Until recently, virtual physiotherapy services represented the minority of support offered by the private and public healthcare sectors. The Covid-19 outbreak created a sudden need for digital health services to be rolled out more widely.
Ascenti wanted to use its dataset of 27,000+ virtual appointments to see how results for online physiotherapy compared with those for in-clinic care and to gather views from patients and clinicians to enable further improvement.
A retrospective evaluation was conducted using data collected through routine care from Ascenti MSK physiotherapy practitioners.
Anonymised data was exported, mapping the treatment journeys of 27,096 patients who accessed virtual physiotherapy support before and during the Covid-19 crisis - running until 10 June 2020. Of this population, which included NHS, medico legal and self-funding patients, 9,506 had received virtual-only treatment, while 17,590 had received a blend of virtual and in-clinic care.
A comparison group was built using the data of 6,226 patients treated with in-clinic physiotherapy only.
The evaluation compared:
- Virtual physiotherapy-only - all treatment delivered via videocall using the Ascenti Physio digital app, with access to videos and patient records within the call and afterwards.
- In-clinic physiotherapy only - all treatment delivered in one of Ascenti’s 300 community clinics with no access to the app.
- Integrated support - a blended approach of in-clinic and virtual physiotherapy treatment.
Descriptive analysis found that most patients (81%) who had been scheduled to have in-clinic treatment were happy to transition to virtual appointments and continue beyond their first session. At discharge, 92% were satisfied with the effectiveness of their treatment.
Measured on an 11-point pain Numerical Rating Scale (NRS), the differences reported in outcomes between virtual and in-clinic treatment were minimal.
Patients who only accessed in-clinic treatment reported an improvement of 3.4 NRS points on average, while people who were treated only virtually reported an improvement of 3.1. Patients that combined both methods saw the biggest improvements, moving from a 5.4 NRS score at Initial Assessment (IA) to 1.8 on discharge - an average improvement of 3.6 points. This represents a clinically significant change in NRS (Salaffi et al 2004) in all groups, with the literature associating a reduction of 2 points or change score of 30% with “much better” improvement.
For patients with a low or medium NRS score at IA, the differences in results were negligible. Those with a low NRS score saw improvements of 1.5 for virtual treatment and 1.6 for in-clinic, while those with a medium NRS score improved by 3.5 with virtual and 3.6 in-clinic.
Patients with a high NRS score at IA saw an average improvement of 4.7 points through virtual treatment compared to 5.2 points through in-clinic care, suggesting that online physiotherapy remains a clinically significant alternative.
Qualitative patient interviews (n=5) identified a number of perceived benefits of virtual treatment, including the convenience of not having to leave the house or book time off work, and the effectiveness of digital tools (videos, diaries, reports) for use outside of the appointments. Further evaluation found that patients who accessed videos again after the session reported the best results overall.
Informal feedback from clinicians suggested that some patients were more motivated to learn and self-manage during video appointments as they knew that passive treatment options were not available. Clinicians also described how having insight into a client’s home environment facilitated a more relevant exercise program.
A number of perceived disadvantages of virtual physiotherapy were also identified through feedback, including clinicians missing the power of therapeutic touch for manual assessment, treatment and to correct movement where necessary. It was also felt that reduced trust in the process among some patients could impact results in those cases.
Cost and savings
The digital physiotherapy service was built by Ascenti’s in-house information technology team.
Potential savings could include staff travel and clinic costs, as the service can be delivered from home. It could also reduce the potential costs for patients by removing the need to travel, book time off work or arrange childcare.
The results of this evaluation suggest that virtual physiotherapy can provide a valid alternative to in-person treatment in some cases.
It is likely that the responses of some patients were influenced by the exceptional circumstances of the Covid-19 lockdown. However, with the UK Government estimating that social restrictions will last until March 2021 (Gov.uk) it is likely that the need for digital healthcare services will remain high for the time being.
As measures ease it will be important to see if the outcomes reported here continue when people have a choice between digital and in-person pathways.
The issue of digital equity should also be considered. This evaluation found that most patients were happy to transition from planned in-person treatment to virtual appointments. It would be useful to understand from those that declined whether this was based on a lack of digital access or low confidence in their ability to use digital tools.
Top three learning points
- In this evaluation, the outcomes reported by patients accessing virtual physiotherapy compared favourably with those who accessed in-person treatment. The best results were reported by those accessing a blend of virtual and in-person treatment.
- While there are some hands-on treatments and diagnostic tests that cannot be modified to be delivered virtually, there are huge benefits in convenience, patient engagement and patient insight that can help make up for that. Digital technology innovations are likely to see this service continue to improve in the future too.
- Key to the success of virtual physiotherapy going forward will be the ability of healthcare providers to identify the circumstances when this treatment should be offered; providing the right treatment, at the right time, to the right patient through the right clinician to achieve the best outcomes overall.
The service and evaluation were funded internally.
For further information about this work please contact Alison Day.
Salaffi F et al (2004) Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. European Journal of Pain 8 283–291