Patient-Reported Experiences of Musculoskeletal Virtual Care Delivered by Advanced Practice Physiotherapists

Abstract

Purpose:

To better understand patients’ perspectives on virtual care (VC) delivered by advanced practice physiotherapists (APPs) for hip/knee, foot/ankle, shoulder/elbow, and low back related symptoms.

Method:

A patient satisfaction questionnaire was developed and distributed electronically to all patients seen by APPs from August 1, 2020 to January 31, 2021. The questionnaire contained quantitative items using a 5-point Likert scale and open-ended questions that yielded qualitative findings. Descriptive statistics were applied to the quantitative data. Qualitative findings were analyzed using a qualitative description approach to identify recurrent themes.

Results:

Response rate was 74% (374/505) across all clinics. Videoconference was the most common delivery method (91.7%). Overall satisfaction with VC was very high (4.7–4.8/5). Emergent qualitative themes were related to Personal Connection; Preparatory Materials; Virtual Physical Examination; Practical Advantages of VC; Virtual Waiting Room; and Technical Issues.

Conclusions:

Overall, across several facets including personal connection, patient experience with VC for a variety of musculoskeletal conditions was rated high. Clinically, a systematic approach to the physical examination with preparatory patient education materials was key to positive patient experience.

In late 2017, the Ministry of Health in Ontario expanded Rapid Access Clinics across the province for people with hip/knee (H/K) and low back (LB) pain.¹ At a large urban teaching hospital, advanced practice physiotherapists (APPs), with supportive leadership, have further expanded the musculoskeletal focus to also include people with shoulder/elbow (S/E) and foot/ankle (F/A) pain. APPs lead these clinics, working collaboratively with orthopaedic surgeons to provide care for patients with musculoskeletal problems impacting the LB, S/E, H/K, and F/A. A recent survey by Tawiah and colleagues² reported a World Physiotherapy policy statement describing advanced practice physiotherapy to include a higher level of practice, functions, responsibilities, activities, and capabilities. For example, in Ontario, with medical directives, APPs can order and interpret diagnostic tests. Some APPs are trained within single institutions by medical colleagues; and others are trained through accredited competency-based programmes such as the Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program.³ The role of the APPS in our setting is consultative. They refer to various professions, including physiotherapy, for ongoing conservative management strategies. Prior to the onset of coronavirus disease of 2019 (COVID-19), APPs provided comprehensive in-person initial examinations either independently or collaboratively with orthopaedic surgeons to expeditiously assess and manage patients for specialist care. Dependent on the outcome of the initial examination, patients were either provided conservative management recommendations or were referred on to specialist care for injections and/or surgery. In-person APP-led models have been studied by various authors, with overall good outcomes, including high patient satisfaction.^{4, 5, 6}

Early in the COVID-19 pandemic, closures of outpatient clinics impacted in-person care creating a backlog of patients with musculoskeletal conditions waiting for in-person assessment. Prior to the pandemic, impact of delaying total joint replacement (TJR) was well documented with potential to negatively impact patient outcomes and satisfaction.^7,8 There is further evidence that patient outcomes and satisfaction can be negatively impacted due to delays secondary to COVID-19.⁹ American authors studying impact of delayed orthopaedic care, including TJR, since the onset of the pandemic, have demonstrated physical and emotional ramifications.¹⁰ A large proportion (68%) of patients who had TJR delayed due to COVID-19 reported emotional distress from the delay. Lower joint function scores, and higher pain levels and pain catastrophizing scores, were also reported. Longer latency from time when personally deciding to have surgery was associated with reported need by patients for immediate surgery. However, 90% of respondents also reported delays in surgery were in their best interests; and 45% reported a desire to wait longer for the pandemic to subside. Italian authors determined patients suffering from orthopaedic and traumatological pathologies during the first wave of the pandemic experienced increased pain, decreased physical activity, variation in consumption of pharmacological drugs, and increase in sedentary lifestyle.¹¹ A Canadian time series modelling study estimated the size of the nonemergent surgical backlog during the first wave (March 15–June 13, 2020) of COVID-19 in Ontario at 148,364 surgeries, some of which included TJR surgeries.¹² Not all patients assessed for elective orthopaedic surgery require the procedure. For example, it was determined that four of five patients assessed by an orthopaedic surgeon did not receive surgery and that many patients require conservative management.¹³ Overall, evidence suggests that delays affect those on surgical wait lists (well studied) and also, those awaiting assessment (less studied). This supports the rationale for our study.

