The Role of Virtual Physical Therapy in the Management of Musculoskeletal Patients: Current Practices and Future Implications

Abstract

Purpose of Review

The rapid evolution of virtual technology and artificial intelligence (AI), combined with physical distancing limitations imparted by the COVID- 19 pandemic, has hastened the shift of healthcare toward digitally enabled practitioners. As physical therapy embraces virtual care, its impact is far-reaching across stakeholders, affecting patients, providers, and payors. This article seeks to explore the role of virtual physical therapy (VPT) in managing patients with musculoskeletal (MSK) conditions and its impact on healthcare and patient outcomes.

Recent Findings

While research on VPT is growing, high-quality studies remain limited due to challenges in conducting blinded, randomized controlled trials, sponsor bias, and the diversity of digital solutions that complicate comparative studies. Nevertheless, general literature trends show that VPT, particularly when guided by a physical therapist, can yield improvements in pain and function comparable to in-person therapy. VPT demonstrates fair to excellent reliability and validity across key assessment areas, successfully identifying MSK diagnoses and delivering outcomes similar to conventional treatment for pain, function, and quality of life across multiple MSK disorders. Additionally, VPT addresses adherence issues by reducing travel, costs, and exposure risks, while technology enhancements foster patient engagement and communication with therapists. By increasing access and adherence to PT, VPT has the potential to optimize outcomes and curb long-term healthcare costs by preventing progression to more expensive interventions.

Summary

Virtual care harnesses technology to advance musculoskeletal care by improving access, enhancing patient-provider communication and connection, and optimizing patient engagement and outcomes. VPT moves beyond replication of the in-person experience to an enhanced patient journey. This journey taps into technological advancements to deliver a more integrated experience that engages and supports the patient. VPT offers a sophisticated model of care from the therapist, emphasizing evidence-based practice and critical thinking.

Introduction

The rapid evolution of technology, artificial intelligence (AI), and machine learning (ML), combined with the added impetus of the COVID- 19 pandemic, is pioneering a movement toward the digitally enabled healthcare practitioner. Physical therapy, as a profession, is on the precipice of a great transition toward virtual care. This transition impacts many stakeholders, including patients and population health, payors, providers, and government regulators. It is, therefore, imperative to define and evaluate the benefits and challenges of virtual care and the appropriate parameters of its delivery.

For over fifty years, there has been mention of telemedicine, telehealth, eHealth, and telerehabilitation in some capacity in the literature [1]. The diversity of terms and the relative frequency of their presence in both scientific and non-academic documents may lead to confusion and misunderstanding of the full efficacy or potential value of care delivered in a virtual capacity. In their Clinical Practice Guidelines (CPG), the American Physical Therapy Association (APTA) defines telerehabilitation as “the use of telehealth technologies by physical therapists, or physical therapist assistants under the supervision of a physical therapist, who provide patient and client management, which includes diagnosis, prognosis, and intervention to optimize physical function, movement, performance, health, quality of life, and well-being across the lifespan [2]."The APTA very clearly states that the term “physical therapy” is not an all-encompassing term. Physical therapy describes the services provided by or directed by a licensed physical therapist [3]. Therefore, for this article, the term, “virtual physical therapy” or “VPT” will describe the digital examination, diagnosis, prognosis, and intervention performed or directed by licensed physical therapists.

According to the United States Bone and Joint Initiative, more than one in two American adults reported MSK disease in 2015. This prevalence increased to nearly three of four adults aged 65 or older [4]. The economic burden of these conditions far exceeds that of other conditions, totaling approximately $380.9 billion in 2016 [5]. The scope of VPT is vast, mirroring the scope of in-person physical therapist practice, spanning neurorehabilitation to oncology, women’s health to pediatrics. Given the significant impact described above, the objective of this article is to explore the role of VPT in managing patients with MSK conditions and its impact on healthcare and patient outcomes.

