This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.For the underprivileged population in rural or remote areas with low population density, it takes a long time and costs compared to the urban population to understand and accept various environmental changes [1]. In particular, that absence is prominent in a disaster situation such as the recent COVID-19 pandemic, and as the time and frequency of individual outdoor activities have decreased by more than 80% since this pandemic, environmental changes at the national level are inevitable [2]. This is cased to be caused by preemptive measures to limit individual outside activities in the national level in order to prevent individuals from being exposed to various environmental variables. Due to these restrictions, procedures for receiving medical services for individuals or patients are delayed or situations in which medical services are not provided occur, which has a fatal effect on individual health and maintenance of daily life. In particular, the damage to the underprivileged population, such as chronic patients, the elderly, and children, who absolutely need medical services, is enormous, and it is urgent to prepare countermeasures for this [3].
As an alternative to this, medical professionals are proposing the use of Tele-Health Service, which can provide medical services in a non-face-to-face environment through Information and Communication Technologies (ICT) [4]. The World Health Organization (WHO) has defined telemedicine services as “medical services provided using telecommunications and virtual technology outside of traditional medical facilities” [3]. As the Internet and communication infrastructure have advanced at an astounding rate over the past few years, it has become possible to provide remote medical services that can overcome barriers of time and distance. In addition, as compared to existing medical services (face-to-face environment), as it provides information and counseling services of a similar level, the reliability of remote medical services gradually increases, and the use of remote medical services is expanding worldwide [2]. This telemedicine service utilizes information and communication technology (ICT) to transmit health information such as voice and data or image information over short and long distances, the delivery method is divided into synchronous (real-time) and asynchronous (store and transfer) methods that include information delivery in terms of treatment such as assessment, diagnosis, treatment, and prevention [5].
In particular, due to the COVID-19 pandemic, the use cases of telemedicine services are increasing worldwide, and in particular, among telemedicine services, the cases of application in the rehabilitation field are increasing noticeably [1,5]. Telerehabilitation service was developed for the purpose of continuous communication with patients and effective intervention, and its utilization value is recognized in that it promotes the improvement of individual health and welfare to the patient group in need of professional medical services [4,5].
The increase in application cases of telerehabilitation service will be expanded the information about the service and serve as a good opportunity to verify the effectiveness of telerehabilitation service and patient satisfaction [2]. Thus, it is necessary to verify reliability and validity of whether this service is a useful approach for performing patient assessments, formulating treatment plans, providing interventions, conducting recovery procedures leading to discharge, and comprehensive patient management [6,7]. In particular, performing patient assessment is the most important information collection process for a therapist, and is an essential process for implementing effective treatment strategies such as treatment plan establishment, clinical reasoning process, and intervention selection [9].
Therefore, in order to confirm the clinical effectiveness of telerehabilitation services, it is essential to conduct tele-assessments using Telerehabilitation services to understand their reliability, effectiveness, and wide-ranging utility. Several previous studies reported on the validity and effectiveness of assessment and diagnosis derived from telerehabilitation services even before the COVID-19 pandemic [10-14].
In a preceding study, a tele-assessment related to musculoskeletal disorders was conducted, and based on the results of evaluating the subject's swelling, ROM, pain, muscle strength, balance, gait, functionality, etc., potential applicability of the telerehabilitation service was reported [15]. Another study investigated the reliability tele-assessment y and validity of adult musculoskeletal assessment through synchronous tele-assessment and demonstrated the applicability of shoulder and elbow joint assessment and management, but nerve testing, scar assessment, and lumbar posture assessment Low reliability reported [16]. Other studies confirmed the reliability and validity of the assessment of the ROM in all movements of the knee, wrist, elbow, and shoulder joints through tele-assessment. In addition, the result of tele-assessment based on telerehabilitation service for patients with elbow joint disorder [11], neck pain [12], back pain [14], ankle disorder [15], and general musculoskeletal disorders [10], high reliability and validity was found.
Among patients with musculoskeletal disorders, 14.6% complain of neck pain, and as the number gradually increases every year, it can be seen that musculoskeletal problems around the cervical spine have a significant impact on personal health. To predict such acute or chronic neck pain-related musculoskeletal conditions, most therapists use the measured value of the cervical ROM as a standard for assessment and diagnosis of the musculoskeletal system around the cervical spine [17,18]. In a preceding study, it was confirmed that a rapid decrease in cervical ROM within 4 weeks of onset of whiplash injury symptoms could predict chronic cervical pain [17], and cervical joint pain in patients with cervical headache ROM measures differentiated headache from other types, such as migraine or tension-type headache [18]. As such, cervical ROM measurement is an essential process to objectively evaluate the condition of patients with cervical dysfunction or neck pain and to document treatment plans and intervention effects, and depending on the results of cervical ROM can be treatment plan adjustment or intervention method can be modified.
