Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: protocol for a mixed-methods systematic review.

Introduction

Chronic MSK conditions are characterized by pain, physical limitations, stiffness and swelling (Briggs et al., 2018; Cottrell et al., 2017a). These conditions are considered as the leading contributors to the global burden of disability with a reported 19.6% increase between 2006 and 2016 in the global disability-adjusted life years (DALYs) (GBD, 2017). Further, the economic, social, and functional impact of chronic MSK conditions has been reported globally with significant costs associated with medical care, lower productivity, loss of wages, emotional wellbeing, and poor quality of life (Breivik et al., 2006; Hagen et al., 2020; McMahon et al., 2021). Current treatment guidelines and interventions recommend non-pharmacological self-management strategies that aim to be preventative and can include education, exercise and following rehabilitation protocols (Lin et al., 2020). However, factors that can influence the uptake of such programmes include the perspectives of patients and clinicians of their effectiveness (e.g., pain reduction), accessibility (e.g., convenient for those with mobility limitations), and flexibility (e.g., time-efficient, mode of delivery) (Hofstede et al., 2016; Turolla et al., 2020; van den Berg et al., 2008; Wade et al., 2014). As such, interventions addressing these factors might encourage adoption of recommended non-pharmacological self-management programmes and address the global economic and social impact.

The growing burden on healthcare resources from longer waiting lists and those who cannot access care due to their location, work/caring responsibilities or symptoms has led to poor implementation of guidelines and access to treatment (Hunter, 2011; van Beugen et al., 2014). To address this, the interest in and use of digital models of care has increased due to their accessibility and flexibility (Turolla et al., 2020). Further, the coronavirus disease 2019 (COVID-19) pandemic has shown that healthcare settings can adapt and offer flexible programmes that can be delivered online. Recent systematic reviews have found that delivering online programmes for the management of chronic MSK conditions is effective and comparable to face-to-face care (Agostini et al., 2015; Cottrell et al., 2017a). For example, trials on telerehabilitation for patients with osteoarthritis (OA) reported clinically meaningful improvements in pain, physical function, quality of life and self-efficacy (Bennell et al., 2017; Bossen et al., 2013; Cuperus et al., 2015; Pignato et al., 2018). However, technical capabilities and access to equipment has led to poor uptake of online programmes (Aily et al., 2020). Additionally, clinician acceptance can influence the development, uptake, and sustainability of telehealth programmes (Wade et al., 2014). Furthermore, the perceptions of clinicians on the effectiveness of interventions are significantly valued and often mirrored by patients’ (Hofstede et al., 2016; Iversen et al., 2004; van den Berg et al., 2008). As global life expectancy and prevalence of chronic MSK conditions continues to grow, we must determine the role of perceptions in the uptake of ODEPs to help address the growing demand for healthcare resources and offer approaches that allow increased participation in timely healthcare.

Prior systematic reviews on patient and clinician perspectives of ODEPs have been conducted. For example, (Fernandes et al., 2022) qualitatively synthesized patient perceptions for engaging in synchronous and asynchronous delivery of a telehealth pain management intervention. Similarly, (Amin et al., 2022) quantitatively investigated patient and rehabilitation professionals’ satisfaction with telehealth interventions. Methodologically inclusive literature reviews have been used to report perceptions of participants related to interprofessional collaboration and sustainability of health policies or programmes in health practices (Seaton et al., 2021; Shoesmith et al., 2021). They are appropriate for exploring questions addressing intervention need, appropriateness and acceptability, and allow for primary data from qualitative and quantitative studies to be pulled together to generate new models (Barnett-Page & Thomas, 2009; Tong et al., 2012). This approach will facilitate a richer understanding of perceptions of patients and clinicians of ODEPs for chronic MSK conditions compared to investigating quantitative or qualitative findings alone. Thus, the primary aim of this study is to synthesise the perceptions of patients and clinicians of ODEPs for chronic MSK conditions. Our secondary aim is to present the common or differing perceptions of patients and clinicians to inform our understanding of the complexity and interplay of factors related to uptake of such programmes. The current study aims to address important gaps in the existing literature including, significantly heterogeneous data due to previous focus on different aspects of patient and clinician perceptions of ODEPs. It builds on and synthesizes the existing literature by including both quantitative and qualitative patient and clinician data, and telehealth interventions either entirely (e.g., real-time video-based exercise session) or partially (e.g., website with exercise videos) delivered via synchronous mediums. Future interventions can adapt our findings to develop implementation strategies to encourage uptake and long-term sustainability for ODEPs for chronic MSK conditions.

Methods

The study has been registered on the PROSPERO database of systematic reviews (registration number CRD42021273773). The reporting of this protocol is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) checklist (Moher et al., 2015).