Current Trends in VPT for MSK Care

As with the scope of VPT, the delivery method of virtual physical therapy is equally diverse. The origins of telerehabilitation began with phone calls where a provider checked in with a patient and offered education and instruction. With the advancement and availability of telecommunications technology in the early 2000s, video calls began to gain traction but didn’t truly hit peak levels until 2020 due to necessity during the COVID-19 pandemic. This expedited implementation of virtual care has led many to view VPT as a direct attempt to recreate in-person care virtually. In fact, virtual care is an evolutionary opportunity to utilize technology to enhance patient care by changing the method of service delivery, meeting patients where they are, altering the frequency of contact and communication, and improving the patient-provider connection while optimizing patient engagement and outcomes. Advancements in motion capture, AI, and ML enable the creation of an enhanced patient journey that goes beyond replicating the in-person experience. This approach fosters a more integrated experience that supports patients while providing therapists with a sophisticated model of care, emphasizing evidence-based practice and critical thinking.

Virtual physical therapy may be delivered synchronously, transmitting data and communicating in real-time, or asynchronously utilizing record, store, and forward technology [1]. Because patients and providers lack face-to-face, simultaneous, two-way communication with asynchronous VPT, there is a need for more frequent, brief feedback and open communications. Virtual care provides easier access to channels of communication, utilizing text messages, portal messaging, or secure email [6]. VPT can also incorporate self-guided home programs that use computer vision technology or wearable sensors to guide patients through exercises and offer real-time feedback on performance. Therapists may monitor this data and patients’ progress through remote therapeutic monitoring (RTM), utilizing text or portal messaging to stay engaged with patients and assess their progress effectively [7]. Additionally, providers may adopt a hybrid method of delivery, combining a regimen of in-person and synchronous and/or asynchronous virtual care.

Challenges and Limitations of Virtual Physical Therapy

Implementing alternative delivery models can be daunting. Successful delivery of VPT relies on the presence of working communications and technology, including computers and mobile devices, as well as access to broadband internet. Efficacious participation can be limited by digital literacy and acceptance of both patient and provider [8–11]. During the COVID- 19 pandemic, many providers were rushed into using technology without suitable preparation and education. They lacked the proper change management to embrace virtual care as a dynamic and effective patient care tool. The overwhelming feeling of isolation many experienced during the pandemic may have inappropriately reflected in attitudes toward virtual care.

Health literacy and access to technology have traditionally been limited among populations of low socioeconomic status, limited education, and individuals from racial and ethnic minorities in the United States. Although still an obstacle to virtual care, this gap in digital access shows promise of narrowing. A 2018 study by Vangeepuram et al. reported prevalent smartphone ownership and usage when they surveyed members of a traditionally underserved community, with 82% of participants reporting cell phone ownership and 88% of those with cell phones reporting smartphone ownership. Participants also expressed interest in interactive apps promoting health topics, including exercise, which indicates a paradigm shift toward digital care [12]. A report from the Pew Research Center indicates that as of early 2024, this dependence on mobile technology has risen significantly with individuals from lower-income households likely to rely solely on their smartphones for online access [13]. This shift in digital access is important to consider when designing user interfaces to broaden access to virtual care.

Another potential barrier to virtual care may be cost if payors limit coverage [2, 8]. Limited reimbursement may result from companies and providers contracting with payors and employers under wellness benefits rather than medically based care. This issue is especially evident in app-based exercise therapy solutions and platforms with limited physical therapist interaction and program responsiveness. These delivery methods may use a physical therapist as a launching point for a program, but once initiated, therapists have minimal contact with users who follow a self-guided, algorithm-based program [7]. While wellness is a facet of physical therapy, the true scope of VPT should not be limited to a portion of its breadth. By contracting outside of medical benefits, VPT may limit its referrals from medical providers due to both lack of presence in a provider network and the perpetuation of the belief that VPT is an exercise delivery system only rather than an interactive, individualized, evaluative, and responsive experience.

The loudest critics of VPT emphasize limitations concerning absent palpation or hands-on assessment and treatment. Yet, eighty years ago, in her letter to the editor of Physical Therapy, Lydia Holley called out the obtuseness of pigeonholing the practice of physical therapy into the application of modalities and hands-on treatment."The limits set by our ‘broken record’ statement…that physical therapy is not being practiced if there is no laying on of the hands or of equipment… Are we expressing the idea that physical therapists cannot contribute from their basic knowledge and skill in a wider scope and through various functions [14]?"It is important to remember that the value of VPT is not in replicating what is done in the clinic but in enhancing the delivery of physical therapy. Physical therapy encompasses a vast scope of practice, and neglecting treatment solely due to the absence of hands-on care undermines both the profession and patient outcomes. While many standard, in-person assessments may be conducted virtually (see Table 1 for a sample list of cervical spine assessments in this category), physical therapists must rely on observation, a strong foundational understanding of functional anatomy, and clinical patterns to compensate for absent tactile input. Therapists should recognize that virtual care can be equally effective when high-level clinical thinking and creativity are employed. Table 2 provides an example of how a physical therapist can obtain the same results from a virtual exam compared with a traditional, manual exam Fig. 1.

