Abstract
BACKGROUND:
Artificial Intelligence (AI) refers to the simulation of human intelligence in machines that are programmed to perform tasks that typically require human intelligence. The integration of AI and telehealth applications in healthcare raises ethical concerns such as bias, transparency, data privacy, and accountability for errors. Several studies have assessed this topic, particularly with regard to musculoskeletal disorders, which will be the focus of this manuscript.
OBJECTIVE:
We will examine key ethical concepts including informed consent, data protection, confidentiality, physician malpractice, liability, and telemedicine regulations.
METHODS:
Ethical issues pertaining to the topic were explored through a review paper. The primary objective of this scoping review was to map and synthesize the existing literature concerning ethical considerations in telehealth and AI for work-related musculoskeletal disorders.
RESULTS:
Research demonstrates that medication effectiveness, patient and physician satisfaction, and accessibility costs are higher with telemedicine and AI methods compared to in-person approaches, particularly for work-related musculoskeletal disorders. Therefore, addressing ethical issues, including patient data privacy and security, is crucial in this field. By considering these factors, the adoption of emerging AI and telemedicine applications, especially for work-related musculoskeletal disorders, is likely to increase.
CONCLUSION:
AI and telemedicine offer significant advantages, particularly in addressing work-related musculoskeletal disorders. However, ethical and legal issues surrounding their practice require standardized rules to ensure equitable access, quality care, sustainable costs, professional liability, patient privacy, data protection, and confidentiality. Further practical research studies are needed to address these considerations more effectively.
Keywords
Introduction
Work-related musculoskeletal disorders (MSDs) stem from occupational factors such as repetitive motions and awkward postures, leading to conditions affecting muscles, bones, tendons, ligaments, and other parts of the musculoskeletal system. These disorders can result from various workplace activities, repetitive motions, awkward postures, forceful exertions, and other ergonomic or biomechanical stressors [1–3]. Examples of work-related MSDs include carpal tunnel syndrome, tendonitis, back pain, and neck strain. Preventing and addressing these disorders is crucial for a healthy workplace, involving collaboration between employers, employees, and healthcare professionals [4–6].
Telehealth, also known as telemedicine, employs digital technologies for remote healthcare delivery, enabling consultations, diagnosis, treatment, and education via electronic communication channels [7]. It improves healthcare access, particularly valuable when in-person visits are impractical, and plays a significant role in managing work-related MSDs, offering convenient and effective remote healthcare solutions [8]. Telehealth is versatile across medical specialties and especially valuable when in-person visits are difficult. It enhances healthcare accessibility, promotes preventive care, and facilitates timely interventions. With advancements in digital communication technologies, the prevalence of telehealth has increased, addressing the growing demand for remote healthcare solutions. In managing work-related musculoskeletal disorders, (MSDs), telehealth offers a convenient and effective means of delivering healthcare services remotely[9, 10].
Artificial Intelligence (AI) replicates human intelligence in machines, enabling tasks such as learning, reasoning, problem-solving, perception, speech recognition, and language understanding [11]. AI systems analyze data, adapt, and improve performance over time without explicit programming. In healthcare, AI is utilized for medical imaging interpretation, drug discovery, personalized medicine, and predictive analytics to enhance patient care and streamline processes [12]. As AI becomes more widespread, ethical considerations are paramount, including addressing algorithm bias, privacy, transparency, and responsible use of AI systems [13, 14].
Ethics delves into the fundamental principles underlying moral values. It can be described as moral philosophy, offering a systematic framework for discerning between good and evil, right and wrong [15]. While legal frameworks like laws and regulations serve as essential guidelines, they may not always suffice. Hence, the establishment of codes of ethics, both written and verbal, becomes imperative. These codes function as compasses for professionals within their respective fields, fostering ethical behavior and enhancing their professionalism [16]. Professional ethics, therefore, encompasses a set of principles and rules dictating appropriate conduct within a specific professional community [17]. Its primary objective lies in cultivating public trust and ensuring adherence to prescribed standards of behavior [18]. Within the realm of medicine, ethical considerations govern the interactions among professionals and between professionals and patients, guided by moral principles[19, 20].
Ethical considerations are pivotal in the fusion of telehealth and artificial intelligence (AI) to combat work-related musculoskeletal disorders (MSDs). As these technologies become more prevalent in the healthcare setting, it is essential to ensure that they are implemented in a manner that prioritizes patient well-being, privacy, and equitable access to care [21, 22].
Thus, the objective of this study is to implement telehealth and AI for work-related musculoskeletal disorders, focusing on addressing privacy concerns, promoting equitable access, ensuring technological reliability, respecting patient autonomy, maintaining professional oversight, and proactively mitigating biases.
Method
Study design
A scoping review is a form of literature review designed to chart the existing literature on a specific topic, identify key concepts, and determine the breadth and depth of available research evidence. In contrast to systematic reviews, scoping reviews encompass a wider range in scope and do not typically assess the quality of individual studies. Instead, they provide a comprehensive overview of the literature to identify gaps in knowledge, highlight areas for future research, and inform policy or practice.
