Ep 176: Musculoskeletal rehabilitation in a digital age, with Dr Alessio Bricca and Nikolaj Nøhr

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:09] research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today.

[00:00:20] Have you been scrolling the app store wondering if there's anything worthwhile to recommend

[00:00:26] to patients? Today we're uncovering what makes a quality

[00:00:30] app for monitoring and promoting physical activity in chronic conditions, including musculoskeletal

[00:00:36] pain. Joining me to share the latest research and discuss how to apply it in practice are

[00:00:41] exercise physiologist Dr Alessio Bricker and physiotherapist Nicolai Noor.

[00:00:47] Alessio is an assistant professor at the University of Southern Denmark. His work

[00:00:52] is in understanding how to help patients with chronic conditions boost their physical activity

[00:00:56] using digital technology. Nicolai has a master of science in exercise and health and combines

[00:01:02] his clinical work in CrossFit and high-intensity functional training with research in digital

[00:01:08] health. Okay, here's today's episode. Dr Alessio Bricker, Nicolai Noor, welcome

[00:01:15] to JOSPT Insights. Thanks for the invitation.

[00:01:19] There's an app for just about everything today, including in musculoskeletal rehabilitation

[00:01:24] and exercise therapy. And we're going to get to talking about different apps in our field

[00:01:30] of practice. You've been doing a ton of work collating and cataloging these apps and really

[00:01:36] trying to pull together what we know about how effective these apps are. But before

[00:01:41] we get there, I'd like to do a little bit of setting the scene with you, Alessio

[00:01:45] and Nicolai, because we're talking about interventions and tools that fall broadly under

[00:01:51] an umbrella referred to as digital health. I'd like to start by defining some of the

[00:01:57] terms that people might hear about or read about in digital health. So, Alessio, let's

[00:02:02] start really broad. What is digital health? Thanks Claire for the question. I want to

[00:02:08] make a disclosure and that's because I have to confess that I was never particularly fond of

[00:02:16] digital technology until the COVID pandemic hit. However, during that time, I began

[00:02:25] utilizing smartphone apps, so mHealth, to exercise at home like many of us maybe did.

[00:02:33] And surprisingly, I found the experience to be quite positive, quite the opposite of what I had

[00:02:40] expected. And this really prompted me to explore the research surrounding digital health tools

[00:02:48] and conduct some research myself on this field. So, what is digital health? Well,

[00:02:55] digital health is defined as the use of digital technologies in medicine and other

[00:03:02] health professions to manage illnesses and health risks and promote wellness. And this may include

[00:03:10] the use of wearable devices, health information technology, electronic health records, telemedicine,

[00:03:18] eHealth and mHealth, virtual care, you name it. The very important thing I think about this

[00:03:24] definition is that we are at a pivotal moment in the digital health era. And that is because maybe

[00:03:33] we have found a definition that pleases everyone working on the field of digital health.

[00:03:39] And there's been a lot of work from the World Health Organization in this area as well that

[00:03:44] we can alert folks to. So, I think you're right that this is very much a topic that has

[00:03:49] captured the world's attention. And I'm sure that your story about using apps or discovering apps

[00:03:56] or their power during the pandemic time is going to resonate with many of our listeners.

[00:04:01] Nikolai, how have you come to digital health? For the last six years, I've been working as a

[00:04:06] physical therapist. I've done work in both general practice and with athletes.

[00:04:12] I've been using some of the tools to do rehabilitation remotely. And either this is for

[00:04:19] patients who are not able to come to the clinic or it will be as an add-on to an existing

[00:04:26] face-to-face consultation. Often, this is with patients who benefit from extra attention.

[00:04:33] So, this could be by the use of apps, but it could also just be as simple as a

[00:04:38] phone call. Depending on the situation, some tools offer valuable resources that extend beyond

[00:04:45] communication. So, there could also be screening tools and questionnaires and ways to collect data

[00:04:52] such as vast pain scales or have some functional tests that could be relevant in the rehabilitation.

[00:05:00] I'm glad that you mentioned the simple phone call because the temptation,

[00:05:04] I think, often is that we try to create these very complex interventions or we always go to the

[00:05:09] more complex end of things. Sometimes the quite simple telephone call is just what is needed

[00:05:15] or is just what the person would like and works well with their environment.