Nevertheless, studies dealing with comprehensive musculoskeletal assessment of cervical joints, which refer to cervical motion or posture patterns, are still insufficient, and studies on reliability and validity of cervical disorders have been reported less than other musculoskeletal disorders.
In this study, we conducted tele-assessment of the cervical ROM in healthy adults to investigate whether this assessment was a clinically valid and reliable result, and also, the purpose of this study is to determine the clinical value of telerehabilitation services by examining the satisfaction and opinion of evaluators and subjects about tele-assessment method and environment.
The protocol of this study was designed as a cross-sectional study, and 22 healthy adults aged 20 years or older were recruited from students at Sahmyook university in Seoul, and 22 people who met the selection and exclusion criteria were selected. Inclusion criteria for study selection were: (1) those who understand the purpose of the study and follow the procedures and (2) those who no cognitive impairment and (3) those who no physical impairment such as vision and hearing. Exclusion criteria were: (1) those who no previous surgery or procedure experience and (2) those who no pain that makes it difficult to move their upper limbs, (3) those who no serious upper limb functional damage, and (4) individuals with limited neck movement resulting from upper extremity pain. The number of study subjects was calculated using G-power 3.1.9.7, and the number of subjects required for reliability and validity analysis of video conference-based physical therapy assessment was determined. The reliability of the cervical ROM and posture angles as set as the primary hypothesis, and the effect size was 0.5, the significance level was 0.05, and the test power was based on the evidence that a correlation effect size of 0.5 or more is a large effect. A total of 15 subjects were required under the 0.8 condition [18], but in this study, a total of 22 subjects were recruited considering a dropout rate of 20%. The study was conducted with the consent of all subjects participating in the study and was conducted with the approval of the Bioethics Committee of Sahmyook University (SYU 2022-05-016-002).
The evaluators were composed of 10 physical therapists with more than 3 years of clinical experience. All assessments were conducted in an independent environment, and among the evaluators, those who did not have experience in telemedicine service and telerehabilitation service, and those who did not have experience in tele-assessment including video conferencebased ROM assessment were recruited.
In this study, in order to confirm the effectiveness and reliability of tele-assessment of cervical ROM based on video conference, the study was conducted according to the procedure by dividing the face-to-face and tele-assessment methods. First, for traditional face-to-face musculoskeletal assessment, an experienced evaluator extracted reference angle values sing a measuring tool. Secondary, for tele-assessment, both the subject and the evaluator were connected to Zoom (Version 5.0.5, Zoom Video Communications Inc., USA), a video conferencing application, and the assessment was conducted (see Figure 1). All tele-assessments were conducted synchronously (real-time), and the subject performed the motion twice for each assessment item according to the order of the researcher, and the evaluators evaluated only by VI when performing the first motion, The second motion was measured using a UG. After all assessments were completed, the satisfaction of subjects and evaluators with the video conference-based tele-assessment method and environment was investigated.
To measure the cervical ROM for the UG assessment, we utilized the CROMⓇ (Cervical Range of Motion Instrument, Performance Attainment Associates, USA) device (see Figure 2). The CROMⓇ device is a reliable measurement tool, exhibiting inter-rater reliability (r＝0.91) and intra-rater reliability (r＝0.90) [20]. This device securely attaches to the head using a cervical spine to obtain reference values of cervical ROM during face-to-face assessments [21].
The CROMⓇ device employs two of its three protractors to measure flexion, extension, and side flexion, while one protractor is dedicated to measuring rotation. Additionally, a magnet is utilized to stabilize the upper torso, allowing for controlled chest movement while simultaneously capturing rotation [21].
The six contents configured to assess the cervical ROM are as follows (see Figure 3). Assessments: (a) Cervical Flexion, (b) Cervical Extension, (c) Right side of Cervical Side-bending, (d) Left side of Cervical Side-bending, (e) Right side of Cervical Rotation, (f) Left side of Cervical Rotation.
For tele-assessment method and environment designed in this study, the satisfaction of the participants and evaluators who actually participated was investigated. In order to confirm whether awareness and understanding of telerehabilitation services and tele-assessment were facilitated, this study investigated the satisfaction of subjects and raters who participated in the study using TUQ [22]. Telehealth usability questionnaire is a comprehensive and verified questionnaire that evaluates subjects’ perceptions of telehealth services by investigating the usability and satisfaction of various types of telehealth services, including smartphone applications and computer-based video conferencing applications [22].
