The utility of physiotherapy assessments delivered by telehealth: A systematic review

Background Telehealth use is increasing due to its ability to overcome service access barriers and provide continued care when disease transmission is of concern. However, little is known of the validity, reliability and utility of performing physiotherapy assessments using synchronous forms of telehealth across all physiotherapy practice areas. The aim of this systematic review was to determine the current clinometric value of performing physiotherapy assessments using synchronous forms of telehealth across all areas of physiotherapy practice. Methods A comprehensive search of databases (PubMed/MEDLINE, The Cochrane Library, Embase and EBSCO) was undertaken to identify studies investigating the clinometric value of performing physiotherapy assessments using synchronous forms of telehealth across all physiotherapy practice areas. Following selection, a quality appraisal was conducted using the Brink and Louw or Mixed Methods Appraisal Tool. Evidence regarding validity, reliability and utility of synchronous telehealth physiotherapy assessments was extracted and synthesised using a critical narrative approach. Results Thirty-nine studies conducted in a variety of simulated (n = 15) or real-world telehealth environments (n = 24), were included. The quality of the validity, reliability and utility studies varied. Assessments including range of movement, muscle strength, endurance, pain, special orthopaedic tests (shoulder/elbow), Berg Balance Scale, timed up and go, timed stance test, six-minute walk test, steps in 360-degree turn, Movement Assessment Battery for Children (2nd Edition), step test, ABILHAND assessment, active straight leg raise, and circumferential measures of the upper limb were reported as valid/reliable in limited populations and settings (many with small sample sizes). Participants appeared to embrace telehealth technology use, with most studies reporting high levels of participant satisfaction. If given a choice, many reported a preference for in-person physiotherapy assessments. Some inconsistencies in visual/auditory quality and challenges with verbal/non-verbal communication methods were reported. Telehealth was considered relatively cost-effective once services were established. Conclusions Performing physiotherapy assessments using synchronous forms of telehealth appears valid and reliable for specific assessment types in limited populations. Further research is needed in all areas of physiotherapy practice, to strengthen the evidence surrounding its clinometric value. Clinicians contemplating using this assessment mode should consider the client/family preferences, assessment requirements, cultural needs, environment, cost considerations, access and confidence using technology. Protocol registration PROSPERO: CRD42018108166.

Yes -reported in the 'Inclusion and Exclusion Criteria', 'Quality Assessment' and 'Data Extraction, Synthesis and Analysis' sections of the methods Data items 10a List and define all outcomes for which data were sought.Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses), and if not, the methods used to decide which results to collect.

in each stu
y were sought (e.g., for all measures, time points, analyses), and if not, the methods used to decide which results to collect.

Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 10b List and define all other variables for which data were Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 10b List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.
ought (e.g., participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.

Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods


Study risk of bias assessment

11 Specify the methods used Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods

Study risk of bias assessment
11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.
o assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.

Yes -reported in the 'Quality Assessment' section of the methods.

Effect measures 12 Specify for each outcome the effect measure(s) (e.g., risk Yes -reported in the 'Quality Assessment' section of the methods. Effect measures 12 Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results.
ratio, mean difference) used in the synthesis or presentation of r sults.

Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods Synthesis methods 13a Describe the processes used to decid Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods Synthesis methods 13a Describe the processes used to decide which studies were eligible for each synthesis (e.g.tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).
which studies were eligible for each synthesis (e.g.tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).


Yes -reported in the 'Inclusion and Exclusion Criteria' and 'Study Selection' section of the methods


Section and Topic


Item


# Checklist item

Location where item is reported 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.

Yes -reported in the 'Inclusion a

# Checklist item
Location where item is reported 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.
Yes -reported in the 'Inclusion and Exclusion Criteria' section of the methods 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.
d Exclusion Criteria' section of the methods 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.
Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, meta-regression).

s -reported in the 'Data E
traction, Synthesis and Analysis' section of the methods 13e Describe any methods used to explore possible causes of hetero eneity among study results (e.g., subgroup analysis, meta-regression).

Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 13f Describe any sensitivity analyses co Yes -reported in the 'Data Extraction, Synthesis and Analysis' section of the methods 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results.N/A -In the qualitative synthesis that was conducted, a sensitivity analysis was not performed, however included studies providing only low level evidence, such as case studies, and those of poor methodological quality were reported as such and this is noted in the 'Quality Assessment' section of the methods ducted to assess robustness of the synthesized results.N/A -In the qualitative synthesis that was conducted, a sensitivity analysis was not performed, however included studies providing only l

dence, such as c
se studies, and those of poor methodological quality were reported as such and this is noted in the 'Quality Assessment' section of the methods


Reporting bias assessment

14 Describe any meth

Reporting bias assessment
14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).
ds used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).

N/A -as a meta-analysis was not conducted and the s N/A -as a meta-analysis was not conducted and the synthesis was qualitative in nature, funnel plots were not constructed.Other methods of assessing risk of reporting biases were also not employed.
nthesis was qualitative in nature, funnel plots were not constructed.Other methods of assessing risk of reporting biases were also not employed.

Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.Yes -reported in the 'Quality Assessment' section of the methods.


RESULTS


Study selection 16a

Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.

Yes -reported in Figure 1 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.

Yes -reported in Figure 1 Study characteristics 17 Cite each included study and present its characteristics.Yes -reported in Tables 4 and 5 Risk of bias in studies 18 Present assessments of risk of bias for each included study.Yes -reported in Table 5 and further reported in the Supplementary Material Critical Appraisal Tables


Results of individual studi Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.Yes -reported in the 'Quality Assessment' section of the methods.

Study selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.
Yes -reported in Figure 1 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.
Yes -reported in Figure 1 Study characteristics 17 Cite each included study and present its characteristics.Yes -reported in Tables 4 and 5 Risk of bias in studies 18 Present assessments of risk of bias for each included study.Yes -reported in Table 5 and further reported in the Supplementary Material Critical Appraisal Tables

19 For all outc
19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.confidence/credible interval), ideally using structured tables or plots.
mes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.confidence/credible interval), ideally using structured ta les or plots.

Yes -reported in Tables 4 and 5 Results of syntheses 20a For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.Yes Yes -reported in Tables 4 and 5 Results of syntheses 20a For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.Yes -reported in the results section and Tables 4 and 5 20b Present results of all statistical syntheses conducted.If meta-analysis was done, present for each the summary estimate and its precision (e.g., confidence/credible interval) and measures of statistical heterogeneity.If comparing groups, describe the direction of the effect.
-reported in the results section and Tables 4 and 5 20b Present results of all statistical syntheses conducted.If meta-analysis was done, present for each the summary estimate and

ts precision (e.g.
confidence/credible interval) and measures of statistical heterogeneity.If comparing groups, describe the direction of the effect.

N/A -no meta-analysis or statistical synthesis was conducted.

Information is reported in Table 5 regarding relevant statistical estimates and their precision, as reported in the N/A -no meta-analysis or statistical synthesis was conducted.
Information is reported in Table 5 regarding relevant statistical estimates and their precision, as reported in the included studies.
ncluded studies.

20c Present results of all investigations of possible causes of heterogeneity among study results.Yes -reported in Tables 20c Present results of all investigations of possible causes of heterogeneity among study results.Yes -reported in Tables 4 and 5 and in the first 4 subsections of the results and 5 and in the first 4 subsections of the results

20d Present results of all sensitivity analyses conducted to assess 20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.N/A -In the qualitative synthesis that was conducted, a sensitivity he robustness of the synthesized results.N/A -In the qualitative synthesis t at was conducted, a sensitivity


Section and Topic


Item


# Checklist item

Location where item is reported analysis was not performed, however included studies providing only low level evidence, such as case studies, and those of poor methodological qualit

# Checklist item
Location where item is reported analysis was not performed, however included studies providing only low level evidence, such as case studies, and those of poor methodological quality were reported as such in Table 4 and Table 5 and in the Supplementary Material Critical Appraisal Tables.
were reported as such in Table 4 and Tab e 5 and in the Supplementary Material Critical Appraisal Tables.


Reporting biases

21 Present ass

Reporting biases
21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.
ssments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.

N/A - N/A -as a meta-analysis was not conducted and the synthesis was qualitative in nature, funnel plots were not constructed.
s a meta-analysis was not conducted and he synthesis was qualitative in nature, funnel plots were not constructed.

Other methods of assessing risk of reporting biases were also not employed.