Virtual care (VC) was identified as a Canadian health care system priority from both clinical and research perspectives, prior to the COVID-19 pandemic.¹⁴ Prepandemic literature revealed VC by orthopaedic surgeons in various orthopaedic settings had high rates of patient satisfaction, comparable to in-person care.¹⁵ With the acceleration of pandemic-related VC, studies have shown patient–practitioner engagement and confidence in diagnosis/management recommendations as reasons for high levels of satisfaction.¹⁶ In addition, there is evidence supporting ongoing rehabilitation delivered virtually is effective for a variety of musculoskeletal patient populations.^{17, 18, 19, 20}

Studies have demonstrated satisfaction with APP-led in-person clinics.^{5,17, 18, 19} However, to our knowledge, no literature exists that is specific to patient satisfaction with VC led by APPs. Patient feedback and satisfaction is an important driver of change within health care systems.²⁰ Through collaborative efforts between APPs, orthopaedic surgeons, and hospital leadership, VC was rapidly developed and implemented across all APP-led clinics at a large urban teaching hospital during the first wave of the COVID-19 pandemic, and ongoing. The aim of our quality improvement (QI) initiative was to understand perspectives of patients with H/K, F/A, S/E, and LB pain on APP-led orthopaedic VC. Quality improvement is “a distinct management process and set of tools and techniques that are coordinated to ensure health needs of communities are met.”²¹

Methods

In parallel with the implementation of VC in April 2020, a patient satisfaction questionnaire with specific questions related to VC was developed by the APP clinical team. At the time, we could not identify any questionnaires (that had undergone reliability and validity testing) in the literature that were specific to our VC needs. However, we did include one concept related to ability to manage one's condition from the Client-Centred Rehabilitation Questionnaire that had undergone reliability and validity testing.²² Our initial satisfaction questionnaire (long version) consisted of 10 items (Table 1). We subsequently produced a short version with 4 items (items 4, 7, 8, and 10) from the 10-item version. The main goal of the short version was to understand if VC was a viable option for patients with LB pain. The LB team opted for this version with the goal of maximizing response and minimizing time to complete for respondents. Both versions prompted quantitative and qualitative responses. The quantitative items were scored on a 5-point Likert scale. The least favourable response item was labelled as one with the descriptor “not at all” and the most favourable response item was labelled five with the descriptor “definitely.” The three interim response options (2, 3, 4) were not labelled. The qualitative items prompted open-ended feedback. Questionnaire items are presented in Table 1.

Table 1.

Patient Satisfaction Questionnaire Items – Long Version

Item	Statement	Quantitative response option 1 (not at all) 2 3 4 5 (definitely)
1	I had confidence and trust with the virtual care assessment.
2	The virtual care appointment helped me feel I could better manage my condition.
3	The main reason for my virtual care visit was dealt with to my satisfaction.
4	Do you feel receiving virtual care is a good option if face-to-face care is not possible?
5	Did you find the video and any resources provided helpful to allow you to better prepare for the virtual care appointment?
6	Was your privacy and confidentiality respected?
7	Would you participate in a video or phone assessment again?
8	Overall, I am satisfied with my virtual visit.
	Qualitative items
9	What parts of a video assessment worked well? Please provide examples.
10	Do you feel there was anything missing or that could be improved from the assessment because it occurred through video or phone? Please provide examples.

