The role of Technology-Assisted

Interventions in Musculoskeletal

Physiotherapy

Majed Jazi Alharbi1*, Abdullah A. Alshalawi2, Abdulrahman D. Alotaibi3, Faisal M.

Alotaibi4, Nouf AlAwfy5

1 Senior Physiotherapist Specialist-Physiotherapy, HHC in Prince Sultan Medical Military Hospital

2 Senior Specialist-Physiotherapy, Prince Sultan Medical Military Hospital

3 Technician-Physiotherapy, Prince Sultan Medical Military Hospital

4 Specialist-Physiotherapy, Prince Sultan Medical Military Hospital

5 Senior Clinical Dietitian, Prince Sultan Medical Military City

Abstract - Physiotherapy specialising on the musculoskeletal system offers non-invasive

treatment options for many health issues. Due to poor self-efficacy and a lack of supervision,

fitness programmes are currently not very popular. One potential answer to this issue might be

the adoption of mHealth interventions, which would assist encourage self-management at home.

On the other hand, musculoskeletal physiotherapy's best mHealth practices are not well-

supported by research. The purpose of this PAER is to review the research on mobile health

applications in musculoskeletal physical therapy and to provide conclusions based on those

findings. In March 2022, researchers in Saudi Arabia performed a scoping study of six datasets

that had been peer-reviewed. Only items published in English were chosen, and there were no

restrictions on the dates. Data extraction followed article screening by two more researchers who

randomly selected a subset of the papers. Despite high levels of patient satisfaction with mHealth,

disengagement was seen due to issues such as slow internet and a lack of high-quality

information. Short training periods and unfamiliarity with the technique were obstacles to its

clinical acceptance. One area where mHealth shows promise is in improving treatment adherence;

it has the ability to be both more cost-efficient and just as effective as traditional physiotherapy

care. Currently, mHealth works best when a healthcare provider can provide continuous feedback.

Keywords - Physiotherapy, Musculoskeletal, mhealth, Exercise, Interventions.

INTRODUCTION

The evaluation, diagnosis, and treatment of disorders involving the musculoskeletal system are areas in

which physiotherapists excel [1]. The Saudi Arabian healthcare system has included advanced

musculoskeletal physiotherapy positions for more than 30 years, and these professionals have been

essential in providing musculoskeletal treatment to patients throughout the country [2]. When

physiotherapists were accepted as the best professionals to handle most patients' ailments, their

incorporation into orthopaedic and neurosurgery treatments marked the beginning of advanced practice

recognition. Improved patient care via newly created positions that adapt to local needs and fill gaps in

medical and surgical professionals [1,3,4], as well as through in-house training [5]. Through the utilisation

of both full and extended scopes of practice, Advanced Physiotherapy Practitioners (APPs) have proven

to be both clinically and financially beneficial in a variety of settings, including but not limited to:

paediatrics, rheumatology, emergency, primary care, persistent pain, and therapy departments.

Educational courses have been designed and put into place to better equip and future-proof the

workforce in response to the growth of advanced practice jobs within the rapidly expanding and

continuously evolving scope of practice for physiotherapy [8]. For decades, the worldwide Federation of

Orthopaedic Manipulative Physical Therapists (IFOMPT) has set worldwide musculoskeletal standards of

practice [9] to guarantee the right degree of clinical practice, governance, and treatment quality. As the

first specialist sub-group of the World Council of Physical Therapists (WCPT), MAPP has consultative

status with the UN and an official relationship with the World Health Organisation. Many worldwide

curriculum match the requirements specified by IFOMPT for advanced musculoskeletal physiotherapy

education and practice [4]. The rigorous postgraduate specialisation courses in musculoskeletal

physiotherapy mirror the IFOMPT Educational Standards [9], which include ten aspects and forty-three

learning objectives that are operationalized by the MACP for the Saudi. The ability to analyse, evaluate,

and treat health issues originating from musculoskeletal diseases is a hallmark of advanced practice in

thorough examination and conservative management, which physiotherapists achieving MACP

membership eligibility requirements may show. Knowledge of evidence-based practice concepts and

clinical reasoning processes at the master's level are foundational to effective work at the advanced

practice level.

