Scoping Review of Telehealth for Musculoskeletal Disorders: Applications for the COVID-19 Pandemic.

OBJECTIVE: The purpose of this scoping review was to identify information about telehealth and rehabilitation for the evaluation and management of musculoskeletal disorders, patient satisfaction, cost, and access as may be applicable during the COVID-19 pandemic. METHODS: We searched MEDLINE for studies published between January 1, 2000, and June 1, 2019. Search terms consisted of MEDLINE medical subject headings and other words relevant to this review, including "telerehabilitation," "musculoskeletal," "telemedicine," "therapy," "chiropractic," "ergonomics," and "exercise." This review targeted studies of people aged 18 years and older with musculoskeletal concerns. Articles on diagnostic tests, effectiveness of treatment, patient satisfaction, access to care, and cost were included. RESULTS: Eleven studies were included in this review. Interrater reliability and agreement were moderate to high for several assessment procedures for the lower limb, elbow, and low back. Two clinical trials demonstrated that provider and patient simultaneous telehealth were equally as effective as in-office care. Patient and provider satisfaction with telehealth were reported to be equal to or higher than for conventional rehabilitation. We found no studies reporting cost or access. CONCLUSION: In the COVID-19 pandemic environment, telehealth is feasible for health care providers to provide rehabilitation services for their patients with various musculoskeletal conditions. Current evidence suggests that for some musculoskeletal disorders, telehealth evaluation may be reliable, treatment may be effective, and patient satisfaction may be good or better than for in-office care. Results from this study may help physiatry, physical therapy, and chiropractic health care providers in their decisions to implement telehealth during and after the COVID-19 pandemic.

The Global Spine Care Initiative: public health and prevention interventions for common spine disorders in low- and middle-income communities.

PURPOSE: The purpose of this study was to develop recommendations for prevention interventions for spinal disorders that could be delivered globally, but especially in underserved areas and in low- and middle-income countries. METHODS: We extracted risk factors, associations, and comorbidities of common spinal disorders (e.g., back and neck pain, spinal trauma, infection, developmental disorders) from a scoping review of meta-analyses and systematic reviews of clinical trials, cohort studies, case control studies, and cross-sectional studies. Categories were informed by the Global Spine Care Initiative (GSCI) classification system using the biopsychosocial model. Risk factors were clustered and mapped visually. Potential prevention interventions for individuals and communities were identified. RESULTS: Forty-one risk factors, 51 associations, and 39 comorbidities were extracted; some were associated with more than one disorder. Interventions were at primary, secondary, tertiary, and quaternary prevention levels. Public health-related actions included screening for osteopenia, avoiding exposure to certain substances associated with spinal disorders, insuring adequate dietary intake for vitamins and minerals, smoking cessation, weight management, injury prevention, adequate physical activity, and avoiding harmful clinical practices (e.g., over-medicalization). CONCLUSION: Prevention principles and health promotion strategies were identified that were incorporated in the GSCI care pathway. Interventions should encourage healthy behaviors of individuals and promote public health interventions that are most likely to optimize physical and psychosocial health targeting the unique characteristics of each community. Prevention interventions that are implemented in medically underserved areas should be based upon best evidence, resource availability, and selected through group decision-making processes by individuals and the community. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: model of care and implementation.

PURPOSE: Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions. METHODS: The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps. RESULTS: Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up. CONCLUSION: The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: methodology, contributors, and disclosures.

PURPOSE: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. METHODS: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative's mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. RESULTS: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. CONCLUSION: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: World Spine Care executive summary on reducing spine-related disability in low- and middle-income communities.

PURPOSE: Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources. METHODS: Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders. RESULTS: Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care. CONCLUSION: The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: care pathway for people with spine-related concerns.

PURPOSE: The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally. METHODS: The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used. RESULTS: After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records. CONCLUSION: A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material.

A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders.

OBJECTIVE: The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders. METHODS: A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities. RESULTS: Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders. CONCLUSION: Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

Systematic review of ß blocker, aspirin, and statin in critically ill patients: importance of severity of illness and cardiac troponin.

Non-cardiac critically ill patients with type II myocardial infarction (MI) have a high risk of mortality. There are no evidence-based interventions to mitigate this risk. We systematically reviewed the literature regarding the use of medications known to reduce mortality in patients with cardiac troponin (cTn) elevation due to type I MI (ß blockers, statin, and aspirin) in studies of critically ill patients without Type I MI. All PubMed publications between 1976-2/19/16 were reviewed. Search terms included: ß blocker or aspirin or statin and intensive care unit (ICU) or critically ill or sepsis; 497 primary references were obtained. Inclusion criteria were as follows: (1) study population consisted of critically ill patients in the ICU with non-cardiovascular illnesses, (2) mortality end point, (3) severity of illness (or injury) was measured, and (4) the antiplatelet agent was primarily aspirin. Retrospective investigations, prospective observational studies, meta-analysis, systematic review, and randomized controlled trials were included; case reports were excluded. 25 primary references were obtained. The data were extracted and tabulated using data collection headings as follows: article title, first author/year/reference number, study type/design, population studied, outcome and intervention, and study question addressed. Evidence was not graded as the majority of studies were non-randomized (low-to-moderate quality). 11 studies were found through bibliography reviews for a total of 36 references. In conclusion, ß blockers, statins, and aspirin may play a role in reducing mortality in non-cardiac critically ill patients. Benefit appears to be related to severity of illness, for which cTn may be a marker.

Epidemiology of concussion in sport: a literature review.

OBJECTIVE: The purpose of this study was to summarize sport concussion incidence data, identify sports that present higher injury frequency, reveal the degree of risk in some lesser-known sports, and outline specific details within the sports literature that raise additional concerns, such as helmet-to-helmet contact and player positions that experience frequent impact. METHODS: A systematic literature review of Pub Med using keyword search on injury, concussion, and sports was performed through May 2012. Abstracts were identified, selections were made based upon inclusion criteria, and full-length articles were obtained. Additional articles were considered following review of reference sections. Articles were reviewed and tabulated according to sport. RESULTS: Two hundred eighty-nine articles were screened, and 62 articles were reviewed. The overall incidence of concussion in sport ranged from 0.1 to 21.5 per 1000 athletic exposures. The lowest incidence was reported in swimming and diving. Concussion incidence was highest in Canadian junior ice hockey, but elevated incidence in American football remains a concern because of the large number of participants. CONCLUSIONS: The literature reviewed included incidence of concussion on the field of play under real-world conditions and influenced by the current culture of sport. The studies examined in this article show that there is risk of concussion in nearly every sport. Some sports have higher concussion frequency than others, which may depend upon the forces and roles of the positions played in these sports. Younger athletes have a higher incidence of concussion, and female incidence is greater than male in many comparable sports. Headgear may reduce concussion in some sports but may also give athletes a false sense of protection.