From August 1, 2020 to January 31, 2021, patients undergoing initial VC consultation in the APP-led S/E, LB, H/K, and F/A clinics were emailed a link to our electronically administered questionnaire within 1 day of their initial consultation. Based on programme choice, the patients in the spine clinic were emailed the short 4-item version and all other patients were emailed the long 10-item version. Only patients who responded to the survey were included in the study. Questionnaires were completed by patients electronically through SurveyMonkey and submitted anonymously with no personal health information collected. Response was considered implied consent. Survey response data were entered and stored in a secure Excel spread sheet. Our work was approved by the Quality Improvement Review Committee as they determined the scope fell outside what is required by Research Ethics Board (REB) as described in the Tri-Council Policy Statement V.2. This determination was also confirmed by the REB Chair.

Quantitative analysis

The guidance of Boone and Boone²³ informed metrics used to describe Likert scale responses. For example, they recommend means for analyzing Likert scale data. Descriptive statistics were applied to the data including frequencies and means. Mean response scores for each questionnaire item were calculated using Excel software for each respective clinical area (S/E, LB, H/K, F/A), and for all clinics, collectively.

Qualitative analysis

All text from the open-ended questionnaire items was collated into one document. These qualitative findings²⁴ were independently analyzed by two of the authors (LS and AC) using a qualitative description approach.²⁵ Both authors have qualitative research experience and integrated teachings from the practical guide by Carpenter and Suto.²⁶ Each quote was analyzed line by line using a coding process identifying words or groups of words that addressed the objectives. Words and groups of words were categorized under themes inductively.²⁵ The members met to compare their respective interpretations and understandings of emergent themes. A reconciled list of emergent themes was subsequently agreed upon. It is important to note that the qualitative description approach utilized did not include development of a conceptual or theoretical framework, as proposed by Bradshaw and colleagues.²⁵

Results

Between August 1, 2020 and January 31, 2021, 505 questionnaires were sent via electronic mail to patients undergoing initial VC consultation. Three hundred seventy-four questionnaires were completed for a response rate of 74%. The majority (91.7%) of virtual assessments were completed via videoconference and 8.3% by telephone.

Quantitative analysis

Responses (mean scores/5) to quantitative survey items are presented in Table 2. Data were analyzed by question. As such, any missing data meant denominators varied by question as noted in Table 2 for number of responses for each question. Overall, satisfaction with VC was high across all APP-led clinics.

Table 2.

Mean 5-Point Likert Scale Response Scores/5

Item/Number of responses	S/E/5	LB/5	H/K/5	F/A/5
I had confidence and trust with the virtual care assessment. (n = 318)	4.6	N/A	4.7	4.7
The virtual care appointment helped me feel I could better manage my condition. (n = 318)	4.2	N/A	4.3	4.3
The main reason for my virtual care visit was dealt with to my satisfaction. (n = 319)	4.6	N/A	4.7	4.6
Do you feel receiving virtual care is a good option if face-to-face is not available? (n = 372)	4.4	4.8	4.7	4.7
Did you find the video and any resources provided helpful to allow you to better prepare for the virtual care appointment? (n = 311)	4.2	N/A	4.5	4.5
Was your privacy and confidentiality respected? (n = 318)	4.8	N/A	4.8	4.8
Would you participate in a video or phone assessment again? (n = 369)	4.7	4.9	4.8	4.9
Overall, I am satisfied with my virtual visit. (n = 372)	4.7	4.8	4.7	4.7

Qualitative analysis

Six themes emerged from the open-ended questionnaire items (Table 1, items 9, 10). These items asked what parts of the video assessment worked well and asked if there was anything missing or that could be improved on. Emergent themes were as follows: Importance of Personal Connection; Preparatory Materials Key to VC Success; Patient Perspectives on Virtual Physical Examination; Practical Advantages of VC; Invisible in the Virtual Waiting Room; and Technical Issues.

Importance of personal connection

Overall, respondents reported they were able to establish a personal connection with APPs virtually. This reported important personal connection was enabled with videoconferencing and the ability to “see” their APP, as illustrated by the following quotes:

“All the typical things that one would presume in having a ‘face-face’ interaction … it felt personal and just as good as being in person given the circumstances. Full range of emotions were shared and connection was made.”