METHODOLOGY

Participants’ characteristics

The age was recorded in 20 trials, with the experimental group having an average age of 46.6 ± 8.1 years

and the control group at 46.8 ± 9.2 years. The majority of the studies failed to record participants'

educational backgrounds. The proportion of participants with only a primary or no formal education was

28.8% in the group.

Stage 1: Identifying the Research Question

 Objectives

The main goal was to examine the results of musculoskeletal physiotherapy using mHealth, such as pain

reduction and claimed increases in self-efficacy. The secondary goals were to ascertain the following: the

history of mHealth applications, the conditions for which mHealth has been used, the interventions that

have been developed and implemented with mHealth, the factors that have facilitated and hindered the

use of mHealth, and the obstacles to clinical uptake.

 Eligibility Criteria

The studies that were considered for inclusion or exclusion were evaluated using the following criteria:

Inclusion criteria

o The articles are written in English.

o Articles that have been peer-reviewed and published in publications that make their entire texts

accessible

o Let's hone in on how musculoskeletal physiotherapists and their patients may benefit from mobile

health.

o It's possible to use mobile health in a home or outpatient environment.

o Research involving the use of mobile health either entirely or in conjunction with other treatment

methods.

Exclusion criteria

 Research examining the use of mobile health in several medical fields (such as obesity and

mental health))

Stage 2: Finding Appropriate Research

Important databases such as MEDLINE, Embase, CINAHL Plus, AMED, ProQuest Health and Medical

Complete, and IEEE Xplore were used to find peer-reviewed papers. These databases were selected

because they include extensive collections of physiotherapy research papers and health technology

papers. In order to include other pertinent research that were not found via database searches, the grey

literature was also reviewed. In March of 2022, the search was carried out in Saudi Arabia.

In order to acquire as much relevant material as possible, three researchers (JMRA, DK, and CH)

searched databases without applying any date limits in order to find all relevant literature.

Stage 3: The Process of Study Selection

In order to eliminate any possibility of duplicate references, all relevant sources were imported into

RefWorks (ProQuest). At least one researcher (JMRA) met the requirements for both the abstract and title

reviews as well as the full-text reviews. In order to facilitate agreement on the qualifying criteria, two extra

researchers (DK and CH) examined 10% of the chosen studies. Finally, three researchers (JMRA, DK,

and CH) read and evaluated all of the included papers' entire texts.

Stage 4: Charting the Data

The data gathering process for the included studies was guided by a data-charting form. Along with more

generic information like author and publication year, this form also asked for details that were pertinent to

the review at hand. A random selection was made from the database search results to pilot the data-

charting form. This gave us the go-ahead to make the necessary adjustments before plotting the data

from the other trials. Three further researchers checked a subset of these experiments for additional

rigour after one of them (JMRA) plotted the data from all the others.

Stage 5: Gathering Data, Consolidating It, and Sharing It

To assist in the synthesis of the literature about the use of mHealth in physiotherapy, a number of tables and

infographics were used to summarise the quantitative aspects of the included research. This included things

like who was using mHealth, what the intervention was, and the most prevalent medical issues treated with

mHealth. The literature also included a narrative explanation of the final data extraction. Using the study

question and data generated via an iterative approach, the research team established topics and categories.

RESULTS

Study Selection

There were 1,495 titles found in the first database search for mHealth literature. A total of 311 titles, or

20.8% of the total, were duplicates. After reviewing the titles, an extra 66.42%, or 993/1495 studies, were

discarded because they did not satisfy the inclusion requirements. After abstracting 191 titles (12.78%),

99 articles (51.8%) were culled from the original 1495. Out of these, 21 articles (21% of the total) were

discarded due to erroneous results, 32 articles (32% of the total) were discarded because they did not

pertain to physiotherapy, 27 articles (14% of the total) were culled because mHealth was not a part of the

study, 14 articles (14% of the total) were culled because they were not written in English, and 5 studies

(5%) were discarded because they were carried out in settings not covered by this evaluation. Twenty

articles, or 14.7%, were included in the final full-text review of the remaining 92 papers (48.2%). The

reasons for exclusion included the following: seventeen (18%) papers did not have full-text available;

sixteen (17%) papers did not focus on physiotherapy; ten (11% of the papers) did not include mHealth;

and twenty-one (23% of the papers) studies were conducted in the incorrect setting, as mentioned earlier.

