Abstract
To the editor,
We read with great interest the paper by Doral and Bilge, 1 and we agree that Coronavirus Disease 2019 (COVID-19) may bring forth a new era. The outbreak of COVID-19 is challenging humanity at every frontier, including medical practice. In this letter, we want to express that telehealth might step up into a more significant role during and after the pandemic, especially in orthopaedic and rehabilitation.
COVID-19 pandemic pushed every area into a new era, including medical practice to be delivered through audiovisual technology. Drastic reduction in surgical treatment, most notably elective orthopaedic procedures (e.g. carpal tunnel syndrome, arthroscopy, total joint arthroplasty, plates and implants removal), leads to a massive cutback in orthopaedic healthcare services. 2 The practice of self-quarantine and isolation results in a significant decrease in the number of traffic accidents and consequently trauma-related surgeries.
Post COVID-19 era, sustainable resumption of elective procedures may be slower than expected, thus implementation of telehealth has been suggested for the healthcare system to survive economically. 3 Without exception, orthopaedic and rehabilitation also shifted from face-to-face visits to audiovisual-guided sessions. The question is whether these specialties are really suitable with telehealth innovation given their reliance on physical examination. How can orthopaedic surgeons do medical assessments without touching or examining the injury or wound in-person? However, in the immediate future, teleconsultation and telerehabilitation could be more effective considering the growth of medical technology and possible application of digital biomarkers from smartphones, wearable sensors and smart-home devices. 4
To date, there are growing evidences 5,6 suggesting that the clinical outcomes of virtual consultation and rehabilitation sessions are not inferior to standard face-to-face appointments for the majority of cases. Some positives can be taken from this new method of service, including its cost-effectiveness, reduced travel expenses and saved time for patients, increased patients’ satisfaction, improved effectiveness of post-operative rehabilitation and enhanced quality-adjusted life years gained. Its implementation in outpatient department has been reported to be safe and without major adverse events. Moreover, distance is no longer an issue considering technology-based platform ability to bridge communication between medical providers (e.g. clinicians, physiotherapists) and patients. People with advanced age and comorbidities, such as hypertension, diabetes, cardiovascular and cerebrovascular diseases and chronic obstructive pulmonary disease, have a higher risk of mortality, should they contract COVID-19. 7 –16 These patients will benefit from minimization of physical contact, which will reduce the chance of being infected with COVID-19.
Presumption that telehealth can assist in making diagnoses, planning treatments and assessing outcomes is well supported by a large proportion of medical professionals. 17 While major trauma or serious injury definitely needs to be assessed and treated urgently in-person, elective conditions may be efficiently managed through virtual sessions. Connected via screen in devices, medical practitioners can ask and observe their patients performing physical examinations while also request additional investigations (laboratory or radiographic results) to complete the assessment. Measurement of range of motion aided by Web-based goniometer (e.g. Protractor) is also helpful, which can be augmented by the use of other measuring tools or applications. High-quality audio together with high-resolution video enables individuals from separate locations to communicate clearly, complemented by vast yet quick Internet connection. Currently, the adoption of fifth-generation (5G) mobile technology enables a real-time connection without lag, and remote robotic surgery has been successfully performed recently.
Obviously, no new system is free of problems, including the introduction of audiovisual-assisted-assessment in orthopaedic and rehabilitation. Individual unwillingness and technological limitations are among the greatest barriers in establishing this service. The reluctance of medical staffs to conduct online practices is partly due to their concerns of inadequate assessment if not carried out without direct contact. 18 Having clinicians in regional sites to accompany patients and aid consultation or rehabilitation can guarantee success in telehealth, albeit at additional costs. Furthermore, restriction from private and public health insurance is another obstacle that hinder consumers from seeking virtual health services. 17 Admittedly, one of the downsides of remote technologies is privacy and data security issues which should be addressed. Therefore, a specific and strict regulation should be warranted to counter privacy and cyber-security challenge.
Despite some limitations, there seem to be evident advantages from consultation and rehabilitation in the distance regardless of telecommunication methods, whether synchronous (real-time) or asynchronous (store-and-forward). The implementation of telehealth in orthopaedic and rehabilitation, which was initially considered impossible, now has been forced to be utilized widely. Teleorthopaedic and telerehabilitation will undoubtedly help most people with chronic disabilities to exercise at home, in an effective yet sustainable way. 19 Online health service in these specialties appears to be a promising alternative to in-person appointment for certain areas of care, including post-operated patients (e.g. knee arthroplasty, hip replacement) or those in remote areas. 5,20
The next steps are to develop standardized audiovisual-guided examination and validated measurements that allow universal use by any medical providers worldwide. Individualized yet interactive physical examinations and exercises are possibly the next progress as we inevitably move to this new realm. Virtual Exercise Rehabilitation Assistant 21 has successfully delivered clinician-prescribed physical therapy regimens to patients at home through animated-coaches, enabled assessors to track patient progress and provide real-time feedback and created custom protocols using biometric data to ensure appropriate rehabilitation. With the advancement in medicine and technology, who knows whether in the future robots or surgeon-directed machines will increasingly be used to replace the surgeons and their assistants in performing various procedures. Nevertheless, improvement in security should even be greater than the progression of the telehealth technology itself. Hacking of medical databases may leak sensitive information, and hacking of robotic surgery may prove detrimental.