[00:05:19] And it also reminds me that digital health encompasses all things as you mentioned,

[00:05:24] Alessio, including digital medical records. Now we're seeing emerging use of AI,

[00:05:32] intelligence in machine learning in healthcare from a delivery point of view and also note-taking

[00:05:38] and recording. And there's lots of privacy and data sharing and data integrity concerns with

[00:05:44] those technologies. And we won't get into that today. That's a whole separate podcast.

[00:05:49] Nikolai, I want to stick with you. You alluded a little bit to how you have been using

[00:05:54] digital health in your musculoskeletal and your physiotherapy practice.

[00:05:58] Can you expand a little bit more on that and particularly how you choose which tool

[00:06:03] to use with which person? I always try to see what's relevant to the patient

[00:06:09] and not see what I like to use the most. I have a story from when I was working in general

[00:06:15] practice and I had a patient with Parkinson's disease and he was recommended by his

[00:06:21] general practitioner, his doctor to increase his physical activity. So this could be done

[00:06:29] by his recommendation. It could be done by increasing his step count.

[00:06:33] So he was recommended to buy a variable watch that could count his steps. The patient

[00:06:40] started walking more and in his mind, he increased his physical activity.

[00:06:45] However, it did not show on the wearable watch. So he was kind of disappointed with

[00:06:51] the tools because in his mind, he figured that he'd actually increase his physical activity.

[00:06:56] Important to note that this patient was walking with a walker. So a wrist-worn step monitor

[00:07:04] was not a good tool for this person. So I think it's important to figure out what's

[00:07:09] important to the patient in question instead of trying to put tools on them that might

[00:07:15] not be useful in their situation. What's actually important for the patient?

[00:07:22] There are also patients who could benefit from more extended tools. So at the moment,

[00:07:28] I work more with athletes. For some of them, they have a need to sometimes communicate more

[00:07:35] often and sometimes have it functioning very quickly such as a chat function or as a video

[00:07:43] they can send me and I can review them and send them some feedback. I think those needs are different

[00:07:48] and that must be respected as a clinician. Yeah, great examples. Thanks for sharing those,

[00:07:54] Nicolai. It reminds me too that there are plenty of people in our community who use things like

[00:08:00] smart watches or the phone that's in people's pockets. Whether this is good or bad, let's not

[00:08:05] get into that. Our technology, the devices that we use every day are collecting a lot

[00:08:10] of information about us and certainly smart watches are a way, if people already have access

[00:08:16] to those devices, they're already using them, building that into how you're gathering information

[00:08:21] to support your clinical decisions is a useful way of using them I think.

[00:08:27] Yeah, that's an important point because if we want to collect data, we don't want to

[00:08:32] do it just for the sake of collecting it. We want to do it for something useful. So that

[00:08:37] could be in terms of goal setting or knowing when to add a progression to the rehab or

[00:08:45] entering a different phase of a rehab, especially the variables. Sometimes they become a little bit

[00:08:51] collecting data for the sake of collecting it. A consensus paper has just come out setting

[00:08:59] the scene on how to really use, setting the direction for how to really use digital health

[00:09:07] in clinical practice. And they have highlighted that if we want to take a step forward and

[00:09:14] improve the way we use digital health, we should first understand the acceptability

[00:09:21] of using digital health from the patients, the feasibility of it based on the setting context

[00:09:28] beliefs, costs and so on, as well as the effectiveness and cost effectiveness.

[00:09:36] We are still at the beginning on how to use effectively digital health in clinical practice,

[00:09:43] but I think that in the next few years we will get there.

[00:09:47] That's great. And it's nice to know that people are thinking through some of these

[00:09:51] challenges and trying to lay out a bit of a roadmap. It reminds me of a paper I read

[00:09:56] recently where they had calculated the amount of research funding that had gone to musculoskeletal

[00:10:03] pain apps. And shockingly, to me at least, there was millions of dollars in research

[00:10:09] funding wasted because we'd put money into projects that were developing apps that then

[00:10:15] people were not using because they were sitting in the app store not being updated or for

[00:10:21] various reasons people could no longer use those apps or they didn't work for people.

