Abstract
Background:
Remote monitoring physical therapy (RMPT) is an innovative and effective solution for postoperative rehabilitation in orthopaedic care. However, its ability to increase access particularly in socioeconomically disadvantaged communities is yet to be fully explored. This study investigates the association between RMPT utilization and socioeconomic disadvantage, as measured by the Area Deprivation Index (ADI), in patients undergoing upper extremity orthopaedic rehabilitation.
Hypothesis:
Patients from more socioeconomically disadvantaged neighborhoods, represented by higher ADI quartiles, would demonstrate increased utilization and compliance with RMPT compared with those in lower ADI quartiles.
Study Design:
Case series; Level of evidence, 4.
Methods:
A retrospective review was conducted on the records of 875 patients receiving upper extremity RMPT from January 2022 to January 2024 across 8 institutions. Patients were divided into 4 quartiles based on ADI scores. Data collection included demographics, number of completed sessions/exercises, and duration of RMPT. Analysis of variance and the Tukey honestly significant difference test were performed for continuous variables using RStudio with a P value <.05 considered significant for comparisons.
Results:
A total of 875 patients with a mean age of 59.3 ± 11.4 years and a mean rehabilitation duration of 22.8 ± 10.7 weeks were included in the analysis. Among them, 785 (90%) underwent RMPT for shoulder conditions, 73 (8%) for hand conditions, and 17 (2%) for elbow conditions. Patients in the highest ADI quartile had significantly longer treatment durations (mean, 25.5 ± 14.2 weeks) and completed more sessions (mean, 62.2 ± 74.9) compared with those in the lowest quartile (mean, 20.7 ± 7.9 weeks; mean, 33.4 ± 47.9 sessions; P < .001). A statistically significant difference was noted when comparing the change in visual analog scale (VAS) pain score (P = .04) across the ADI quartiles (19%-20% change ≥4 points in Q1-Q3; P = .019). Despite these differences, there were no significant differences in exercise compliance (P = .313) or session compliance (P = .416).
Conclusion:
This study found that patients from socioeconomically disadvantaged areas, as measured by the ADI, utilized RMPT more extensively compared with patients from less disadvantaged areas. However, compliance across sessions and exercises was consistent across all ADI groups. RMPT shows potential for improving access to physical therapy among disadvantaged populations, although further research is needed to evaluate the clinical effect of these findings.
Keywords
Social determinants of health (SDOH), defined as the conditions in which individuals are born, live, work, and engage in daily activities, significantly affect health risks and outcomes. 25 In the context of orthopaedic surgery, there is growing evidence that SDOH play a critical role in influencing patient outcomes,13,21 particularly by limiting access to essential postoperative care such as physical therapy (PT).2,22 Barriers such as financial constraints, long travel distance and wait times, and limited access to therapists in rural areas are well-documented challenges. 5 Such barriers are concerning given that physical rehabilitation is a vital component of recovery after orthopaedic surgery, with proven efficacy in preventing complications and accelerating the return to normal activities.1,12,27
To address these barriers, advancements in health care technology have led to the emergence of remote monitoring PT (RMPT), offering an innovative solution to the challenges traditional in-person PT models face. RMPT has demonstrated equivalent patient satisfaction and clinical outcomes to in-person PT models.6,14,17 Along with this, it has proven to be effective in reducing rehospitalization rates and lowering short-term health care costs in orthopaedic care.16,18 While RMPT shows promising benefits, its potential for expanding access to rehabilitation services has yet to be fully explored. By overcoming geographic and financial limitations, RMPT offers a critical opportunity to improve access to care for populations disproportionately impacted by SDOH.
In trying to understand the effect socioeconomic status can have on a patient's ability to access care, the majority of studies in the current literature have focused on individual factors without assessing their combined influence. While this approach provides a general understanding, it is a limited interpretation of a multifactorial origin. To address this limitation, the present study utilized the Area Deprivation Index (ADI), a widely recognized tool for quantifying socioeconomic disadvantage. 15 The ADI aggregates 17 US Census variables, including education, income, employment, and housing quality, into a single score, providing a comprehensive measure of neighborhood-level deprivation. The combination of these variables has been shown to affect individuals’ health care outcomes.19,24 By assigning percentile rankings from 1 to 100, with higher scores indicating greater socioeconomic disadvantage, ADI values offer a multidimensional representation of the socioeconomic barriers individuals face. As a publicly available resource, the ADI provides detailed data for all geographical regions in the United States, offering a critical perspective on the influence of an individual's neighborhood on health outcomes. In this study, the ADI allows for a nuanced analysis of how socioeconomic disadvantage influences both access to and compliance with RMPT.