“It was a good substitute when in-person assessment is not possible. It is still easy to establish a therapeutic relationship.”

“I was delightfully surprised at the efficiency and effectiveness of the visit. Not having experienced a virtual or telephone appointment before, I was impressed at how personal it was.”

“Being able to meet face to face rather than voice only worked well for me. It was reassuring that my medical issue was being properly assessed. I have had only phone conversations with my general practitioner that I felt didn’t quite have a great success rate.”

Although some respondents were satisfied with telephone assessment, others expressed more confidence with videoconferencing.

“Phone would be a less viable substitute to in-person without the visual connection, but video works well.”

Some respondents looked forward to in-person visits, whereas others suggested that at least for initial assessments, videoconferencing should be considered for routine care for the future.

“Everything was fine. Once the COVID problem will be resolved, returning face to face visits will be the improvement required. For now, this is sufficient.”

“I would be willing to do this type of assessment even after COVID is dealt with.”

“Excellent tool that probably should be used prior to any face-to-face meeting as it is efficient and could save the ‘system’ and patient considerable time required for face-to-face meetings. Should be a precursor.”

There were also some respondents who expressed preference for in-person visits. This points to the future need to determine not only who is suitable for VC but also who is best served by, and prefers, in-person assessment.

“Video does not replace human interaction – so going forward, it should not be assumed that though it is working for now, this is how it should be in future.”

“I would feel better, more reassured, in a face-to-face meeting.”

Preparatory materials key to virtual care success

Prior to the VC assessments, administrative staff provided patients with preparatory materials including instructions regarding access to the videoconferencing, tips on web browsers, audio requirements, video requirements, and electronic access to a preparatory video on what to expect with assessments. Preparatory videos were specific to the body part being assessed and demonstrated what to expect in a physical examination of the respective body part, what clothing to wear, and equipment needs. Overwhelmingly, respondents provided positive feedback on preparatory advice and materials.

“The video to prepare in advance was extremely helpful.”

“The preparation video, so I was able to rearrange furniture to accommodate the movements beforehand.”

“‘TEST the settings’ option contained in the email invitation very useful. It was easy to follow and good to test audio and video settings.”

Patient perspectives on virtual physical examination

Generally, respondents felt that a physical examination (for H/K, F/A, LB, S/E) could be accomplished relatively well using videoconferencing and expressed confidence in the thoroughness of the physical examination.

“Physical testing seemed quite normal. As close to [in-person] as possible.”

“Was able to show the problem with my feet easily and clearly.”

“The assessment of the motion worked well with descriptions of what to do and showing where to place the arm and hand.”

“The video component worked well. Using an iPhone I was able to demonstrate both hip and knee issues.”

However, many respondents expressed concern that the hands-on aspect of a physical examination is missing with VC as illustrated by the following quotes:

“[The physical examination] worked okay but the video clearly doesn’t give the opportunity to really assess range of motion and any issues that come from feeling movement versus seeing.”

“Could not palpate the affected area and get a feel for exactly where the tenderness occurs.”

“Physical examination part by touching is missing. I don’t have any idea how it can be fulfilled.”

Practical advantages of virtual care

Respondents expressed many practical advantages of VC. These included less overall time commitment compared to in-person appointment, less travel, avoiding parking challenges and expense, avoiding unnecessary potential exposure to COVID-19, less waiting in a waiting room, easier to include family members, less missed work time, and overall, less stress.

“Firstly, I was more comfortable speaking of my condition while at home. Secondly, I was able to take notes. I remembered to ask all my questions. My husband was able to understand the whole condition and support me.”

“For me distance is a factor to consider as well as COVID.”

“Avoiding travel time was great. I did the appointment over lunch.”

“I felt at ease talking from my own dining room. When my husband joined our meeting, [APP] re-explained the process and answered our questions.”

“Confidentiality, comfort at being at home, safe right now with COVID, time saver, no need to travel and take time away from work, cost saving … I did not have to commute to Toronto.”