Table 1.

A sample listing of cervical spine examinations that may be completed virtually

Observation	Posture Assessment, Gait, Scapulohumeral Rhythm
Range of Motion (ROM)	Cervical Flexion/Extension ROM, Cervical Lateral Flexion ROM, Cervical Rotation ROM, TMJ AROM, Thoracic Flexion/Extension ROM, Thoracic Lateral Flexion ROM, Thoracic Rotation ROM, Functional Shoulder Internal Rotation, Functional Shoulder External Rotation, Shoulder Flexion AROM, Shoulder Abduction ARM
Mobility	FMS Shoulder Mobility, Pectoralis Major Muscle Length Test, Seated Torso Rotation Test, Upper Extremity Wall Slide, Cervical Quadrant Test
Strength/Endurance	Neck Flexor Endurance Test, Cervical Lateral Lift Hold, Isometric Chest Raise Endurance Test, Prone Bilateral Elbow Lift-Off Test—Lower Trap, Serratus Push Up with Chin Tuck, Prone Ys Unsupported with Chin Tuck, Prone W, Prone T, Scapular Endurance Test
Special Tests	Cervical Rotation Lateral Flexion Test, Subscapularis Wall Push Off Test, Vestibular/Ocular-Motor Screening (VOMS) – Convergence, VOMS—Horizontal Saccades, VOMS—Horizontal Vestibulo-Ocular Reflex (VOR), VOMS – Visual Motion Sensitivity (VMS), Modified Dix Hallpike Test, Shoulder Abduction Test, Upper Limb Tension Test (ULTT) 1—Median Nerve, ULTT 2b—Radial Nerve, ULTT 3—Ulnar Nerve, Cervical Flexion Rotation Test
Balance	Tandem Walk, Feet Together, Single Leg Balance, Tandem Stance, Balance Error Scoring System (BESS) Test, Complex Tandem Gait – Backward, Complex Tandem Gait – Forward, Dual Task Gait, Timed Tandem Gait, Walking with Horizontal Head Turns
Function/Performance	Closed Kinetic Chain Upper Extremity Stability (CKCUES) Test, Hand to Head and Back Test, Overhead Squat with Dowel, Traditional Squat, Alternating Foot Taps on Step, Repeated Sit to Stand, Functional Reach Test, Functional Movement Screen (FMS)—Rotatory Stability, Trunk Stability Push-Up

Table 2.

A comparison of in-person versus virtual cervical spine movement assessment

Cervical Spine Segmental Movement
Standard In-Person Assessment	Virtual Assessment	Outcome (In-person and Virtual)
Passive Physiological Intervertebral Movements (PPIVMs): Manual techniques to evaluate the amount and quality of movement at segmental spinal levels. Assesses for movement amount and quality and pain response	Observation of Active Cervical Range of Motion in all directions: Assessing for asymmetries (muscle tone, motion, etc.), reduced movement, and compensatory strategies	Establish whether it is upper, mid, or lower cervical dysfunction to focus intervention
Passive Accessory Intervertebral Movement (PAIVM) Tests: Palpation of spinal segments while applying a passive, accessory movement. Assesses for movement amount and quality at intervertebral joints, and pain response	Sustained Natural Apophyseal Glides (SNAGs): Guide patient to apply either sustained pressure or oscillations at different cervical levels while actively performing a restricted movement (e.g., cervical rotation). Assesses segmental mobility and pain response Active cervical Flexion Rotation Test: Active motion assessing C1/C2 mobility Active Cervical Quadrant Test: Provocative test for facet dysfunction assessing pain and paresthesias	Establish whether it is upper, mid, or lower cervical dysfunction to focus intervention
Case Example
Standard In-Person Assessment	Virtual Assessment	Outcome (In-person and Virtual)
General cervical flexion and extension: Reduced upper cervical interspinous space opening Atlanto-occipital movement: restricted opening and closing motion palpated between the left lateral mass of C1 and the left mastoid process C1/2 rotations: decreased C2 movement with passive head rotation to the left C2 - 7 rotations: WNL	Active Cervical Rotation ROM: Observed increase in right-sided anterolateral neck muscle tone, limited cervical rotation to the left, with slight left lateral flexion as a compensatory strategy at end range [Fig. 1]. Since cervical rotation primarily occurs in the upper cervical spine, this suggests potential dysfunction in that region	Upper Cervical Dysfunction – Treat with: Suboccipital release, targeted joint mobilization (can be done manually by therapist or with SNAGs performed by patient), thoracic mobility, global cervical muscle soft tissue release, cervical joint position error training, VOR × 1, deep neck flexor strengthening