The purpose of this study was to analyze the relationship between RMPT and ADI as a proxy for socioeconomic status. We hypothesized that patients in higher ADI quartiles, indicative of a greater socioeconomic disadvantage, would demonstrate increased utilization and a higher compliance with RMPT when compared with those in lower ADI quartiles.
Methods
Study Patients
A retrospective review was performed on a consecutive series of patients who were prescribed upper extremity RMPT as part of their care plan from January 2022 to January 2024 across 8 different institutions in 4 US states: Ohio (n = 2), Texas (n = 4), Oregon (n = 1), and Florida (n = 1). To mitigate the risk of selection bias, we included all qualified participants who enrolled in RMPT during this time frame. The inclusion criteria were surgical and nonsurgical shoulder, elbow, and hand orthopaedic conditions requiring PT, age >18 years, and use of the RMPT application on a smart device with an active email address. The exclusion criteria were in-office PT treatment and RMPT for nonorthopaedic conditions. Patients who did not meet these criteria were excluded before enrollment and thus not captured in the data set.
Patients were divided into 4 different quartiles based on their ADI scores: Q1 (<25), Q2 (25-50), Q3 (51-75), and Q4 (>75). Categorizing the continuous ADI variable into 4 quartiles is a common approach to better understand its effect across varying levels of socioeconomic disadvantage. The division allows for a more detailed analysis of how increasing levels of deprivation may correlate with patient outcomes and compliance with PT regimens.
Area Deprivation Index
In this study, ADI data were obtained from the publicly available Neighborhood Atlas. These data are a product of the research led by Amy Kind and her team at the University of Wisconsin–Madison, who adapted and refined the ADI metric originally developed by the Health Resources and Services Administration to assess socioeconomic disadvantage at the census block group level. 11 The most recent ADI data from 2022 were used in this study, assigning each 9-digit zip code an ADI score on a scale of 1 to 100 based on 17 variables reflecting relative socioeconomic status. These ADI scores were then aligned with the zip code data captured by the Genie Health RMPT platform, allowing for an analysis of socioeconomic disparities in access to care.
RMPT Application
All patients in this study were prescribed RMPT through the Genie Health application, which was accessible via smart devices regardless of patient age. Each patient was assigned a structured weekly rehabilitation plan consisting of daily exercises that continued until discharge from PT. Although the specific rehabilitation protocols varied by procedure and surgeon, the overall duration of initially prescribed RMPT ranged from 12 to 15 weeks and focused on progressive exercises aimed at restoring shoulder strength and function.
This application was available on iOS and Android devices. It featured both a patient-facing interface and a provider portal accessible via desktop. Once downloaded, the app tracks rehabilitation exercises using the smart device's front-facing camera and marker-less motion capture technology. These data are securely transmitted to the provider portal, where the care team, which consists of the treating physician, physical therapist, and rehabilitation specialist (athletic trainer or PT assistant), monitors progress, modifies the care plan, and communicates promptly with the patient. Adjustments included the addition, removal, or modification of exercises based on patient performance or feedback. Importantly, the patients themselves were not able to alter their exercise program independently; the care team instructed and implemented all changes to ensure the proper rehabilitation route was adhered to.
On completion of the initial prescribed rehabilitation program, patients had the option to continue using the RMPT platform for ongoing strengthening and maintenance exercise. Patients who requested more sessions and hence more exercises continued to be active on the platform, showing that they remained active and recovering, increasing their duration of RMPT usage. The care team continued to monitor this extended use, incorporating additional adjustments as needed to advance long-term shoulder function and health. If the patient chose to discontinue use of the platform, either upon graduation from the rehabilitation program or at any point along the way, the care team was notified, and the patient's status in the platform was updated to prevent further exercise assignments and activity monitoring.