Study selection

The literature will be stored and organised using the reference management software EndNote X9 (Version 9.3.3). After the initial search, articles will be imported, duplicates will be removed, and relevant titles and abstracts will be screened for eligibility by three independent reviewers. Thereafter, relevant full-text articles will be retrieved and screened for eligibility by two independent reviewers. Citation tracking and manual screening of the reference lists of included studies related to the research question will be undertaken. Quality appraisal will be performed using the Critical Appraisal Skills Programme (CASP) Checklists (Critical Appraisal Skills Programme, 2018). Studies will be rated as high, medium and low quality if they met ≥8, 5–7 and ≤4 criteria, respectively (Kanavaki et al., 2017). Discrepancies will be resolved by author consensus and cross-checked for consistency by a third author. The process of study identification and selection will be documented according to a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant flow chart (see Figure 1) (Page et al., 2021).

Figure 1. Flow diagram of study identification and selection, adapted from PRISMA flow chart (Page et al., 2021).

Discussion

According to the World Health Organization (WHO), MSK conditions are the leading contributors for the global need for rehabilitation, accounting for 1.71 billion people globally (World Health Organisation, 2021). The direct and indirect economic, social, and functional costs of chronic MSK conditions are immense, with projections showing an increase in prevalence in the future (Cieza et al., 2020; World Health Organisation, 2021). As such, it is important to offer accessible healthcare services that provide a sustainable option to address this growing public health problem.

Current treatment approaches for chronic MSK conditions include offering accessible and flexible ODEPs. However, slow uptake due to patient and clinician perceptions of their effectiveness has led to a gap in evidence-based care and generated an unmet need for rehabilitation globally (Cottrell & Russell, 2020; Wade et al., 2014; Wade et al., 2016). Further, negative perceptions may create barriers to participation in and referral to guideline-based management programmes (Wallis et al., 2020).

Previous research found that patients frequently access medical advice and treatments from clinicians, whose acceptance of telehealth can in turn influence their own acceptance (Cottrell et al., 2017b; Hofstede et al., 2016). This suggests that the perceptions of patients and clinicians are interconnected and can influence each other. Previous systematic reviews investigating the recommended management of chronic MSK conditions have reported on the perceptions of either patients or clinicians. For example, Fernandes et al. (2022) investigated the perceptions and/or experiences of patients with chronic MSK pain related to telehealth pain exercise, education, and self-management strategies. On the other hand, Egerton et al. (2017) investigated the views of primary care clinicians on providing recommended management of OA. Thus, this review builds on previous work to identify evidence on both clinicians’ and patients’ perceptions of telehealth exercise interventions for chronic MSK conditions. We will investigate if and how these interconnected perceptions play a role in telehealth engagement by synthesizing the literature from two perspectives. Furthermore, this review will address both qualitative and quantitative data, allowing for the inclusion of larger or more diverse populations. To counteract author bias, personal beliefs will be reflexively assessed. Limitations may include publication bias resulting from the exclusion of wider literature from other languages, paediatric populations, other types of telehealth interventions, and other chronic health conditions. Generalisability may be limited to (1) other self-management strategies, (2) other geographical locations, cultures, and healthcare settings, and (3) other healthcare professionals involved in delivery of care for MSK pain.

Insight into both patient and clinician perceptions could allow for implementation of strategies that use targeted education to address perceptions and can be useful in improving uptake and facilitating recommended practice. Policy makers, clinicians, and researchers may find the perception-centred approach helpful in developing and testing telehealth treatments and implementation strategies. Further, by integrating objective numerical and subjective opinions data on the common and differing perceptions of patients and clinicians, a more in-depth understanding of a topic, compared to single method reviews, can be generated. Future studies could evaluate how this approach is helpful in improving patient and clinician uptake of telehealth for chronic MSK conditions.

This protocol describes a planned systematic review that aims to gather primary data from qualitative and/or quantitative peer-reviewed studies investigating the perceptions of patients and clinicians of ODEPs for chronic MSK conditions. It offers an outline of our objectives and methods, and any deviations will be discussed in the systematic review report. By investigating the perceptions of patients and clinicians, we hope to gain a better understanding of how these perceptions may be shared or influence each other. These findings could assist with the development of evidence-based implementation strategies that aim to deliver consistent and tailored interventions targeting the needs of end-users. This will encourage uptake and long-term improvements in health policies and services.

Dissemination

The systematic review will be disseminated in a peer-reviewed journal and access to the dataset will be available from the corresponding author upon request.

Ethics approval and consent to participate

This study is a review of the literature and does not involve conducting experimental research or collecting personal data. Thus, ethical approval and consent to participate is not required.