Abstract
Objectives:
Telemedicine has become a critical component in the evaluation and management of patients with shoulder pathology. However, the reliability and accuracy of findings on a virtual physical exam relative to in-person evaluation is unclear. The purpose of this study is to determine the reliability and accuracy of a recorded telemedicine physical exam for diagnosis of shoulder pathology compared to the traditional in-person physical exam performed in an outpatient shoulder clinic.
Methods:
This study is a randomized controlled trial. New patients presenting with unilateral shoulder pain to a singlesurgeon shoulder clinic were recruited between July and November 2020. In a single visit, patients were evaluated with standardized in-person and telemedicine physical exams, and the order was randomized. The telemedicine exam was recorded and consisted of a pre-recorded video guide displaying self-directed shoulder exam maneuvers that patients performed under remote coaching by an independent observer. The in-person physical exam was performed by the treating physician and results were used as the gold standard. The telemedicine videos were evaluated by two independent observers for inter-observer reliability. The treating physician subsequently evaluated the telemedicine videos after a minimum 2-month washout period for intra-observer reliability. Inter- and intra-observer reliability analyses were conducted using the Kuder-Richardson 20 (KR-20) formula.
Results:
Thirty-two patients (17 male, 15 female; average age 50.2 ±16.2 years) were enrolled and included in the analysis. Overall KR-20 reliability across all 40 physical exam maneuvers was 0.391±0.332 (76.4% ± 15.4% agreement) between the in-person and telemedicine exams. Maneuvers conducted via telemedicine that examined range of motion (ROM) limitations had the highest degree of reliability, sensitivity, specificity, and likelihood of also producing a positive finding on the in-person exam (0.700±0.114, 66.5%, 81.0%, and 6.06, respectively). Exam maneuvers conducted via telemedicine that relied on identifying apprehension associated with glenohumeral instability were found to have the lowest reliability, sensitivity, and likelihood of producing a positive finding on the in-person exam (0.176±0.440, 23.5% and 0.518, respectively). All included patients were satisfied with their telemedicine experience.
Conclusions:
Overall reliability of telemedicine physical examination maneuvers was poor. ROM limitations identified on the telemedicine exams were found to be the most reliable and accurate, while techniques used to evaluate instability were found to be the least reliable and accurate. While the telemedicine exam can be reliable as a screening tool in certain pathologic conditions, providers should use the in-person exam and imaging results to confirm any suspected diagnoses.
Categories of examination techniques assessed.
Summary of sensitivity, specificity, and reliability results.
Simmiary of patient satisfaction survey results.