Fig. 1.

Patient performing active cervical rotation demonstrates limited cervical rotation to the left, with slight left cervical lateral flexion as a compensatory strategy at end range. Cervical rotation primarily occurs in the upper cervical spine. Presentation suggests potential dysfunction in that region

The importance of knowing when to refer a patient to in-person therapy, however, cannot be overstated. By utilizing clinical prediction rules (CPRs), evidence-based practice, and recognizing patient-specific needs, along with understanding their own limitations, therapists bear the responsibility of making informed decisions about the appropriateness of referrals and identifying when in-person evaluation or treatment is essential. There are cases when patients present with complex musculoskeletal conditions that require direct physical assessments and manual interventions. For instance, severe joint dysfunctions and some postoperative cases necessitate precise manual techniques, such as soft tissue mobilization, myofascial release, and joint manipulation, all of which may be challenging for a therapist to guide a patient virtually. Some exercises or treatments demand immediate physical assistance to prevent injury. Furthermore, physical therapists must recognize when progress is not being made with the current virtual treatment plan despite modifications and various interventions. If virtual options have been exhausted, the therapist must decide when to transition the patient to alternative care, including in-person physical therapy.

Patient safety is a primary concern for therapists, and therefore, virtual care may introduce a level of discomfort regarding limited hands-on supervision, especially for older adults who may face mobility challenges, those with poor cognition, or patients with other complicated comorbidities. In these cases, in-person supervision is essential. In a systematic review and meta-analysis of eleven studies of physiotherapist-led, exercise-based telerehabilitation for older adults, Wicks et al. concluded that telerehabilitation does not increase the risk of falls or adverse events compared to in-person care. The authors noted the safety of telerehabilitation may be attributed to the involvement of trained physiotherapists who adjust exercises to suit each patient’s needs [15]. Further safety precautions, such as having emergency procedures in place and knowing the patient's location and contact information in the event of an emergency, are imperative for each VPT encounter [1, 11].

Additional levels of concern focus on privacy and security. Therapists must remain vigilant. Protection of electronic records is critical as potential exposure is so much greater. With greater opportunity for communication comes greater opportunity for breach of privacy, and therapists must not become cavalier with their communication methods. Additionally, with the rapid and universal advancement of AI technology, healthcare providers are encouraged to embrace emerging technology, efficiencies, and opportunities yet remain present in their development and adoption, and cautious of potential errors. Technology can elevate the profession, but the nuanced and creative thinking of human healthcare providers is required for safe implementation [16].

Benefits of Virtual Physical Therapy for MSK Patients

The introduction and utilization of VPT have stemmed from the multiple benefits of virtual care. The first is improved access to care. VPT can meet patients where they are and is a convenient solution. It transcends geographic barriers, allowing high-quality, specialized therapists to offer care to rural and underserved populations or those with transportation limitations, without interruption [1, 17, 18]. VPT provides therapy for patients who are immunocompromised or at risk for infection and need to limit travel or physical contact with others, within the comfort of their homes [19]. Additionally, it eliminates the time and cost spent traveling to and from the clinic, hours off work, and time away from parental or caregiver requirements [2, 7, 17].

Increased accessibility for both patient and provider results in reduced wait times and more flexible scheduling. Existing literature demonstrates that shorter wait times to access care are correlated with better outcomes, decreased complications, fewer comorbidities, and decreased healthcare costs [1, 7, 8, 20, 21]. By simplifying the hassles and reducing the challenges of seeking and accessing care, VPT has the power to move the needle as to when patients initiate care. When people seek care sooner, before conditions escalate, population health will improve.