In this study, SPSS (ver. 25.0, SPSS Inc., USA) was used to statistically process the collected data. The general characteristics of the subjects were analyzed using descriptive statistics, and Shapiro-Wilcoxon was used to confirm the normality of the collected data. Pearson's correlation analysis was used to examine the concurrent validity of the cervical range of motion measurements using video conferencing through the cervical ROM measurements using the CROM Device. And also, intra-rater reliability was analyzed by obtaining the intraclass correlation coefficient (ICC) and 95% confidence to check how consistent the raters’ assessment tendencies were in tele-assessment. An ICC value of .80 or greater is ‘very high confidence’, .60 to .79 is ‘high confidence’, .40 to .59 is ‘moderate confidence’, and less than .40 is ‘weak confidence’. ‘All statistical significance levels were set at α＝.05 [23].
The gender of the subjects was 9 males (40.9%) and 13 females (59.1%), and the number of subjects by age was 10 in their 20s (45.5%), 5 in their 30s (22.7%), and 5 in their 40s (22.7%), and 2 in their 50+ (9.1%) (Table 1).
The relationship between the face-to-face assessment and tele-assessment for all ROM contents were statistically significant with correlation coefficient form r＝0.54 to 0.71 (p<.05) (Table 2).
In tele-assessment, an inter-rater reliability analysis was conducted to check how consistent the evaluators' assessment tendencies were. As a result, the intraclass correlation coefficient (ICC) of the visual inspection assessment was 0.93 and the intraclass correlation coefficient of the universal goniometer assessment was 0.92. appear (Table 3).
The subject's responses with the telerehabilitation service were found to be generally satisfactory with an average score of 5.8/7 (see Figure 4). (1) average score of 5.67/7 in usability, (2) 6.12/7 in ease of use and learnability, (3) 5.94/7 in interface quality of video conferencing program, (4) 5.94/7 in interface quality of video conferencing program the interaction quality item scored 6.28/7 points, and the (5) reliability item scored 5.26/7 points. Among them, satisfaction and future usability items scored 5.73/7 points, with the highest score being the interaction quality of video conferencing programs, and the lowest score being 5.26/7 points for the reliability of telehealth.
The evaluators’ responses with telerehabilitation service averaged 4.6/7 points (see Figure 3). (1) Clinical applicability of tele-assessment was an average of 4.62/7 points, (2) Clinical applicability of tele-assessment results was 4.76/7 points, (3) Subject’s expected satisfaction with tele-assessment was 4.62/7 points, (4) The validity item of tele-assessment result was 4.48/7 points.
As the use of telerehabilitation services increases, it is important to build a foundation to support the reliability of patient assessment and intervention in a non-face-to-face environment [24]. Through the results derived from this study, the validity and reliability of the video conference-based tele-assessment were demonstrated, and the foundation was laid to support the effectiveness of the telerehabilitation service.
Audette et al. (2010) argued the excellent validity and reliability of the CROMⓇ device in evaluating the musculoskeletal system around the cervical spine. The correlation coefficient for cervical spine motion was 0.98 for extension and bilateral rotation, 0.93 for flexion, and 0.96 to 0.97 for bilateral side flexion, demonstrating a high level of reliability. Compared to the highly reliable face-to-face assessment method, significant correlations were shown in all assessment items of tele-assessment conducted in this study, suggesting that there is significant concordance between the two methods for 22 subjects.
Grona et al. (2018) investigated the reliability and validity of synchronous tele-assessment and demonstrated its applicability to the assessment and management of shoulder and elbow joints in the musculoskeletal field. The reliability and validity of the assessment of the ROM in all movements of the knee, wrist, elbow, and shoulder joints were confirmed. In addition, high reliability and validity were confirmed in the musculoskeletal system assessment performed on patients with elbow joint disorder [11], neck pain [12], back pain [14], ankle disorder [15], and general musculoskeletal disorders [10].
However, in a non-face-to-face environment, compared to other musculoskeletal tele-assessments, cervical musculoskeletal assessment has fewer cases and is not common, so there is insufficient evidence to prove the reliability of video conference-based non-face-to-face environments.
Therefore, in this study, by collecting the results of tele-assessment using a video conferencing application, and by analyzing inter-rater reliability for assessment items to check whether the assessment values of evaluators for the same subject are the same, we tried to prove the reliability of musculoskeletal assessment. In addition, in this study, in order to minimize the occurrence of errors due to the researcher's intervention, the subjects were instructed to perform the motions only by the researcher's instructions without any physical contact or intervention while performing the motions for each item.
As a result of this study, the inter-rater reliability for all assessment items in tele-assessments showed a high confidence level of 0.9 or higher for both the VI assessment method and the UG assessment method. This, in the end, suggests that there is effectiveness for the video conference-based tele-assessment method and environment designed in this study. In addition, the inter-rater reliability of 10 evaluators derived a high level of reliability of 0.9 or higher, suggesting that it can be sufficiently used for telerehabilitation services for patients who cannot visit in person. In addition, the validity of tele-assessment method was verified by confirming the excellent correspondence between the traditional face-to-face assessment method and the video conference-based tele-assessment method.