All patients engaged in 2-way communication with their care team via the RMPT app, with frequency varying according to individual clinical needs. The rehabilitation protocol also included regularly scheduled telehealth sessions with licensed physical therapists as part of the standard care pathway. Importantly, the app does not require additional hardware and is compatible with a wide range of smart devices with Wi-Fi access; however, certain exercises occasionally incorporate basic items such as resistance bands, light weights, yoga mats, or a step, depending on individual rehabilitation needs.
Data and Outcomes
Baseline data collection for each patient included patient age, sex, body region for which RMPT was prescribed (shoulder, elbow, or hand), visual analog scale (VAS) score for pain at the initiation and completion of the rehabilitation plan of care, and the duration of RMPT. To measure the outcomes of the study, data collection included the number of sessions available (initially prescribed and requested), number of exercises performed, number of exercises completed, and number of sessions completed. From there, compliance was calculated by dividing the number available by the number of completed exercises or sessions.
The app's AI-driven motion capture technology detects key body landmarks to verify exercise completion. If a user attempts to click “done” before performing any movements, the system does not record data, and the session is marked incomplete. If only part of the exercise set is completed, the app logs completed movements and marks the remaining as incomplete. This ensures that recorded compliance data reflect actual exercise performance rather than user-reported completion. Utilization in this study refers to the total number of sessions completed and the overall duration of rehabilitation.
All the data were collected via the Genie Health RMPT application. Before using the Genie Health application, patients’ consent was obtained for their data to be collected. The collected data were automatically de-identified and stored in a secure database (PowerBI; Microsoft). The number of sessions and exercises completed were not self-reported and were collected directly from the application. Patients self-reported VAS before and after each session. The data collection conducted was not for any specific project. These parameters gave us exemption from institutional review board approval in accordance with the National Institutes of Health decision tool.
Statistical Analysis
Descriptive statistics were performed on patient characteristics. The data are reported as mean ± standard deviation for all continuous variables. Comparison of the categorical variables (sex, age groups, body regions, and ADI quartiles) was performed using chi-square tests. If a significant difference was observed, post hoc pairwise chi-square tests with Bonferroni correction were performed to identify specific between-group differences. Analysis of variance tests were performed to assess the statistical significance of the difference in continuous variables (exercise compliance, session compliance, duration of app usage, and number of completed sessions) among ADI quartiles. When statistically significant differences were detected, post hoc pairwise comparisons were performed using the Tukey honestly significant difference (HSD) test to identify specific between-group differences. All statistical analyses were performed using RStudio Version 2024.04.01.748 (Posit). A P value <.05 was considered significant for all comparisons.
Results
A total of 875 patients were included in this study. The mean age of the participants was 59.3 ± 11.4 years, with the majority of patients being treated for shoulder conditions (90%). Patients went on to complete a mean of 45.6 ± 64.3 sessions for a mean duration of 22.8 ± 10.7 weeks (Table 1). Of the 875 patients included in the study, 840 (96%) were postsurgical cases and 35 (4%) were treated nonoperatively. The study included 475 males (55%) and 393 females (45%). Seven patients did not report their sex and were excluded from this portion of the analysis. These patients were included in all other analyses where sex was not a variable.
Overall Patient Characteristics a
Values are given as n (%) or mean ± SD unless otherwise indicated.
When comparing variables across all 4 ADI quartiles, no statistically significant difference was observed between males and females (P = .232) or in age (P = .054). A statistically significant difference was noted when comparing the mean duration of RMPT use across ADI quartiles (P < .001). Patients in the highest ADI quartile (Q4) had a mean treatment duration of 25.5 ± 14.2 weeks, compared with 20.7 ± 7.9 weeks in the lowest quartile (<25). Post hoc analysis using the HSD test revealed that patients in Q3 and Q4 had significantly longer rehabilitation durations compared with those in Q1 (Q3–Q1: +3.76 weeks, P < .001; Q4–Q1: +4.63 weeks, P < .001). Q2 also had a modest but statistically significant increase in duration compared with Q1 (+2.32 weeks; P = .04) (Table 2).