Early initiation of physical therapy results in a potential reduction in healthcare system costs including hospital admissions, re-hospitalizations, physician visits, imaging, pain medication, injections or surgery, and overall decreased episodes of care [22–26]. Evaluating over 3,000 cases, Zigenfus et al. found early PT intervention led to a 39% reduction in missed workdays, fewer physician visits, and shorter case durations compared with delayed PT [22]. Childs et al. reported early PT initiation resulted in average low back pain-related costs being $1200 lower over two years compared to those who started PT after 14 days [24]. Horn and Fritz found early PT within 14 days for neck pain lowers 1-year medical costs by 36%, with late PT (PT within 91–364 days) increasing mean healthcare costs by $2172 and delayed PT (PT within 15–90 days) by $1063 [27]. Overall, early PT reduces 1-year MSK-related medical costs by 22% [25].

In the realm of virtual care, where a provider’s tactile sense is removed, therapists place heightened reliance on communication to discern and craft an effective treatment plan. Virtual care, particularly asynchronous care, changes the traditional dynamic between therapist and patient. This emphasis on communication consequently enhances the experience for the patient because therapists must rely on patient feedback, inherently making the patient an equal partner in their care. The active listening practiced by the therapist fosters greater patient engagement, encouraging the patient to take a more active role in their own care and enhancing their accountability within the program. High patient satisfaction translates to increased attendance, program adherence, and completion [2].

Virtual physical therapy empowers patients. With virtual care, the physical therapist does not have the luxury of manually assessing joint play or providing tactile cues. The therapist instead educates the patient about their anatomy and the forces acting upon it. They teach the patient self-management strategies, how to mobilize hypo-mobile or stiff joints, actively release soft tissue restrictions, or how to ensure proper movement patterning and posture during functional tasks without external manual input from the therapist. The therapist works with the patient in their home environment, ensuring that the home program is feasible for them, finding solutions outside of the gym or clinic setting, and applying real-life solutions to real-life problems. Therapist and patient work together, making shared decisions about care. Patients take an active role in their recovery, breaking out of a fear and avoidance cycle and generating an internal locus of control that impacts the future of their healthcare participation.

During a physical therapy objective exam, clinicians typically utilize assessments such as range of motion (ROM) and manual muscle testing (MMT) to gather clinical data and develop effective care plans. In traditional settings, ROM is measured in person using a goniometer. However, VPT may leverage advanced human pose estimation technology, allowing for accurate real-time assessments of a patient’s range of motion and movement [28]. This innovative approach has the potential to minimize human error while providing valuable insights [Fig. 2]. Strength assessment remains a critical component of physical therapy, yet MMT, the conventional method in the United States, is subjective and heavily relies on clinical judgment. Its limitations, variability due to patient factors and clinician experience, can lead to overestimation of strength, as highlighted in Bohannon's historical study comparing MMT with dynamometry [29]. Considering this, functional strength assessments are essential, offering a more accurate, patient-specific understanding of strength, and are easily assessed through VPT.

Fig. 2.

Utilization of advanced motion capture technology and precise identification of anatomical landmarks by the provider to accurately measure active range of motion for right knee flexion

Focusing on functional impairments rather than isolated, less meaningful data points often provides richer insights into the patient and can be gathered more efficiently. Virtual physical therapy platforms can capture and analyze functional movements, such as an overhead squat, through video consultations and motion-tracking technology, offering valuable insights into a patient’s range of motion across multiple joints, strength deficits due to movement asymmetries, and compensatory patterns that may reveal underlying issues [Fig. 3]. This holistic assessment uncovers problems based on the quality and type of movement patterns that might otherwise go unnoticed. By tracking these functional outcomes over time, virtual care provides a comprehensive view of progress, enabling personalized treatment adjustments and fostering meaningful rehabilitation in a remote setting. This approach leverages the strengths of virtual physical therapy, not by replicating in-person assessments, but by enhancing the treatment journey with continuous, real-time feedback on functional recovery.

Fig. 3.

