Validity and reliability of the assessment and diagnosis of musculoskeletal conditions using telemedicine: A systematic review
Creators: name: Oh, David
name: Cancelliere, Carol
name: To, Daphne
name: Corso, Melissa
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Medicine and Health Sciences
subject: musculoskeletal
subject: reliability
subject: systematic review
subject: telehealth
subject: telemedicine
subject: validity

description: RESEARCH OBJECTIVE To conduct a systematic review to assess the validity and reliability of the assessment and diagnosis of musculoskeletal conditions using synchronous telemedicine compared to standard in-person clinical assessment and diagnosis. METHODS The protocol for this systematic review will be registered with the Open Science Framework (OSF) Registries. ELIGIBILITY CRITERIA Population: This systematic review will target studies of individuals of all ages (general and athletic populations) who present for the clinical assessment or diagnosis of a musculoskeletal (MSK) condition. The International Classification of Diseases lists MSK conditions as a diverse group of over 150 diagnoses that affects the locomotor system: specifically, muscles, bones, joints, tendons, and ligaments(1). MSK conditions are commonly described by their anatomical location and through their association with pain and impaired physical function despite their variability with regard to pathophysiology(1). Furthermore, MSK conditions can vary from those of acute onset and short duration to lifelong disorders(1). Examples of MSK conditions included in this systematic review include low back and neck pain, arthritis, musculoskeletal injury sequelae, and fractures. Patients with neurological conditions such as traumatic brain injury, spinal cord injuries, headaches (e.g. migraine, tension-type, cluster, cervicogenic, etc.) and movement disorders (e.g. Parkinson’s Disease, multiple sclerosis, muscular dystrophy, cerebral palsy, amyotrophic lateral sclerosis, etc.) will be excluded from this study. Exposure: The exposure is the clinical assessment and diagnosis (of risk factors for serious pathology, pain, function, barriers to recovery) of MSK conditions by synchronous, or real-time, telemedicine delivered by any healthcare provider. A clinical assessment includes the combination of a detailed patient history and physical examination to establish a correct clinical diagnosis(2). Studies assessing only single components of a clinical assessment (e.g. range of motion, strength, visual inspection, orthopedic or functional test etc.) will be excluded from this review. Telemedicine is defined by the World Health Organization as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for assessment and diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”(3). Studies of clinical assessments or diagnoses using telemedicine with a completely asynchronous component will be excluded from this review. Comparator: The comparator is the clinical assessment, including a health history and physical examination (of risk factors for serious pathology, pain, function, barriers to recovery) of individuals with musculoskeletal conditions by standard care (e.g., in-person visits) by any healthcare provider. Outcome: The outcomes are the reliability and validity of clinical assessments and diagnoses of individuals with musculoskeletal complaints by healthcare providers. Reliability is defined as the extent to which repeated measurements of a stable phenomenon by different people and instruments at different times and places produce similar results(4). Validity is defined as the degree to which the results of a measurement match to the true state of the phenomenon being measured(4). STUDY DESIGN/CHARACTERISTICS Eligible studies must meet the following criteria 1) articles published in English in peer-reviewed journals (to increase feasibility) Unpublished manuscripts, letters, guidelines, commentaries, conference proceedings, editorials, theses, books, meeting abstracts, lectures, consensus development statements and other descriptive publications will be excluded. A list of potentially relevant articles in other languages will be included as an appendix in the final manuscript. INFORMATION SOURCES AND SEARCH STRATEGY MEDLINE, CINAHL, EMBASE, PsycINFO, and SPORTDiscus will be searched from inception to the proposed search date (to be determined a priori). The search strategy will be developed following consultation with an experienced health sciences librarian and will be reviewed by a second librarian using the Peer Review of Electronic Search Strategies Checklist(5,6) (see Appendix). The search strategy will be developed in MEDLINE and adapted to the other bibliographic databases. Search terms will include subject headings (e.g., MeSH in MEDLINE) for each database and free text words for the key concepts of telemedicine, clinical assessment, in-person assessment, and validity and reliability. EndNote will be used to delete duplicate references electronically across databases and record the number of duplicates identified. DATA COLLECTION AND ANALYSIS Study Selection: A two-phase (titles and abstracts; full-text articles) screening process will be used to select eligible studies. In phase I screening, pairs of independent reviewers will screen citation titles and abstracts to determine the eligibility of studies (categorizing studies as possibly relevant or irrelevant). Pairs of independent reviewers will screen possibly relevant studies in full text during phase II screening to determine eligibility and document reasons for exclusion. Reviewers will meet to discuss disagreements and reach consensus on study eligibility. A third reviewer will be involved provided consensus cannot be reached. Study authors will be contacted for additional information as needed when screening, assessing risk of bias, and conducting data extraction. Data items and data collection process: The lead author will extract data from eligible studies to build evidence tables (see Appendix). A second reviewer will independently extract study results (e.g., reliability and validity measures, 95% CI) and any disagreements will be discussed to reach consensus. For all other data items a second reviewer will verify by checking the extracted data to minimize error. From each study, extracted data will include author, publication year, study design, setting and participant characteristics(e.g., sample size, mean age, sex, and MSK condition), definition of exposure (characteristics of the clinical assessment delivered through telehealth), validity (index test, reference standard, and Chronbach’s alpha) and/or reliability (intraclass correlation efficient) outcomes, and 95% confidence intervals. Methodological quality and risk of bias appraisal: Pairs of trained reviewers will critically appraise eligible studies using the Quality Appraisal Tool for studies of diagnostic Reliability, or QAREL, to assess the methodological quality of the reliability studies6. To assess the methodological quality of the validity studies, pairs of trained reviewers will critically appraise eligible studies using the Quality Assessment of Diagnostic Accuracy Studies-2, or QUADAS-27. Reviewers will meet to reach consensus on the risk of bias of studies and a third independent reviewer will be involved to resolve any disagreements. Evidence Synthesis: We will use the best evidence synthesis methodology and qualitatively synthesize the data from acceptable quality (low risk of bias) studies(10, 11). This type of synthesis not only allows conclusions to be provided based on the best available evidence, it also can report an insufficient level of evidence to make any conclusions(10). We will use evidence tables to create summary statements. We will stratify our synthesis by musculoskeletal regions of complaint (e.g. low back pain, neck pain, headache, etc.) and type of evidence (reliability and/or validity). Following appraisal, studies that are considered adequate for low risk of bias will be classified according to the classification system described by Sackett and Haynes(9). This system is designed to classify diagnostic studies for the potential clinical utility and usefulness of a test in clinical practice(9). Studies in Phase I assess differences in the results of the diagnostic test between patients with a known condition and healthy individuals. Studies in Phase II assess the association between test results compared to a reference standard in patients diagnosed with the condition. Phase I and II studies identify the clinical utility of a diagnostic test(9). Phase III studies assess the ability of a test to perform in a population with the suspected condition(9). Phase IV studies examine the outcomes of patients who were assessed with the test compared to untested individuals(9). Phase III and IV studies identify the usefulness of a test in clinical practice(9).