christophers, E., et al.,The risk of psoriatic arthritis remains constant following initial diagnosis of psoriasis among patients seen in European dermatology clinics.J Eur Acad Dermatol Venereol, 2010.24(5): p. 548-54.

[3]Zhou, Q.,PLASMACYTOID DENDRITIC CELLS IN THE ENTHESIS: PHENOTYPING AND FUNCTION INVESTIGATION.Annals of the Rheumatic Diseases, 2019.78.

[4]Bridgewood, C., et al.,Identification of myeloid cells in the human enthesis as the main source of local IL-23 production.Ann Rheum Dis, 2019.78(7): p. 929-933.

Disclosure of Interests:

Qiao Zhou: None declared, Jayakumar Vadakekolathu: None declared, Kassem Sharif: None declared, Tobias Russell Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Hannah Rowe Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Peter Millner: None declared, Peter Loughenbury: None declared, Abhay S Rao: None declared, Robert Dunsmuir: None declared, Charlie Bridgewood: None declared, Yasser El-Sherbiny: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC

SAT0358 A ROLE FOR IL-4 AND IL-13 IN MODULATING THE IL-23/IL-17 AXIS IN ENTHESITIS

Background:

IL-4 and IL-13 are related Th2 cytokines, with documented roles in allergic inflammation such as atopic dermatitis (AD). Psoriatic Arthritis (PsA) is typically thought to be a result of Th1/Th17 driven response, and blockage of this pathway (IL-23, IL-17 and TNF) has proven successful. Despite this, there is a strong genetic risk association for IL-13 and PsA(1), however, the precise role of IL-13 in PsA is presently unknown. The enthesis is the region where tendons or ligaments attach to bone, and inflammation of this site (enthesitis) is thought to be the cardinal lesion of PsA, whereas as Rheumatoid Arthritis inflammation is more synovial centric. Dupilumab is a monoclonal antibody that works by blocking the common receptor chain (IL-4α) shared by both IL-13 and IL-4. Recent studies have reported that AD patients receiving dupilumab have developed clinical enthesitis(2).

Objectives:

To investigate whether IL-4 and IL-13 could modulate IL-23production from entheseal myeloid cells and IL-17 production from enthseal T-cells.

Methods:

Healthy enthesis samples from patients undergoing surgery for non-inflammatory conditions such a lumbar decompression or scoliosis were obtained. Enthesis samples were digested and stimulated (Fig 1A) with LPS and anti-CD3 to induce IL-23 and IL-17 respectively. Samples were pre-treated with IL-4 and IL-13 to ascertain whether this modulated entheseal cytokine production.

Results:

Both IL-23 and IL-17 were readily induced from enthesis samples with IL-23 coming predominantly from entheseal myeloid resident cells (Fig 1B) and IL-17A from T-cells (Fig 1C). Pre-treatment of entheseal digested material with either IL-4 or IL-13 attenuated IL-23 secretion (Fig 1D). Neither IL-4 nor IL-13 was able to significantly attenuate IL-17 secretion from enthesis T-cells, however IL-13 trended downwards and IL-4 surprisingly trended upwards (Fig 1E).

Conclusion:

Our clinical and vitro data point towards a previously unknown role for IL-4 and IL-13 having a protective role in entheseal induction of IL23/17 axis cytokines. These findings point towards a novel explanation for IL-13 pathway SNPs in PsA and also a molecular explanation for why anti-IL4/13 therapy may induce entheseal pathology.

References:

[1]BOWES, J., S. EYRE, E. FLYNN, P. HO, S. SALAH, R.B. WARREN, H. MARZO-ORTEGA, L. COATES, R. MCMANUS, A.W. RYAN, D. KANE, E. KORENDOWYCH, N. MCHUGH, O. FITZGERALD, J. PACKHAM, A.W. MORGAN, C.E. GRIFFITHS, I.N. BRUCE, J. WORTHINGTON and A. BARTON. Evidence to support IL-13 as a risk locus for psoriatic arthritis but not psoriasis vulgaris.Ann Rheum Dis, 2011,70(6), pp.1016-9.

[2]WILLSMORE, Z.N., R.T. WOOLF, C. HUGHES, B. MENON, B. KIRKHAM, C. SMITH and A. PINK. Development of inflammatory arthritis and enthesitis in patients on dupilumab: a case series.British Journal of Dermatology, 2019,181(5), pp.1068-1070.