[00:10:25] So I think your point is really well made, Alessio, that designing these tools and technologies

[00:10:31] with the community for whom they are intended is vital for ensuring that they actually do

[00:10:37] what we are intending for them to do and that that's helpful for patients, people who

[00:10:42] are going to use them. Nikolai, I think this leads us nicely to what makes a good

[00:10:49] digital health tool or what makes a good app. What should I look for when I'm scrolling through the

[00:10:54] app store or a patient might come to you in the clinic and say, hey, I've seen this app. What do

[00:11:00] you think? So I think with apps specifically, I think that it should be intuitive and easy to use

[00:11:08] related to your specific to your patient group or the population that you are,

[00:11:14] you're doing rehab for. So where a user might find it, have some goals in mind that should be

[00:11:20] useful maybe at the developer or the engineer behind it is more focusing on the layout or the

[00:11:28] engagement of the app, which might not be super important for the user and also for the

[00:11:34] therapist, there might be specific goals that it's nice to have that could not be relevant

[00:11:39] for the patient. Alessio, what do you look for and what would you recommend people look for in

[00:11:45] digital health tools? That's a very good question. What makes a good digital health tool? Well,

[00:11:52] a digital health tool ideally is a tool that has high quality and a high potential

[00:12:00] for behavior change, which is key particularly if we want patients to maintain

[00:12:07] a healthy lifestyle in the long run. What does it mean high quality and high potential for behavior

[00:12:13] change? And now I will give you four keywords for what it means high quality and four keywords for

[00:12:20] what it means high potential for behavior change. So let's start with the quality

[00:12:26] and the first keyword I would like to give our listeners is engagement. So first of all,

[00:12:34] the app or the digital tool needs to be interesting, fun, customizable and as an example for send

[00:12:43] messages, reminders, feedbacks and alerts to the patients about the targeted behavior.

[00:12:50] Second functionality, it has to be easy to work. It has to be easy to learn and to use

[00:12:59] meaning that the icons should be visible. It has to be the text should be big enough for people

[00:13:05] to read it and so on, and it has to function well. Third aesthetics, it has to look good

[00:13:14] and for example the pictures and the graphics needs to be of high quality

[00:13:19] with colors that everybody can detect. And fourth keyword when it comes to the quality

[00:13:26] is that the tool should include an evidence based content. So the content should be relevant,

[00:13:34] appropriate, coherent and correct. And ideally the app should come from a legitimate source.

[00:13:42] So the four keywords for the quality that clinicians should look at are engagement,

[00:13:49] functionality, aesthetics and evidence based. When we look at the second macro group,

[00:13:57] so the behavior change, what does it mean? It means that the app or the digital tool

[00:14:03] has to have the potential of helping the patient to improve the lifestyle physical activity,

[00:14:11] which we know to be a key behavior for maintaining a healthy life. First of all,

[00:14:16] then the app or the tool should provide knowledge and information about the condition,

[00:14:23] for example the musculoskeletal condition, slow back pain, ulcerative arthritis, what it is,

[00:14:28] what it isn't and so on. And it has to have the feature of allowing the recording of baseline

[00:14:36] participants information. Then very importantly as also Nicolai was saying,

[00:14:42] goal setting and planning. Goal setting seems to be one of the strategies that works the best

[00:14:49] to improve a healthy behavior. So it is important that the app in addition to having a feature

[00:14:56] of setting up goals related to the targeted behavior, also the feature of reviewing goals

[00:15:04] and updating the goals when necessary. Third, feedback and monitoring. It's important to

[00:15:12] be able to self monitor our own behaviors. Again this is another strategy which has been shown

[00:15:20] across conditions to improve health related behaviors such as physical activity.

[00:15:27] And last but not least, action when it's not just about self monitoring but the tool

[00:15:34] should also help the patient to know what to do, when and how.