 Research Features

Outlined above are the study's features and its conclusions. The 25 essays that made it to the final round

had a total of 1400 Saudi participants. From three to three hundred sixty-eight people took part in the

trials.

Table 1. Research Features

Table 2. Research methods and settings.

Comparing the two types of research, Table shows that quantitative studies predominated (23/20, 82% vs.

4/20, 14%). Mixed methods studies accounted for a meagre 4% (1/20). Ten out of twenty studies (36% of

the total) were RCTs, whereas four out of twenty (14% of the total) were systematic reviews, one of which

was a meta-analysis. Ranked controlled trials accounted for 7 out of 20 studies, or 25%; prospective

randomised controlled trials for 2 out of 20, or 7%; and randomised controlled noninferiority trials for 1 out

of 20, or 4%. There were a number of other quantitative designs that were considered, such as a

retrospective pre-post design (4% of studies), a controlled study (4% of studies), a case series (4% of

studies), a prospective single-group clinical study (4% of studies), a repeated measures design (7% of

studies), a pilot study to assess feasibility (4% of studies), a prospective parallel-group feasibility study (4%

of studies), a controlled study (4% of studies), and a nonrandomized controlled trial combining a single-arm

intervention cohort with historical controls (4% of studies). Quarter of the interviews were semi-structured,

accounting for 11% of the total. A qualitative interview was the only method used in just 4% (1/20) of the

investigations. Among studies that analysed data using a mixed methods design, 4% (or one in twenty)

used a mixed methods design. One out of twenty research designs, or 4%, were not clearly stated.

 Features of the Intervention

Even though mHealth was mentioned in every study, several of them didn't provide detailed enough

descriptions of the input to make it replicable. There was a lack of specificity on the protocols used in the

studies that claimed the intervention was a home exercise programme. Elements of stretching and

strengthening were detailed in studies that offered sufficient depth. An intervention that comprised

education, cognitive behavioural therapy, weight reduction, and psychological support was included in

another trial, while one study detailed walking exercises. In order to determine the intra- and interreliability

of remote assessments conducted by telerehabilitation technologies, further research investigated the

use of mHealth in conjunction with physiotherapy evaluations.

 Possible Past Uses of mHealth

1. Earlier Uses of mHealth in Rehabilitation

Out of the 20 papers that were considered, 4 (or 20%) were systematic reviews and 1 (or 4% of the total)

looked at alternative mHealth applications. The papers that were relevant to the systematic reviews were

included in this review independently. The remaining research looked at how well and how practically

certain applications work now and in the future. Four out of twenty reports (14%) of prior mHealth

implementations used telephone-based treatments using internet-connected videoconferencing to reach

patients' homes. The use of web-based telerehabilitation software in conjunction with videoconferencing

was detailed in another study. This software included wireless sensors to track patients' motions, a

programme to show them how to strengthen and increase their range of motion (ROM) after total knee

arthroplasty, and a portal for clinician input. The distribution of mHealth using cellphones or the internet

was mentioned in less depth in other approaches. According to this research, all home-based therapies

included a personalised fitness programme and promoted self-management techniques including group

workouts and talk sessions. Rehabilitation games that are accessible on various platforms, like the Wii,

PlayStation EyeToy, and Xbox Kinect, may also be used as a kind of mHealth application to help with

recovery from soft tissue and bone injuries. Playing these Wii games was a great way to improve your

balance and agility.

2. Prior Mobile Health Apps for Clinical Implementation

Physiotherapy evaluations of musculoskeletal diseases were documented in only 7% (2/20) of the

research [58,61]. Comparing web-based evaluation with more conventional, in-person approaches was

the overarching goal of this research. Patients were asked to self-palpate and complete modified self-

administered special tests using videoconferencing, which was once again used as part of mHealth.

Several objective parameters, including pain, range of motion, muscular strength, gait, and edoema,

might be more precisely measured using mHealth, according to the findings. There was insufficient data

to conclude that mHealth could effectively measure neurodynamic testing and spinal posture.