Example of patient images captured from a functional movement screen, illustrating performance progress alongside clinical analysis and annotations that assess the entire kinetic chain

The digitally enabled therapist can take advantage of both synchronous and asynchronous workflows. Workflows, where patients record a series of tests for asynchronous review by the therapist, empower even novice physical therapists to engage more deeply with each new patient. An asynchronous review allows therapists to listen and observe while providing them with valuable time to process the information independently. This reflective practice fosters a mindset of lateral thinking, enabling therapists to formulate insightful questions and explore various avenues for investigation during the initial visit. As a result, it strengthens their clinical pattern recognition, fosters open-mindedness, and enhances their professional confidence, leading to more genuine, directed conversations instead of mechanical interviews when meeting patients. By taking the time to observe, think, and reflect before interacting with the patient, providers can gain a better understanding of the individual they are about to see. This thoughtful preparation leads to a more productive encounter, fostering trust—an essential component that enhances patient compliance and active participation in their care.

Additionally, therapists have the benefit of digital technology to improve the patient experience. Virtual care allows the provider to capture images, record video, observe patient motion frame by frame, and digitally quantify deficits. This information is easily shared across a patient’s care team and with the patient to educate and engage them in their care. Therapists may think critically about each patient’s movements to select the appropriate interventions and prescribe a comprehensive, evidence-based treatment plan. VPT enhances visibility into the rehabilitation process both for the therapist and the patient. Patients can visually track their progress and see side-by-side images of their increasing range of motion, altered posture, or improved functional performance [Fig. 4]. They can follow along with videos and receive real-time AI-driven feedback on their home exercise performance. Applications such as Virtual Reality (VR) and other forms of virtual care can utilize gamification for motivation during treatment or home program sessions and monitor progression. Immersing the patient in a virtual world of simulated sound and video effects directs the patient’s focus externally which can be particularly valuable when treating patients with chronic pain or kinesiophobia. When patients find an activity simple to participate in and engaging, it increases motivation and may improve patient compliance with their programs. Patients invest in their progress and health, which leads to successful program completion and greater outcomes [30, 31]. Studies show that patient satisfaction with telerehabilitation can be as high as in-person care, emphasizing that care can feel personalized and human-centered in a virtual setting [32]. High satisfaction is linked to direct interaction with the therapist, highlighting that it’s the quality of the provider’s approach, rather than the care modality, that drives positive patient experiences [1].

Fig. 4.

Visual ROM tracking via use Advanced Motion Capture Technology to accurately and objectively evaluate progress throughout the patient’s episode of care

AI offers significant benefits, including the ability to process complex data sets with greater accuracy, perform computations faster than humans, and uncover patterns that might otherwise go unnoticed, leading to more informed decision-making and improved efficiency. Therapists are beginning to harness ML to aid in the efficiency of documentation, as well as enhancing decision support regarding differential diagnosis and treatment planning, affording them more time to focus on the patient [31, 33]. Wearable devices, particularly smart watches and body position sensors, can facilitate remote monitoring, collecting large amounts of data between patient visits, which can help tailor interventions to individual performance [31].

Finally, when provided with appropriate datasets, machine learning (ML) can synthesize evidence-based research and patient outcomes to develop analytic and prescriptive care pathways [34]. Virtual physical therapy (VPT) platforms standardize assessments, integrate clinical guidelines and differential diagnosis tools, and guide therapists toward evidence-based practice. This integration enables providers to make informed clinical decisions that balance best practices, patient values, and clinical expertise while preserving autonomy and creativity. By embedding best practice models into the virtual workflow, VPT ensures consistent, high-quality care across providers.

Clinical Evidence on the Efficacy of Virtual Physical Therapy for MSK Conditions

While there are an increasing number of studies on VPT, telerehabilitation, mHealth, telemedicine, and digital health solutions, there is a paucity of high-quality studies. This may be due to the difficulty of conducting independent blinded randomized controlled trials (RCTs) with video conferencing and rehabilitation candidates. Often, bias is introduced by the study sponsor as it pertains to apps or software platforms. The array and diversity of solutions make comparison between them difficult. A broad examination of the literature reveals positive trends in virtual physical therapy compared to in-person usual care, minimal intervention, or waitlist controls [1, 20]. App-based exercise programs can reduce pain effectively [35]. When guided by a physical therapist, VPT can improve pain and function on par with traditional in-person therapy [36]. Moreover, adding RTM to in-person PT may provide additional gains in pain relief and functional outcomes, though more research is needed [7].