“Being able to review my radiography with [APP]. Probably better than in office because didn’t have the stress of getting to the appointment.”

“The visit actually took place as scheduled, not the usual long wait in the clinic, no parking fees.”

Invisible in the virtual waiting room

Although there were few comments about waiting long periods of time for virtual appointments, we feel it is worth noting that when appointments were not on time, the virtual waiting room was problematic for patients. For example, respondents felt they could not be “seen” in the virtual waiting room, as opposed to waiting in a clinic. The following quotes illustrate the issues posed with waiting unacknowledged in a virtual waiting room.

“Late start so wasn’t sure I was connected properly as first-time user.”

“While I was waiting, I was not sure if I had done something wrong or was I at a wrong place. After waiting for 15 minutes or so, I started contacting different departments to find out my next step. In the hospital, the delays are inevitable, and I understand that, however, some kind of warning or message could have helped.”

“During the delay, it would help to know that the connection and appointment is still okay, but that things may be running a little late, just as if I were in the ‘waiting room’ and was not called in yet.”

Technical issues

Lack of familiarity with videoconferencing platforms, Internet availability and reliability, and access to personal devices with audio and video were reported issues by some respondents. As this was a QI project, we iteratively addressed these issues and revised our preparatory materials. Quotes illustrating technical issues are as follows:

“I live rurally and internet connection is notoriously slow and sometimes unavailable … all systems worked well but the intermittent service may be a problem in future.”

“[The APP] could not hear me so she called and we did phone and video conferencing. It worked well.”

“Perhaps for foot/ankle appointments suggest that using a phone or laptop is easier than a desktop for these appointments!”

“The only issue I noticed was technical on my end. Could use a wider angle camera to capture a larger area.”

Many respondents were very technologically inclined and reported no technical issues.

“There were no audio or video issues.”

Discussion

Studying the extended or advanced practice role of physiotherapists is important as the role is primarily consultative in nature, as opposed to traditional physiotherapy roles where ongoing treatment interventions are often involved. Overall satisfaction with VC was high (4.75) across all APP-led clinics. Satisfaction was also reflected in respondents’ qualitative responses, indicating they appreciated the face-to-face nature of video assessments and the convenience of receiving care inside the comfort of their own homes. Closely related to overall patient satisfaction was the questionnaire item addressing the degree to which patients had trust and confidence in the virtual assessment, which yielded a score of 4.7/5 across the S/E, H/K, and F/A clinics. Trust and confidence with the virtual assessment also emerged from the qualitative responses with respondents reporting a personal connection with their practitioner which “felt” similar to an in-person assessment. Our qualitative findings strongly support the importance of establishing a personal connection. Respondents also felt they were able to accurately describe their clinical issues over the virtual platform, which contributed to feelings of trust and confidence with VC consultation.

Our findings align with American researchers who examined patient satisfaction with telemedicine consultations (video and telephone) for 631 patients from March to June 2020 at an outpatient orthopaedic clinic.²⁷ Study participants rated their experiences as “good” or “very good” 95% of the time, with 93% indicating they would complete another telemedicine consultation if opportunity arose.

The item on the questionnaire addressing whether VC enabled patients to better manage their conditions yielded scores (average 4.27/5) demonstrating the clinical effectiveness of VC across S/E, H/K, and F/A patient populations. Similarly, qualitatively, several respondents reported they felt reassured they were adequately assessed with VC. However, others felt face-to-face would enable a more fulsome physical examination. Interestingly, authors from Norway¹⁵ who compared patient-reported outcomes and satisfaction between those who underwent video-assisted versus face-to-face orthopaedic consultations found overall no difference in patient-reported outcomes after 12 months between the groups as measured by the European Quality of Life 5-dimension Index.²⁸ However, there was a significant difference between groups for the “pain/discomfort” item. For this item, higher pain reduction after 12 months was observed in the video-assisted group compared to the face-to-face group. During the time period of our study, elective surgeries were significantly reduced. For individuals who were being assessed for surgery, less accessibility to surgery may have impacted results. Also, community-based programmes such as aqua fitness and group exercises were closed, possibly contributing to lower scores.