[00:15:40] That's brilliant Alessio, thank you. How does it work for someone who doesn't feel so comfortable

[00:15:45] using the technology? I think this is something you need to talk openly with your

[00:15:52] patient or with your clients about. When I used to work in general practice, I would have a sheet

[00:15:58] of exercise and I would always have this like QR code in the bottom where I could kind of

[00:16:04] navigate them towards an app that I used. And sometimes I could already tell how comfortable

[00:16:10] they were with the technology if they knew what a QR code was and if they knew how to do it.

[00:16:16] Sometimes they would already have the phones out scanning the QR code before I even showed

[00:16:20] them that function. And I think there was some higher likelihood of them using that function

[00:16:26] if they actually knew what it was. If some patients were not familiar with this or saw it

[00:16:32] more of a hassle or a feature that they were not comfortable with, they would not use that

[00:16:38] function. We shouldn't just expect to rely on these digital tools because we think they're

[00:16:44] smart. We should always keep in mind which patients we are working with and what are

[00:16:50] their actual preferences. So I don't think you should necessarily try to nudge people to use

[00:16:58] tools that they're not comfortable with because then one should ask themselves what would the

[00:17:03] reason for that be unless you have a really good reason to. Since the pandemic has your QR code

[00:17:09] test for digital tool comfort had to change, so I feel like the pandemic lots of people got very

[00:17:16] familiar with using QR codes whether they wanted to or not. So maybe the test has to change too.

[00:17:23] Nicolay, I know you've been doing a ton of work leading a network meta-analysis in this field.

[00:17:30] I would love for you to give us a bit of a taster of what you found and maybe before you do,

[00:17:36] could you explain what a network meta-analysis is and why it's so helpful?

[00:17:41] A network meta-analysis is a method of meta-analysis where you can compare more than two treatments

[00:17:49] or more than two interventions. So a traditional meta-analysis, you compare two treatments but here

[00:17:56] you can do kind of a network of different treatments. So this was relevant in our case

[00:18:02] because we conducted a systematic review or our coworker, Graciela, conducted a systematic

[00:18:07] review on digital health and related to different outcomes in patients with chronic conditions.

[00:18:15] There was a small effect but what we also saw that when looking into a lot of these studies or

[00:18:22] RCTs performed with digital health tools, there was a very big heterogeneity in

[00:18:29] what kind of tools they used, what kind of components they had. It's a very broad

[00:18:35] umbrella term. So what we tried to do with the component network meta-analysis was firstly

[00:18:43] to separate all of the RCTs into how they were delivered. So we made an analysis based on if

[00:18:49] they were delivered with phone call, text messages, smartphone apps, wearable devices, web pages,

[00:18:58] video conference calls or some of them had a mix of more and then compared them to

[00:19:04] say each other first but also in-person treatments. Secondly, we also compared the

[00:19:10] different type of components they included. So whereas some of them would be solely exercise,

[00:19:17] some of them could be more how to say incorporating self-management techniques like

[00:19:21] Alessio talked about with motivational interviewing, goal-setting, patient education and such.

[00:19:28] Some of them had a combination of the two and then we had a few studies that

[00:19:32] introduced the financial incentive and we chose to look at one outcome which was physical activity.

[00:19:39] So in short how effective were these different components and both of delivery

[00:19:44] in terms of increasing physical activity? Just to be transparent, I want to say that these are only

[00:19:52] preliminary results. So we have chosen to update the search before we submit it because we want

[00:19:58] this review to be as updated as possible before we submit it. I think that's

[00:20:04] that's the right thing to do with with systematic reviews because there's always new

[00:20:09] studies coming out. We have included 137 studies in this analysis so it's it's quite big and again

[00:20:17] this is containing not just musculoskeletal conditions but a variation of 13 different chronic

[00:20:24] conditions and we found out so far it looks like the digital tool needs to have some kind of

[00:20:32] self-management to be most efficient like Alessio talked about and it looks like so far that

[00:20:39] the mixed interventions are most effective and then also the the smartphone apps. My own

[00:20:47] interpretation of it is that this could be related to patient preferences. Yeah, it's like

[00:20:53] they it gives people options they choose what fits well with their life and fits well with

[00:20:59] how they like to engage with technology. I think that makes a lot of sense, Nicolai.