Virtual MSK evaluation has shown fair to excellent validity and reliability in assessing various categories, including observation, pain, ROM, strength, and functional tests, while also effectively determining MSK diagnoses [1, 18, 37–39]. VPT demonstrates outcomes comparable to or better than conventional treatments for pain, function, and disability, with improvements noted in health-related quality of life and self-efficacy [20, 40–43]. Similar outcomes were found across different MSK disorders, including neck pain, low back pain, knee osteoarthritis, and hip arthroplasty [1, 18, 40, 43]. RCTs by Moffet et al. and Pruv Bettger et al., reported the comparability of virtual rehabilitation programs to standard in-person care following total knee arthroplasty (TKA) in terms of functional status (measured by the Western Ontario and McMaster Universities Osteoarthritis Index – WOMAC and the Knee Injury and Osteoarthritis Outcome Score -KOOS), gait speed, Six-minute walk test, Timed stair test, knee ROM, and pain [36, 44]. Pruv Bettger et al. did observe patients in their virtual rehabilitation group had more falls (19.4% in the virtual care group, 14.6% in the usual care group) but fewer rehospitalizations. Additionally, those in the virtual rehabilitation group reported less difficulty with knee function during sporting activities [44].

VPT addresses common adherence issues in rehabilitation by eliminating travel burdens, reducing costs, and minimizing pathogen exposure [6]. It also tackles barriers to home program compliance, such as low self-efficacy and lack of feedback, by utilizing technology like gamification and AI for real-time performance tracking, thereby promoting patient engagement and facilitating communication with therapists [Fig. 5] [31, 44]. The success of virtual physical therapy is dependent on patient satisfaction. Strong rapport and a therapeutic alliance are essential for patient-centered care, fostering both trust and engagement. The alliance and trust between therapist and patient are reflected in positive patient satisfaction scores and outcome metrics [18, 39]. Tenforde et al. observed high levels of patient satisfaction with telerehabilitation across age, therapist, condition, and visit characteristics, with ratings between 93.7% and 99% for patient-centered outcomes and 86.8% for the perceived value of future telehealth visits [45]. In a randomized controlled trial (RCT) of 205 patients, Moffet et al. examined three dimensions of patient satisfaction (satisfaction with the relationship with the professional, satisfaction with the delivery of services, and satisfaction with the organization of services) and found similar results for both virtual physical therapy and traditional in-home physical therapy for post-surgical rehabilitation following TKA. The authors reported high satisfaction across both groups, noting that satisfaction was not dependent on preoperative characteristics or service model but rather associated with improvements in walking and stair-climbing abilities, suggesting that the delivery method had less impact on patient experience as long as functional outcomes were achieved [32].

Fig. 5.

An example of a VPT home program featuring easy-to-follow instructional videos with dose-specific parameters and progress tracking

Improving access and adherence to physical therapy has the potential to reduce long-term healthcare spending by optimizing outcomes and preventing escalation to more costly interventions [7, 25]. Additionally, cost savings have been demonstrated in post-acute care. In a 287-patient RCT by Pruv Bettger et al., the authors reported skilled telerehabilitation following TKA resulted in lower 12-week postoperative costs than traditional PT with a mean difference of $2,745 [37]. These lowered billable costs for virtual post-operative rehabilitation can have significant implications for payors, employers, patients, and healthcare systems, particularly concerning bundled payment and value-based programs.

Future Directions and Implications for Practice

The capabilities of digital healthcare are advancing quickly. It is imperative to ensure VPT is positioned at the forefront of the digital movement and that the caliber of service delivery aligns with the pursuit of excellence described by the APTA’s Standards of Practice [46]. Therefore, it is necessary to ensure the term “virtual physical therapy” refers to true physical therapy practice. As with in-person practice, the focus of VPT should not be measured merely by a subjective measure of pain but rather by prioritizing functional movement and active patient participation.

Transitioning to VPT can be a significant challenge for many therapists, primarily because it eliminates a fundamental aspect of practice: hands-on care. This shift necessitates the adoption of alternative methods to gather the information needed for effective treatment planning. As a result, therapists must increasingly depend on patients to provide crucial insights that inform sound clinical decision-making. To navigate this transition successfully, it is essential to employ active listening and lateral thinking from the very first patient encounter. These skills enable therapists to extract the most relevant data to develop a clinical hypothesis.