As suggested by Chatterji and colleagues,²⁹ our data (quantitative and qualitative) support the importance of standardized physical examination and preparatory materials for successful VC. Our preparatory videos for patients included a person demonstrating what to expect during the physical examination and how to prepare for it. O’Connor and colleagues³⁰ studied a patient population undergoing TJR surgery. Patients were randomized to control and treatment groups. The treatment group was subjected to a playlist of videos aimed at creating a virtual hospital experience related to TJR. Because there is often anxiety amongst patients undergoing TJR, the Generalized Anxiety Disorder measure³¹ was used by the authors. Results demonstrated a trend to less anxiety in those who viewed the videos. Although their videos had a different purpose than our videos, the results support the value of preparatory videos for patients with musculoskeletal conditions.

Although our findings are encouraging, pandemic-specific factors may have positively impacted responses during the time period we studied. We concur with other authors who report investigating patient experience with VC during the early stage of the COVID-19 pandemic may be impacted by vaccines not being widely available and options for in-person care limited.^27,32,33 Patients’ experiences with VC may have changed now that in-person care is more widely available. Also, previous literature showed that patient satisfaction with health care was higher during the initial months of the pandemic compared to prepandemic.³⁴ This suggests that perhaps patients were particularly appreciative of all health care workers during this initial period of the pandemic.

Our study has several limitations; mainly we did not have access to a patient experience questionnaire related to VC that had undergone rigorous development including reliability and validity testing for items. A potential limitation of our questionnaire is that we did not have qualitative descriptors for all numeric response options. In addition, we did not collect any data that would describe our population such as age, sex at birth, self-identified gender, highest level of education, language spoken at home, socio-economic status, and type of device used for virtual consultation. However, we did know which clinic patients attended and therefore to which body part they referred. All our patients are adults, 18 years and older, with the majority having degenerative conditions. It is important to consider that data collection was undertaken when in-person care was limited due to clinic reductions to minimize risk of COVID-19 transmission. This may positively influence the responses we received related to VC. Although we had two open-ended questions which yielded qualitative findings,²⁴ the responses were narrowed in scope by direct questions. We did not have an “additional comments” question which may have allowed broader responses. Lastly, there was potential response bias to those who could access technology and respond to our survey. For example, those who had access to, and were comfortable with, technology may have responded more favourably than those who did not have access to technology (we do not have data from the latter group).

Conclusion

Overall, across several facets including personal connection, the patient experience with VC for a variety of musculoskeletal conditions, including S/E, LB, H/K, and F/A was rated high. Because the majority (91.7%) of our respondents utilized videoconferencing, our data mostly represent this method of VC as opposed to telephone. Our data also support a systematic approach to the physical examination with preparatory patient education materials is key to positive patient experience. We acknowledge that further research is necessary to validate physical examination findings elicited virtually with those in-person. In addition, determining when VC is the preferred format for health care delivery as opposed to in-person care warrants further study. Our study focused on the patient experience. There is opportunity for further research to explore health care provider experiences. These opportunities for future research align well with three of the seven priorities identified to address Canada's response to the COVID-19 pandemic: system adaptation and organization of care; VC; and public and patient engagement.³⁵

Key Messages

What is already known on this topic?

Patient satisfaction with in-person care delivered by APPs is high overall.

VC was not widely utilized by APPs prior to the COVID-19 pandemic.

Prepandemic, VC delivered by a variety of health care providers, excluding APPs, was used for triage purposes.³⁶

What this study adds?

Patient experience with VC delivered by APPs for S/E, LB, H/K, F/A was rated high overall, during a time period when in-person care was not readily accessible.

A personal connection between health care provider and patient can readily be established with VC.

Preparatory materials, such as videos, for patients to enable a successful VC experience, are key.

Rich qualitative data describing barriers and enablers to VC for patients can inform future study.