Furthermore, a recently published study mentioned the need for an analysis of patient satisfaction with the service, concerned about a serious knowledge gap in subjects’ awareness and understanding of telerehabilitation services.
Accordingly, in this study, we tried to confirm whether the perception and understanding of the service was facilitated by examining the satisfaction of the participants and evaluators who actually participated in the video conference-based tele-assessment method and environment designed for the provision of telerehabilitation services. The most commonly used tool to evaluate user satisfaction in the remote field is a questionnaire, and in this study, the satisfaction of participants and evaluators who participated in the study was investigated using the TUQ [22]. The telehealth usability questionnaire is a comprehensive and verified questionnaire that evaluates subjects' perceptions of telehealth services by investigating the usability and satisfaction of various types of telehealth services, including smartphone applications and computer-based video conferencing applications. (1) Usability refers to patients' perceptions of how telehealth services work overall to deliver health care, and (2) Ease of Use and Learnability refers to how easy the system is to learn and use. (3) The interface quality of the video conferencing program is an item that evaluates whether it is easy for the subject to navigate the program through the graphic interface of the video conferencing program, and (4) the interaction quality of the video conferencing program is an audio-visual item. It is an item that evaluates the interaction between the subject and the evaluator, including quality, and (5) the reliability item means a reliability item that indicates whether the subject's face-to-face assessments and tele-assessments were considered the same.
In this study, the satisfaction of tele-assessment of the subject and the evaluator was investigated using the telehealth usability questionnaire, and it was confirmed that both groups were satisfied overall by deriving above-average satisfaction results. In interviews with subjects, the audio and visual clarity of the video conferencing program used in this study was excellent, and most subjects responded that they could perform the assessment without much difficulty, similar to the face-to-face assessment. In addition, they answered that they would recommend it to patients or acquaintances who have difficulty receiving face-to-face medical services due to physical distance or disability. On the other hand, in the interview with the evaluator, they complained of difficulties in selecting an accurate reference point for each individual in a non-face-to-face environment and performing assessment such as compensation. mentioned it would be possible. In addition, indicators for motion performance are needed, and it is proposed to create a shooting environment from various angles for accurate assessment.
Regarding these limitations, Ekeland et al. (2010) suggested a service improvement plan that in order to derive higher satisfaction with telerehabilitation services, the authority of patients and medical professionals should be expanded to increase the level of trust and understanding of the results [25-27].
The limitations of this study are, first, that evaluators with little clinical experience may have an impact on formulating an accurate diagnosis as the assessment is performed in an environment different from the existing clinical experience along with insufficient clinical experience ability. This is expected to improve the results when a physical therapist with extensive clinical experience performs the assessment in the future. Second, since the demographic characteristics of the participants were confined to the university community, although they spanned various age groups, it is necessary to exercise caution in generalizing the results of this study to other population groups. We predict that these limitations can be addressed by providing larger sample sizes and diverse demographic backgrounds.
Through the results of this study, the applicability and effectiveness of videoconference-based tele-assessment for the provision of telerehabilitation services were demonstrated. The broad clinical meaning of this study is to implement video conference-based tele-assessment as a standard clinical practice for patients or the underprivileged who cannot directly participate in professional rehabilitation services, for the purpose of prevention and management of potential patients with musculoskeletal disorders. We want to support individuals to have equitable access to rehabilitation services.
General characteristics of subjects (n＝22)
| Characteristics | n (% ) | |
|---|---|---|
| Gender | male | 9(40.9%) |
| Female | 13(59.1%) | |
| Age (years) | 20∼29 | 10(45.5%) |
| 30∼39 | 5(22.7%) | |
| 40∼49 | 5(22.7%) | |
| 50+ | 2(9.1%) |
Pearson’s correlation values between tele-assessment and the face-to-face assessment (n＝22)
| Measurements | Face-to-face Assessment | |
|---|---|---|
| r | ||
| Cervical Flexion | 0.643 | 0.001 |
| Cervical Extension | 0.636 | 0.001 |
| Cervical Side-bending, right | 0.435 | 0.043 |
| Cervical Side-bending, left | 0.709 | 0.000 |
| Cervical Rotation, right | 0.450 | 0.036 |
| Cervical Rotation, left | 0.541 | 0.009 |
*
Intra-rater Reliability of tele-assessments (n＝22)
| Variable | ICC | 95% CI of ICC | Cronbach α |
|---|---|---|---|
| VI | 0.93 | 0.93-0.95 | 0.93 |
| UG | 0.92 | 0.90-0.94 | 0.92 |
ICCs (p) were calculated using a 2-way mixed-effects model.
ICC: Intraclass correlation coefficients; CI: Confidence interval; VI: Visual inspection; UG: Universal goniometer
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