Disclosure of Interests:

Charlie Bridgewood: None declared, Kassem Sharif: None declared, Hannah Rowe Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Tobias Russell Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC

SAT0361 HEALTHY HUMAN SPINAL PROCESSES PERI-ENTHESEAL T-CELLS EXHIBIT A TR1 RATHER THAN A FOXP3 REGULATORY PHENOTYPE

Background:

We have previously reported that the normal spinal enthesis has populations of conventional T-cells including CD4+ & CD8+ T-cells that could be induced to produce IL-17A and TNF following anti-CD3/CD28 stimulation. The biology of such cells in health including their normal function and antigen reactivity is completely unknown. The purpose of this work was to define the phenotype, functionality and TCR reactivity of such T-cells in health.

Objectives:

To investigate whether the T-cells at the normal enthesis were regulatory in nature and to determine the type of regulatory T-cell as Tr1 or FOXP3 regulatory T-cell and to determine T-cell reactivity.

Methods:

Healthy interspinous ligament and spinous process with matched peripheral blood were harvested from patients undergoing elective spinal surgery (n=20). Entheseal soft tissue (EST) & peri-entheseal bone (PEB) was enzymatically digested and then sorted. Tr1 and Treg phenotypes were investigated using flow cytometry. Analysis of cytokines, growth factors and chemokines was performed by qRT-PCR, ELISA and flow cytometry. TCR sequencing was performed and a search for putative T-cell reactivity was done using TCR3 database.

Results:

Pro-inflammatory cytokine transcripts including IL-17A, IL-17F, IL-22, IL-23 (p19) & TNF were very low or undetectable in the Enthesis T-cells (Fig 1). Flow cytometry confirmed entheseal T-cells had a Tr1 phenotype (CD4+ LAG3+ CD49b+). Intracellular flow cytometry showed enthesis T-cells had very low FOXP3 expression, when compared to their blood counterparts. Intracellular flow cytometry and gene expression showed high basal expression of growth factors and regulatory proteins such as IL-10 & TGFβ, when compared to blood T-cells. RNA-Seq data, showed 13 potential TCR clonal sequences the most common of which are predicted to be reactive viral infection was CMV present in 8 sequences and Influenza A virus present in 2 sequences.

Conclusion:

The healthy human enthesis has regulatory T-cells of a Tr1 phenotype rather than a FOXP3 Treg phenotype. Many clones have antigen specificity indicating reactivity to prior infection. These findings suggest that conventional entheseal T-cells have a role in enthesis immune homeostasis.

Disclosure of Interests:

Hannah Rowe Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Abdulla Watad: None declared, Tobias Russell Grant/research support from: Novartis UK Investigator Initiated non-clinical research funding support, Kassem Sharif: None declared, Darren Newton: None declared, Miriam Wittmann: None declared, Qiao Zhou Grant/research support from: Funded by the PARTNER fellowship program, Almas Khan: None declared, Peter Loughenbury: None declared, Robert Dunsmuir: None declared, Abhay S Rao: None declared, Peter Millner: None declared, Tony Kenna: None declared, Matthew Brown: None declared, Charlie Bridgewood: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC

Musculoskeletal injury quality outcome indicators for the emergency department

High standards of care for musculoskeletal injuries presenting to emergency departments (ED) must be maintained despite financial constraints, the model of care in place, or the pressure to reach time-based performance measures. Outcome quality indicators (QIs) provide a tangible way of assessing and improving the outcomes of health-care delivery. This study aimed to develop a set of outcome QIs for musculoskeletal injuries in the ED that are meaningful, valid, feasible to collect, simple to use for clinical quality improvement and chosen by experts in the field. The study used a multi-phase mixed methods design, commencing with a systematic review of available outcome QIs. An expert panel then developed a set of preliminary QIs based on the available scientific evidence. Prospective observational data collection was undertaken across eight EDs with subsequent retrospective chart audits, follow-up phone calls and audit of administrative databases. After statistical analysis, validated results were presented to the expert panel who discussed, refined and formally voted on a final outcome QI set. A total of 41 preliminary outcome QIs were field tested in EDs, with data collected on 633 patients. Using the field study results, the expert panel voted 11 outcome QIs into the final set. These covered effectiveness of pain management, timeliness to discharge, re-presentations to the ED and unplanned visits to health professionals in the community, missed injuries, opioids side effects and the patient experience. An evidence-based set of outcome quality indicators is now available to support clinical quality improvement of musculoskeletal injury care in the ED setting.