The primary aim of this scoping review was to map and synthesize the existing literature on the ethical considerations in telehealth and artificial intelligence for work-related musculoskeletal disorders. A comprehensive search was conducted across multiple electronic databases, including PubMed, and Google Scholar. In this study, a total of 46 references were retrieved from these databases, 28 from Web of Science, 12 from PubMed, and 6 from Google Scholar.
The search strategy involved a combination of keywords and controlled vocabulary terms related to telehealth, telemedicine, ethical consideration, musculoskeletal disorders, work-related musculoskeletal disorders, artificial intelligence, and various combinations thereof. The search terms were tailored for each database to ensure optimalcoverage.
Eligibility criteria
Studies were deemed eligible for inclusion if they met the following criteria:
Published in peer-reviewed journals or full-text in a proceeding book. Written in English. Published within the last seven years, with a focus on those published within the last year. Pertinent to the intersection of telehealth or artificial intelligence and ethical considerations regarding work-related musculoskeletal disorders.
Search strategy
The initial screening of titles and abstracts was performed independently by two reviewers. Full-text articles were then assessed for eligibility based on the inclusion criteria. Discrepancies were resolved through discussion or by consulting a thirdreviewer.
Data items
A standardized data extraction form was developed to capture relevant information, including author(s), publication year, study design, key findings, and any other pertinent details.
Data synthesis
In a scoping review article, the synthesis of results entails collating and summarizing the findings from the included studies coherently and comprehensively. Unlike systematic reviews, which frequently employ statistical meta-analysis, scoping reviews typically utilize a narrative synthesis to present and interpret the results. Data were synthesized using a narrative approach, emphasizing key themes, patterns, and gaps identified in the literature.
Quality appraisal
Given the scoping nature of this review, a formal quality appraisal was not conducted. However, the methodological rigor of individual studies was considered in the synthesis and interpretation offindings.
Results
Study selection
As outlined in the Supplementary Material, employing the search strategy across relevant databases yielded a total of 230 articles. Initially, 19 articles were excluded due to their publication before the year 2011. Upon closer examination, it was determined that articles predating 2018 were not directly related to the search criteria, resulting in the exclusion of 43 additional records. Among the remaining 168 records published between 2018–2023, 152 articles were excluded as they solely focused on musculoskeletal disorders without relevance to telehealth or artificial intelligence. Consequently, only 16 articles were deemed suitable for inclusion in the study on work-related musculoskeletal disorders.
Study characteristics
Half of the studies examined telehealth applications, while the remaining focused on artificial intelligence interventions for work-related MSDs. Among the telehealth-related studies, three explored the significance of telehealth amid the COVID-19 pandemic, emphasizing infection prevention and cost reduction. Some articles investigated WMDs such as hip and knee arthroplasty, wrist, arm, waist, and back pain [2, 13]. One study reported a WMDs prevalence of 66.8% and assessed influential factors like physical activities, posture changes, vibration exposure [8]. Another study evaluated social pressures from colleagues regarding telemedicine integration in sports medicine, identifying both challenges and opportunities [12].
In the realm of artificial intelligence, studies primarily examined risk factors and clustering of WMDs. Some attempted to predict patient exercise programs using deep learning or artificial neural networks [1, 14]. Wearable technologies emerged as crucial aids in WMDs-related therapies [23]. Several telehealth articles detailed the usage rates of telephone, video conferencing, and computers for telehealth services [9, 10]. An article addressing the ethical and legal challenges in telemedicine during the COVID-19 pandemic, emphasized the need for standardized codes of practice [24]. Another article highlighted the ethical considerations of musculoskeletal physiotherapy and telemedicine, advocating for adherence to established ethical norms [25]. Additionally, a study underscored the ethical gaps in the current legislation, particularly concerning patient data privacy and interaction [26]. The results of all studies included in this scoping review are presented in Table 1.
Summary of Findings
Summary of Findings
Discussion
The compilation of literature presented herein encompasses a diverse array of studies investigating the use and perspectives of telehealth services, particularly within the realm of musculoskeletal conditions. These studies collectively contribute to a nuanced understanding of the evolving landscape of healthcare, with a focus on continuity of care during the COVID-19 pandemic and the broader implications for allied health clinicians.
For instance, multiple studies emphasize the need for robust safeguards to protect sensitive health information transmitted and processed through telehealth platforms and AI algorithms. Several studies have emphasized how crucial it is to have robust security measures in place to secure private health data that is processed and transferred via AI algorithms and telehealth platforms. These security measures are essential to guaranteeing the confidentiality, integrity, and privacy of patient health data as it travels across digital platforms and is processed by AI systems. Using encryption techniques, access controls, safe data storage procedures, and adherence to pertinent privacy laws are all part of putting strong measures in place. To allay worries about data security and privacy and preserve confidence in telehealth services and AI-driven healthcare solutions, these steps are crucial. Strong security measures are necessary to secure sensitive health information as telemedicine and artificial intelligence continue to transform healthcare. This entails putting in place cutting-edge security measures, making sure that regulations are followed, preserving data integrity, and encouraging openness and patient consent [27–29]. As the adoption of wearables and remote monitoring devices increases [30], ensuring the confidentiality of patient data becomes paramount. Striking a balance between maintaining patient autonomy and fostering meaningful human interaction amidst AI-driven interventions is imperative. Clinicians must remain vigilant in interpreting AI-generated insights and hold themselves accountable for the decisions made based on these technologies. Continuous education and training are crucial to ensure healthcare providers are well-equipped to navigate the ethical challenges associated with the integration of AI into their practice.