Patient Characteristics by ADI Quartile a
Values are given as n (%) or mean ± SD unless otherwise indicated. ADI, Area Deprivation Index; Q1, quartile 1; Q2, quartile 2; Q3, quartile 3; Q4, quartile 4.
Similarly, the number of completed sessions varied significantly across quartiles, with patients in the highest quartile completing a mean of 62.2 sessions, compared with 33.4 sessions in the lowest quartile (P < .01) (Table 3). Despite the variations in treatment duration and session completion, no statistically significant differences were found in exercise compliance (P = .313) or session compliance (P = .416) across ADI quartiles (Table 3).
Number of Sessions and Exercises Completed and Prescribed for Each ADI Quartile a
Values are given as mean ± SD unless otherwise indicated. ADI, Area Deprivation Index; Q1, quartile 1; Q2, quartile 2; Q3, quartile 3; Q4, quartile 4.
A significant difference was observed in the number of sessions requested and the number of exercises performed across ADI quartiles (P < .001). Patients in the highest ADI quartile (Q4) had a mean of 180.8 ± 156.4 sessions available and performed a mean of 1919.9 ± 2192.7 exercises, compared with 118.9 ± 105.8 sessions and 1045.3 ± 1197.4 exercises in Q1. Overall, patients in the highest quartile completed significantly more sessions (mean, 62.2 ± 74.9) than those in the lowest quartile (mean, 33.4 ± 47.9) (P < .001). Despite this increased utilization, there were no statistically significant differences in exercise compliance (P = .313) or session compliance (P = .416), which ranged from 25% to 34% across quartiles. Post hoc analysis using the HSD test revealed that patients in Q3 and Q4 completed significantly more sessions than those in Q1 (Q3–Q1: +20.5 sessions, P = .004; Q4–Q1: +30.3 sessions, P < .001). No significant differences were observed among Q2, Q3, and Q4 in session volume.
When comparing the change in VAS, a statistically significant difference was seen across the different ADI quartiles (P = .04) (Table 4). Post hoc pairwise chi-square tests with Bonferroni correction revealed a statistically significant difference in VAS change between Q1 and Q3 (P = .019). Comparison between Q1 and Q4 and the remaining pairs demonstrated no statistical significance.
Reported Change in VAS During the Entire Rehabilitation Period Across Each ADI Quartile a
Values are given as n (%) unless otherwise indicated. Bold P value indicates statistical significance. ADI, Area Deprivation Index; Q1, quartile 1; Q2, quartile 2; Q3, quartile 3; Q4, quartile 4; VAS, visual analog scale.
Discussion
The major findings in our study demonstrate that patients from disadvantaged groups, as indicated by a higher ADI quartile, exhibited a significantly longer duration of RMPT use and completed more sessions (mean, 25.5 ± 14.2 weeks and 62.2 ± 74.9) compared with patients in lower ADI quartiles (mean, 20.7 ± 7.9 weeks and 33.4 ± 47.9). Despite these differences, there was no statistically significant differences in exercise or session compliance between the ADI quartiles. These findings indicate that patients from socioeconomically disadvantaged neighborhoods may have increased utilization of RMPT, although compliance rates were consistent across socioeconomic levels.
This study is the first to investigate the relationship between RMPT utilization and socioeconomic status using ADI as a comprehensive metric. The use of remote monitoring has shown promising outcomes in orthopaedic care, although its potential for increasing utilization in disadvantaged communities remains to be fully explored. The majority of the previous literature has primarily focused on individual socioeconomic indicators such as race, income level, educational level, employment, and insurance status as a proxy for disadvantaged communities. 7 Individually, these factors play some role in predicting orthopaedic outcomes, but they often yield mixed results. For instance, Bram et al, 2 in their study on assessing the effects of race in the care of anterior cruciate ligament injuries, found that Black patients and public insurance users have fewer PT visits compared with White patients. Conversely, Ziedas et al 28 observed that Black patients undergoing rotator cuff repair had more PT visits than their White counterparts, with no significant differences in insurance type. To address the limitation that individual socioeconomic indicators play on this determination, the utilization of ADI was undertaken. Hadad et al 8 investigated the association between race and orthopaedic outcomes using ADI and found that ADI was a partial mediator of the associations observed between race and outcomes after patients underwent total hip arthroplasty and total knee arthroplasty, highlighting the importance of a multidimensional view rather than sole factors such as race and insurance status in determining outcomes. By using ADI in our study, we were able to view how socioeconomic disadvantage affects RMPT utilization. Our findings suggest that disadvantaged groups tend to have higher utilization of RMPT, completing nearly twice as many sessions when comparing patients in the first and fourth ADI quartiles. While the ADI should not be used as the sole predictor for prescribing PT, it may serve as a useful tool in identifying patients who could potentially benefit from RMPT. These results suggest that RMPT could help reduce disparities in access to postoperative rehabilitation, particularly in underserved populations.