Experienced clinicians excel in this area, drawing on a wide array of knowledge gained from diverse patient presentations throughout their careers. This extensive background allows them to quickly recognize clinical patterns and formulate comprehensive differential diagnoses based on key phrases shared by the patient. The context clues identified by the provider can lead to more targeted questioning, fostering a deeper understanding of the patient’s condition and motivations for seeking care.

While the above path of clinical thinking is innate in a seasoned therapist, novice therapists lack this level of experience to draw upon. With technology, however, virtual care has the potential to tap into AI and ML models to bring that level of recognition of clinical patterns to greener therapists with clinical decision support systems (CDSS) and drivers of evidence-based pathways built into VPT platforms [47].

VPT requires an enhanced therapist skill set with increased emphasis on history taking, observation, communication, and creativity. Additionally, it behooves the profession to broaden the scope of PT delivery to encompass technological advancement, transforming the traditional frequency and duration of care, feedback exchange between patient and therapist, and billing of services. These elements, with AI and ML, need to be incorporated into educational curricula to prepare new graduates and novice clinicians for the demands of the discerning, digitally enabled therapist.

The benefits of VPT will only be fully realized when virtual care is accessible to the masses. This a spectrum of areas of opportunity, from improvements in infrastructure and expansion of broadband internet to affordable healthcare coverage. Integrating VPT into existing medical coverage plans with reimbursement rates comparable to in-person care will encourage provider referrals to VPT, increase the visibility of VPT options to plan members and employees, and help navigate appropriate members to preventative or early and conservative management of conditions, using health plan data and predictive analytics [7].

To accomplish this, and to demonstrate the efficacy of VPT regarding outcomes and potential cost savings, it is necessary to ensure quality studies are completed. Researchers are called to produce larger RCTs and blinded studies that maintain consistency across the groups they are comparing, including modality, method of delivery, frequency, duration, and diagnosis. Assessment and outcomes of VPT need to be compared to in-person care, and long-term follow-up studies need to examine overall episode spending, surgery avoidance, and impact on behavior and attitudes toward health.

Finally, therapists and healthcare professionals must remain actively engaged in the development of AI algorithms and large language models (LLMs). Therapists need to contribute their vast knowledge, clinical predictive rules, and evidence-based practice guidelines to train models and build inclusive algorithms. Therapists need to actively contribute to recommendations and oversight to ensure the responsible and ethical use of AI to enhance VPT and promote population health.

Conclusion

As physical therapy continues to explore virtual care, its impact extends across patients, providers, and payors, shaping the future of musculoskeletal care. While high-quality research on VPT remains limited due to challenges in study design and the diversity of digital solutions, existing literature suggests that VPT, particularly when guided by a physical therapist, can achieve outcomes comparable to in-person therapy. It demonstrates strong reliability and validity in MSK assessment, effectively improving pain, function, and quality of life while addressing access barriers by reducing travel, costs, and exposure risks.

VPT does not replicate traditional care, it enhances the patient journey by leveraging technology to improve engagement, streamline communication, and optimize outcomes. The integration of AI and ML further advances the field, enabling therapists to process complex data more efficiently, enhance clinical decision-making, and standardize evidence-based care pathways. As these technologies evolve, they hold the potential to support differential diagnosis, treatment planning, and long-term patient management.

However, for VPT to reach its full potential, critical challenges such as broadband access and limited payor reimbursement must be addressed. By overcoming these barriers, VPT can continue to expand access to care, drive adherence, and ultimately reduce long-term healthcare costs by preventing the progression of musculoskeletal conditions. With its ability to standardize assessments, support clinical decision-making, foster patient engagement, and improve outcomes, VPT represents not just a shift in delivery but a transformation in the way physical therapy is practiced and optimized for the future.

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Author Contribution

Both authors, MS and MK, contributed equally to this work. They were both involved in the concept development, research, and execution of the project.

Funding

No funding was received.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Conflict of Interest

Maureen Suhr, PT, DPT is employed by and has an equity interest in ViewFi Health, a virtual orthopedic practice. Madelyn Keese, PT, DPT, OCS, COMT, CMTPT, CSCS is employed by and has an equity interest in ViewFi Health, a virtual orthopedic practice..