3. Musculoskeletal Disorders That Have Made Use of mHealth

Researchers have identified specific musculoskeletal disorders that have been treated with mHealth, but

other studies have used a more general term that encompasses a variety of conditions. Arthroplasty, or

complete knee replacement, accounted for 14% of the properly characterised musculoskeletal disorders

(4/20). In addition to total hip replacement or arthroplasty (2/20, 7%), anterior cruciate ligament repair

(2/20, 7%), shoulder joint replacement (2/20, 7%), and subacromial decompression (1/20, 4%), mHealth

was also used in other surgical operations. Among the chronic conditions covered in various articles

were: rheumatoid arthritis (2% of the total), adhesive capsulitis of the shoulder (4% of the total),

mechanical low back pain (4% of the total), chronic neck pain (2% of the total), and chronic knee pain or

osteoarthritis of the knee (11% of the total). Prolapsed intervertebral discs (1/20, 4% of cases) and tennis

elbow (1/20, 4% of cases) were less prevalent.

 Programmes That Have Used mHealth to Make a Difference

When compared to earlier applications of mHealth, it seems like no new intervention is being put into

place. The majority of research found that effective mHealth therapy relies on open lines of contact

between the patient and treating therapist. Teleconferencing and videoconferencing, such as Skype

(Microsoft Corporation), are two possible means of doing this. Most recent research has shown that

mobile health (mHealth) is most effective when used in conjunction with standard treatment, which

includes in-person physical therapy sessions that include both exercise and manual manipulation.

Participating doctors made weekly teleconference calls to a number of trials that also contained

pamphlets. A variety of web-based applications and smartphone-based apps were used in trials where

teleconferencing was not an intervention. As part of these treatments, patients were given narrated

videos of exercises and asked to record themselves doing them and send the footage back. With the use

of physician comments, this would make exercise progression suitable. In one study, participants used a

wearable motion sensor device in conjunction with a patient app and a physician app. Both the patient

app and the physician app were designed to aid users in visualising the proper range of motion (ROM) for

exercises, and the physician app also allowed users to submit text to track their progress.

 Justifications for Participation or Nonparticipation in mHealth

Ninety percent (18/20) of the articles explained why people participated in the intervention or didn't. In

sum, their explanations were lacking in specificity. Participants rated the interactive elements and easily

accessible help as very vital, leading to generally high patient satisfaction. Constant interaction with their

doctor led to a decline in surgical interest, according to studies examining preoperative regimens.

According to many studies, mHealth improves treatment adherence over the long term (defined as 6

months) due to the fact that specialised supervision helps keep patients motivated, confident, and

establishing goals on a consistent basis. People said that technical issues, including slow internet or

poorly designed applications, were to blame for their disengagement. Since the majority of users would

likely have access to mobile devices with sufficient data capabilities, it was suggested that this may be

mitigated by using a web-based platform on these devices. Researchers found that patients benefited

best from video-based therapies, which taught them the proper form and boosted their self-assurance so

that they could complete the exercises as prescribed.

 Challenges in the Implementation of mHealth

Among the studies that looked at mHealth, only 4% (1/20) focused on doctors' experiences.

Physiotherapists' approval of a new telemonitoring technology was found to be mediocre at best,

according to this research. Not having enough time to learn how to use the telemonitoring platform might

be the reason for this. Physical therapists' major gripe with the intervention was the extra labour it

required them to do, as they now had to enter patient information into yet another eHealth data log. Users

wanted it to be more efficient, easier to use, and more aesthetically pleasing for future usage. [30] In

order for digital health technology to more readily become ingrained in clinical practice, several therapists

have suggested incorporating it into normal therapy. There was also a preference for apps on

smartphones rather than online apps, although the reasons behind this were not clearly stated. The

research concluded that one last obstacle is the absence of formal training programmes for both present

and future health care workers, which hinders their familiarity with emerging health care technology. More

training and easier integration of new health care technology into professionals' practices are needed in

the future.