Certainty of evidence 22 Present assessments of Other methods of assessing risk of reporting biases were also not employed.
Certainty of evidence 22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.
ertainty (or confidence) in the body of evidence for each outcome assessed.

Yes -reported in  If human subjects were used, did the authors give a detailed description of the samp Yes -reported in  If human subjects were used, did the authors give a detailed description of the sample of subjects used to perform the (index) test on?2.
e of subjects used to perform the (index) test on?2.

Did the authors clarify the qualification, or competence of the rater(s) who performed the (index) test? 3.

Was the reference standard explained?4.

If inter-rater reliability was tested, were raters blinded to the findings of the other raters? 5.

If intra-rater reliability was tested, were raters blinded to their own findings of the tes Did the authors clarify the qualification, or competence of the rater(s) who performed the (index) test? 3.
Was the reference standard explained?4.
If inter-rater reliability was tested, were raters blinded to the findings of the other raters? 5.
If intra-rater reliability was tested, were raters blinded to their own findings of the test under evaluation?6.
Was the order of examination varied?7.
If human subjects were used, was the time period between the reference standard and the index test short enough to be reasonably sure that the target condition did not change between the two tests?8.
Was the stability (or theoretical stability) of the variable being measured taken into account when determining the suitability of the time interval between repeated measures?9.
Was the reference standard independent of the index test?10.Was the execution of the (index) test described in sufficient detail to permit replication of the test?11.Was the execution of the reference standard described in sufficient detail to permit its replication?12. Were withdrawals from the study explained?13.Were the statistical methods appropriate for the purpose of the study?
Table 5 and the 'Limitations of Included Studies and the Present Systematic Review' section of the discussion.
DISCUSSIONDiscussion23a Provide a general interpretation of the results in the context of other evidence.Yes -reported in subcategories throughout the 'Discussion' section of the review 23b Discuss any limitations of the evidence included in the review.Yes -reported in the 'Limitations of Included Studies and the Present Systematic Review' section of the discussion 23c Discuss any limitations of the review processes used.Yes -reported in the 'Limitations of Included Studies and the Present Systematic Review' section of the discussion 23d Discuss implications of the results for practice, policy, and future research.Yes -reported in the 'Conclusion' and 'Contribution of Paper' sections of the reviewOTHER INFORMATIONRegistration and protocol24a Provide registration information for the review, including register name and registration number, or state that the review was not registered.Yes -reported under 'Systematic Review Registration' section 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared.Yes -reported in the 'Systematic Review' section of the methods 24c Describe and explain any amendments to information provided at registration or in the protocol.Yes -reported in the 'Deviations for the Protocol' section of the methods Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.

Table S2 :
[2]lity Appraisal of Included Validity and Reliability Studies Using the Brink Critical Appraisal Tool[2]

Table S3 :
[3]lity Appraisal of Included Utility Studies Using the Mixed Methods Appraisal Tool[3]Is the qualitative approach appropriate to answer the research question?1.2 Are the qualitative data collection methods adequate to address the research question?1.3 Are the findings adequately derived from the data?1.4 Is the interpretation of results sufficiently substantiated by data?1.5 Is there coherence between qualitative data sources, collection, analysis and interpretation?2. Quantitative RCT's 2.1 Is randomization appropriately performed?(Randomised control trials) 2.2 Are the groups comparable at baseline?2.3 Are there complete outcome data?2.4 Are outcome assessors blinded to the intervention provided?2.5 Did the participants adhere to the assigned intervention?3. Quantitative non-randomized 3.1 Are the participants representative of the target population?3.2 Are measurements appropriate regarding both the outcome and intervention (or exposure)?3.3 Are there complete outcome data?3.4 Are the confounders accounted for in the design and analysis?3.5 During the study period, is the intervention administered (or exposure occurred) as intended?4. Quantitative descriptive 4.1 Is the sampling strategy relevant to address the research question?4.2 Is the sample representative of the target population?4.3 Are the measurements appropriate?4.4 Is the risk of nonresponse bias low? 4.5 Is the statistical analysis appropriate to answer the research question? 5. Mixed Methods 5.1 Is there an adequate rationale for using a mixed methods design to address the research question?5.2 Are the different components of the study effectively integrated to answer the research question?5.3 Are the outputs of the integration of qualitative and quantitative components adequately interpreted?5.4 Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?5.5 Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?