The effect of individual socioeconomic factors on PT compliance has also been inconsistent in previous studies. For instance, Rogers et al 20 found that publicly insured patients had reduced access to PT after rotator cuff repair compared with privately insured patients. However, Sarkisova et al 22 reported insurance type to have no significant difference in delaying access to PT. Iversen et al, 9 on the other hand, reported that those with a bachelor's degree or higher were more likely to use PT, while seeing no correlation between employment status. Along with the limited perspective using individual factors, often these studies face the issue of small sample sizes, self-reporting of compliance, and limited geographic coverage. However, a recent study similar to ours, conducted by Suri et al, 26 investigated the association between socioeconomic status and in-person PT compliance after arthroscopic shoulder labrum repair using the ADI. They found that patients with higher ADI scores were significantly less likely to attend scheduled in-person PT sessions. In contrast, our study found that RMPT compliance levels were similar across all ADI groups, suggesting that while socioeconomic status may influence utilization with RMPT, it does not affect adherence to prescribed regimens. This finding indicates that RMPT may help address some of the barriers to PT access associated with socioeconomic disadvantage.
The use of ADI in orthopaedics has gained significant traction in recent years. Many studies have explored the association between ADI and clinical outcomes in orthopaedic procedures. Kiani et al 10 saw that while patients across ADI quartiles had improvement in physical function, those with higher ADI quartiles had significantly higher 9-month pain scores after ACL reconstruction. Shaikh et al 23 observed that higher ADI quartiles had significantly worse postoperative forward flexion after arthroscopic rotator cuff repair despite starting with comparable preoperative range of motion. A well-studied predictor of outcomes after rotator cuff repair is PT, and RMPT has proven to achieve similar outcomes to in-person PT.3,4 This study adds to the current body of evidence and suggests that RMPT may assist in bridging these outcomes.
Despite observing a statistically significant difference in the change in VAS across the ADI quartiles, the absence of a clear trend demonstrates the complexity of using pain scores as an indicator of success after therapy. VAS is subjective pain perception that may be influenced by multiple unmeasured factors, such as baseline pain thresholds, analgesic use, and disparate comorbidities across patient populations. As such, this specific finding may not fully illustrate the broader functional benefits of RMPT.
This study does not come without its limitations. First, ADI values represent a mean for an entire zip code, meaning the value does not account for any variation or disparities within neighborhoods. Therefore, ADI values assigned based on patient home address may not always accurately measure socioeconomic disadvantages. Second, there was no discrete number of PT sessions prescribed to patients, therefore complicating the calculation of session compliance. Third, there is potential selection bias in our patient population as participants were not randomized to receive RMPT. Lastly, the findings of this study are limited in its interpretation for clinical outcomes. Future research will focus on incorporating objective functional measurements alongside patient-reported outcomes to comprehensively understand recovery.
Conclusion
Our study found that patients from socioeconomically disadvantaged areas, as measured by the ADI, utilized RMPT more extensively than patients from less disadvantaged areas. However, compliance across sessions and exercises was consistent across all ADI groups. RMPT shows potential for improving access to PT among disadvantaged populations, although further research is needed to evaluate the clinical effect of these findings.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: P.J.D. has received consulting fees from Arthrex and LifeNet; speaking fees from Arthrex and Pacira; royalties from Arthrex (includes Steelhead); and research support from Arthrex and owns stock in PT Genie (Genie Health). R.G. has received consulting fees, royalties, and research support from Arthrex and owns stock in PT Genie (Genie Health). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval was not sought for the present study.