Principal Findings

This research uncovers five themes of mHealth adoption, including facilitators and challenges to uptake,

and gives a mapping of the range of evidence for mHealth usage in musculoskeletal physiotherapy. The

primary objective of this scoping review was to examine the data pertaining to musculoskeletal

physiotherapy's usage of mHealth and the results it generated. The primary results of this research

indicate that patients prefer to communicate with their clinicians via phone conversations or

videoconferencing because it allows them to provide continuous feedback, which may increase the

likelihood that patients will stick to their rehabilitation programmes. Another research indicates that

practitioners are not well trained to utilise mHealth, which is causing low adoption rates.

This research shows that mobile health has great promise as a future part of musculoskeletal

physiotherapy. Because patients can now access information and take charge of their rehabilitation using

their cellphones, mHealth treatments may be more successful than traditional physiotherapy care,

according to recent research [69]. The evidence for this claim is limited, though, according to this review.

Out of all the studies that were considered, just 11% (3/20) used smartphones, and even fewer compared

mHealth to physiotherapy. Despite this, the review did find that a comprehensive digital care intervention,

in conjunction with ongoing support from regular physiotherapy, greatly improves pain and function

outcomes. Inadequately reported research prevented us from drawing any conclusions, whereas those

that did suggest that mHealth may be at least as beneficial as PT.

When compared to in-person evaluations, there is little proof that mHealth can successfully replace them

in musculoskeletal physiotherapy. Two investigations (representing 7% of the total) found this method to

be valid and reliable; one study focused on elbow-specific evaluations (4% of the total) and the other on

general musculoskeletal diseases (4% of the total). Since the patient was not competent to administer the

neurodynamic tests in the same way that a professional would, the results were unreliable, indicating that

this is not a suitable substitute. The most often used kind of mobile health in musculoskeletal

physiotherapy were therapist-patient phone or video chat sessions. The fact that patients are more like to

react favourably to an app that is easily accessible on their smartphone raises concerns about the lack of

innovation in this area. The necessity for further improvement is further underscored by the fact that the

majority of studies in other medical domains has shown that the most popular intervention is telephone or

videoconferencing conversations. Patients may feel unsupported by the present crop of relevant, high-

quality mHealth applications, thus it's crucial that development keeps going in this area.

This evaluation looked at a lot of different ailments, which means there isn't much data on using mHealth

for specific musculoskeletal issues. In terms of mHealth research, the most common condition was

postoperative rehabilitation following total knee replacement surgery. Out of all the research that looked

at mHealth, only three percent examined its potential for treating chronic low back pain, while four percent

dealt with shoulder pain . Hence, despite the widespread usage of mHealth, there is insufficient data to

completely endorse its use for a variety of illnesses.

Reproducible descriptions of the mHealth intervention were lacking in a number of studies. It is

reasonable to presume that physiotherapy treatment would be considered part of the intervention given

that this study was carried out within the framework of musculoskeletal physiotherapy. The physiotherapy

component was under-discussed by most authors, who instead framed the intervention as a home

exercise programme with follow-up phone calls from a participating clinician, as though it were a specific

treatment rather than a catch-all phrase for a variety of approaches. Based on the findings of 4% (1/20) of

the research included in this analysis, it seems that physiotherapists do not have enough evidence to

properly implement mHealth interventions.

Due to the preponderance of quantitative data, this study draws attention to the dearth of qualitative

studies examining mHealth treatments. To improve the delivery of future treatments, it is crucial to

understand the experiences of those providing and receiving these interventions. Qualitative research has

a lot of value because it gives a deeper picture of the lived experience. This may help physicians and

patients come up with new ideas for improving patient care and mHealth via increased involvement. The

availability of high-quality resources, infrastructure, and time in Saudi Arabia allows for the development

of more effective and engaging mHealth treatments, including elements like gamification.

CONCLUSIONS

It would suggest that mHealth may improve treatment adherence, be just as effective as traditional

physiotherapy care, and even be more cost-effective. The most popular method of patient-clinician

communication right now seems to be videoconferencing or phone calls; patients love these methods

because they allow them to get constant feedback on their progress during rehabilitation, which boosts their

confidence. Because patients are more likely to stick to their rehabilitation programme when they get

feedback from their doctor, this feedback loop has the ability to improve pain management and self-

management.

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