Digital Care Could Help Close Rural-Urban Gap in Musculoskeletal Pain Therapy


People in urban and rural areas saw similar improvement from a digital health program that comprised patient education, an exercise program, and cognitive behavioral therapy.

People with musculoskeletal pain conditions appear to benefit from using digital care programs for their rehabilitation and physical therapy, according to a new study.

The reports suggests “telerehabilitation” may be a means to help extend therapeutic options in areas with little or no access to in-person care.

Fabiola Costa, Ph.D.

Fabiola Costa, Ph.D.

Exercise-based physical therapy is the “mainstay” of treatment for people with musculoskeletal pain conditions, but corresponding author Fabíola Costa, Ph.D., of Sword Health Inc., wrote along with colleagues that 65% of rural counties in the United States are designated as health professional shortage areas. That means patients living in those areas may be at a disadvantage compared to patients in urban areas, particularly if the rural patients do not have the ability to travel long distances.

“These inequities are further compounded by lower educational levels, higher rates of poverty, and lower rates of internet access in rural areas,” the investigators wrote in JMIR mHealth and uHealth.

Although telerehabilitation might be part of the solution for rural patients, Costa and colleagues said there is a risk that lack of internet access or limited digital literacy might restrict the efficacy of digital health solutions.

The investigators decided to conduct a study to compare rates of engagement and utilization of a digital telerehabilitation program between patients in urban areas and rural areas. The intervention used in the study was a digital care plan developed by the Utah-based digital health firm Sword Health. The product incorporates patient education, an exercise program, and cognitive behavioral therapy. It also acts as an interface to connect patients with a physical therapist to monitor their progress.

Patients were invited to participate in the program if they were 18 years of age or older and reported either acute or chronic musculoskeletal pain in the spine, upper limbs, or lower limbs. Patients were excluded if they had a cardiac or respiratory health condition that made it impossible to complete 20 minutes or light to moderate exercise, if they were undergoing cancer treatment, if they reported rapid loss of strength or numbness in the limbs, or if they had recent changes in bowel or urinary function.

A total of 9,992 people started the program, and nearly three-quarters (73.8%) completed their programs. Participants were recommended to complete four, eight, or 12 weeks of therapy. Most participants completed the 12-week program (4,746 participants). The recommended frequency of therapy was three exercise sessions per week.

In addition to tracking patient adherence to training programs, investigators also surveyed patients about their pain, anxiety, work productivity and activity impairment.

Costa and colleagues then used ZIP codes to stratify patients into urban and rural cohorts, which allowed them to track differences in outcomes between the two groups. Most of the participants (8,809) were from urban areas.

The authors found similar rates of program completion between the two group. Those living in rural areas had a 76.6% completion rate compared with a 73.5% completion rate among those living in urban areas. The two groups also had similar behavior in terms of time dedicated to exercise, number of sessions, sessions per week, and interactions with a physical therapist. Asked to rate their satisfaction with the program, both cohorts gave average scores of 8.6 out of 10.

In terms of clinical outcomes, there was similar parity between the results of the two groups. Both groups reported decreases in pain at comparable levels, and both groups said their work productivity improved at similar rates.

Costa and colleagues noted that the patients in the rural cohort had worse clinical outcomes at baseline, but had similar improvements as a result of the intervention. They said those data reinforce “the notion that [the] higher MSK (musculoskeletal) pain burden in rural areas may be associated with lack of access to care.”

They said this study suggests tools like Sword Health’s digital care plan might be able to help narrow some of those inequities.

“The results observed herein support the need for further research and investment in digital rehabilitation to mitigate inequalities in healthcare access and care delivery optimization,” they concluded.

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