[00:21:03] I think it's the complexity of it. The complexity of it is quite high so that's also where

[00:21:11] different approaches go to different people. Yeah, absolutely. It's an attempt to try to

[00:21:17] disentangle the complexity of digital interventions so we will be able I think

[00:21:25] with this network meta-analysy to provide some useful suggestions on how to design

[00:21:31] future apps and to identify the components that we should not compromise when it comes to

[00:21:38] improving physical activity. That's great and we will we will definitely keep an eye out for

[00:21:44] for the work because it sounds fantastic and really helpful. We've had a very positive

[00:21:50] focus in this chat today on digital health and the benefits and how it can help people,

[00:21:56] clinicians and patients. I think it's worth just touching on the limitations or maybe some of

[00:22:02] the things to keep in the back of your mind downsides or potential harms that could come

[00:22:07] out of digital health technologies or tools. Alessio, what would you suggest people think

[00:22:13] about when they are choosing digital health tools? There are harms associated with the use

[00:22:20] of digital tools. However, we can say quite firmly that the benefits outweigh the risks

[00:22:29] of using such tools and that's because when I talk about benefits as Nicolai has said,

[00:22:34] well there are improvements on physical activity, physical function and health

[00:22:40] related quality of life and reduction of depression and anxiety symptoms. They are

[00:22:47] from a small to moderate extent, so it's not a panacea that resolves anything digital health,

[00:22:53] but as compared to not using digital health, so do nothing or just giving some information

[00:23:00] to the patients about being physically active, they provide some benefit. The downsides are that

[00:23:07] the risk of non-serious adverse events is slightly higher in those using digital health solutions

[00:23:17] that target physical activity and that means that people with chronic conditions such as

[00:23:24] musculoskeletal chronic conditions might experience an increased in pain or muscle soreness after

[00:23:33] using these apps potentially because they move more and they consider such physiological responses to

[00:23:41] physical activities or exercise as adverse events. So it is important to educate the patients that

[00:23:50] well this might happen, however the good thing is that they usually resolve without any treatment

[00:23:58] and in a couple of days. The very positive aspect is that at least in the research we have conducted

[00:24:05] by summarizing all the effects, benefits and harms of digital intervention, well is that the risk of

[00:24:12] serious adverse events so that hospitalizations or events which require additional care is not

[00:24:22] increased. Now what is important to tell a patient is that that doesn't mean that if you use digital

[00:24:30] health you won't eventually have any serious adverse events, but the risk of having such

[00:24:38] events as compared to not using this tool is not higher. Overall yes there are benefits

[00:24:47] and it is important to address what patients might experience as non-serious adverse events in the

[00:24:53] education when using these tools. I think this is a lovely place for us to finish, Alessio. You

[00:25:00] and Nikolai have given us a wonderful summary of what we can look to harness in terms of benefits

[00:25:06] of digital health tools while also keeping in mind that there are such a different range of

[00:25:10] tools there's some key things to watch out for and these are not panacea tools they're not

[00:25:15] going to work for everyone either just like any of our other interventions available at our disposal

[00:25:22] as musculoskeletal clinicians. So Dr Alessio Brica, Nikolai Noor thank you for joining me on JOSPT Insights.

[00:25:30] Thank you Claire. Thank you and last but not least I want to give a big thank you

[00:25:36] to the team that has contributed generating and disseminating the knowledge that I've

[00:25:41] presented today about digital health for managing chronic conditions including musculoskeletal

[00:25:47] conditions and they are Graziella Zanger, Nikolai and Alessandro Pellegrini and the research group

[00:25:55] Fof led by Professor Jonas Thorlund and Progress led by Professor Sorin Sco.

[00:26:06] Thanks for listening to this episode of JOSPT Insights. For more discussion of the

[00:26:10] issues in musculoskeletal rehabilitation that are relevant to your practice subscribe to JOSPT

[00:26:16] Insights on Apple podcasts, Spotify, TuneIn, Stitcher, Google or your favourite podcast app.

[00:26:23] If you like JOSPT Insights help others find us tell your friends and colleagues and raid

[00:26:28] and review us. To keep up to date with all the latest JOSPT content be sure to follow

[00:26:33] us on Twitter we're at JOSPT and Facebook we're JOSPT official. Talk with you next time.