Communication service provision and access for people with Parkinson's disease in Australia: A national survey of speech-language pathologists

Purpose: To determine the clinical practices of Australian speech-language pathologists in the management of communication disorders in people with Parkinson's disease (PwPD) and their perspectives on service provision.Method: A cross-sectional, mix-methods online survey was conducted. Nonprobability, purposive sampling was utilised to recruit speech-language pathologists who currently work with PwPD. Descriptive statistics and thematic analysis were employed.Result: Ninety-nine clinicians responded. Most offered services for both motor speech and cognitive-communication disorders, but a greater focus on the motor speech disorder was evident. A range of impairment and functional assessments and interventions were reported. Therapy was most commonly delivered one session a week over 4 or 6 weeks. Service, client and evidence barriers in the management of both communication disorders were identified. Most clinicians felt PwPD accessed communication services at stages later than optimal, they recognised a need to improve their services in varying degrees (92.3%), and believed not enough services exist for PwPD in Australia (78%). Cognitive-communication management was the highest requested area for further research evidence.Conclusion: This study captured the current practices of Australian speech-language pathologists in the management of communication disorders in PwPD. Findings may inform future service planning, research on service effectiveness and new management targets.

Process quality indicators for musculoskeletal injuries in the emergency department

OBJECTIVES

Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED.

METHODS

A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set.

RESULTS

A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of 'just in case' opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures.

CONCLUSION

An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.

The impact of the telerehabilitation group aphasia intervention and networking programme on communication, participation, and quality of life in people with aphasia

Purpose: Aphasia group therapy can result in improvements in communication, participation and quality of life (QOL). However, evidence for aphasia group interventions with combined aims across the International Classification of Functioning, Disability and Health (ICF) is limited. TeleGAIN is a holistic aphasia group intervention that can be delivered via telepractice. This study builds on prior pilot work and addresses the need for additional research into the effectiveness of TeleGAIN. The aim of this study was to describe changes in aphasia severity, communication related QOL and participation, for people with chronic aphasia following TeleGAIN. Method: Nineteen participants with aphasia were assessed on a range of outcome measures before and after a twelve-week block of TeleGAIN delivered via web based videoconferencing. Treatment provided opportunities to participate in conversation, engage with others with aphasia and complete functional communication activities. Result: Statistical analyses revealed statistically significant improvements in communication related QOL, increased engagement in communicative activities, and decreased aphasia severity. Conclusion: Results from this study suggest that the online delivery of a multi-purpose group intervention for people with aphasia can result in improved communication, communicative participation, and QOL. It also highlights the potential for intervention provided via telepractice to offer an alternative to face-to-face services.

Cost-effectiveness of telerehabilitation versus traditional care after total hip replacement: A trial-based economic evaluation

INTRODUCTION

Physical rehabilitation for total hip replacement patients following hospital discharge is beneficial; however, accessing rehabilitation is often challenging. Telerehabilitation helps negate access issues and is efficacious in total knee and hip replacement patients. This study aims to compare the cost-effectiveness of a telerehabilitation programme delivered remotely into patients' homes versus traditional care for total hip replacement patients following hospital discharge.

METHODS

A cost-effectiveness (cost-utility) analysis was conducted from the perspective of a health service alongside a two-arm randomised controlled trial comparing telerehabilitation (n=35) with in-person care (n=35) following hospital discharge after total hip replacement. The primary analysis used an Incremental Cost-Effectiveness Ratio to compare the cost per Quality Adjusted Life Year (QALY) accrued in the telerehabilitation group versus in-person control using costs and effects data from the randomised trial. A secondary analysis was conducted whereby the time accrued by patients attending rehabilitation sessions (including travel time) was considered the "cost" (i.e. a time burden), rather than cost from the health service perspective.

RESULTS

Estimated mean differences in healthcare costs and QALYs gained were detected but were not significant. The estimated mean (95%CI) difference in cost of telerehabilitation versus in-person was -$28.90 (-$96.37 to $40.45), favouring the telerehabilitation group. The estimated mean (95%CI) difference in QALYs gained from telerehabilitation versus in-person was -0.0025 (-0.0227 to 0.0217). The estimated mean (95%CI) difference in time burden favoured less time burden for the telerehabilitation group (-4.21 (-4.69 to -3.74) hours).

DISCUSSION

Telerehabilitation in the total hip replacement population incurred similar costs and yielded similar effects to traditional in-person care. Telerehabilitation significantly reduced the time burden for patients and carers. These findings are valuable for healthcare providers seeking to implement accessible patient-centred rehabilitation services.