Furthermore, a majority of the studies indicate that telehealth interventions delivered at home are as effective as traditional therapy methods. Rehabilitation methods for work-related musculoskeletal disorders have demonstrated success with the integration of telehealth and AI [1, 23]. Moreover, satisfaction levels among both therapists and patients regarding telehealth and AI-driven technologies for work-related musculoskeletal disorders vary from good to high levels. Telehealth services have been reported to aid in cost savings for patients, particularly in reducing transportation expenses [3, 31].
The examination of the impact of the COVID-19 pandemic on physiotherapists provides a critical perspective on the challenges confronting healthcare professionals. Discussions revolve around increased demands, alterations in patient care approaches, and heightened levels of anxiety and stress among physiotherapists, with a notable surge in work-related musculoskeletal disorders. This highlights the imperative need for support mechanisms within the healthcare system to address the well-being of frontline workers [2].
Exploration into telehealth within neurology, particularly concerning neuromuscular and musculoskeletal disorders, offers valuable insights into technological applications, outcomes, and limitations. Discussions highlight the potential to enhance access, diminish travel costs, and provide flexible practice opportunities, emphasizing telehealth’s broader applicability beyond the immediate scope of musculoskeletal conditions [6].
The investigation into the utilization and perceptions telehealth among allied health clinicians treating musculoskeletal conditions during the pandemic highlights the instrumental role of telehealth in ensuring the continuity of care. This finding aligns with a broader trend observed in the literature, where telehealth emerges as a pivotal tool for adapting to patients’ changing needs during thepandemic [22].
The focus on lower limb conditions and the delivery of telehealth by physiotherapists adds granularity to our understanding of telehealth applications. The literature search, spanning multiple databases, underscores the significance of real-time telehealth physiotherapy sessions, elucidating the specific conditions addressed and the modes of delivery employed [4].
Exploring healthcare professionals’ perceptions and experiences with telemedicine in sports medicine provides a comprehensive analysis of adopters and non-adopters. Identification of key domains such as integration challenges, collaborative practices, and benefits contributes to the understanding of factors influencing the uptake of telehealth in specialized medical fields [12].
The proposal for an automated diagnosis system aimed at detecting musculoskeletal disorders among sewing machine operators, utilizing video recordings and machine learning, showcases the potential for technology-driven solutions in overlooked industries. The high accuracy achieved in diagnosing musculoskeletal disorders underlines the feasibility of incorporating automation in occupational health [5]. A review of the application of artificial intelligence in preventing work-related musculoskeletal disorders in industrial settings provides a comprehensive overview. The analysis of risk factors, ergonomic criteria, and the current state of AI in physical ergonomics contributes to our understanding of technological advancements in occupational health. The exploration of AI, Internet of Things (IoT), and machine learning in medical sectors, specifically for musculoskeletal conditions, presents a forward-looking perspective. The potential for AI-driven digital health interventions to reduce pain and improve functionality in patients with chronic neck and back pain highlights the transformative impact of technology on lifestyle choices [32].
Another domain where the utility of artificial intelligence aids in healthcare information dissemination is leveraging ChatGPT’s capacity to provide medical information and treatment options for Supraspinatus Tendinopathy. While the study indicates potential usefulness, caution is advised due to the model’s inherent limitations and potential biases [11]. Moreover, the evaluation of Artificial Neural Networks (ANN) in prognostic studies of musculoskeletal diseases contributes to the growing body of literature on predictive analytics in healthcare. The varying accuracy observed in ANN predictions underscores the necessity for ongoing refinement and validation in prognostic modeling [14].
Furthermore, the discussion on the role of wearable motion capture devices in preventing work-related musculoskeletal disorders reflects ongoing technological advancements in occupational health. The potential for enhanced exposure and risk assessments, coupled with challenges such as miniaturization and international standards, underscores the need for continued research and development [23].
Similarly, the survey of patients in Queensland, Australia, provides a valuable patient-centric perspective on telehealth for chronic musculoskeletal conditions. While the majority expressed satisfaction with the current service, identified barriers underscore the need for targeted interventions. The willingness of over half the participants to use telehealth, particularly if it reduces costs and time, signals a receptiveness to innovative healthcare delivery methods [7].
Moreover, the use of machine learning to predict work-related risk factors for musculoskeletal diseases among bus drivers underscores the potential for proactive intervention. The identification of influential factors and the prevalence of musculoskeletal disorders highlights the importance of personalized strategies for occupational health [9].
Additionally, the novel longitudinal study employing CatBoost regression models in occupational health settings demonstrates the integration of artificial intelligence for predicting workers’ medical appointments and body part protection severity. The study’s effectiveness, as indicated by RMSLE values, highlights the potential for advanced modeling techniques in prognosis [21].
Furthermore, the utilization of deep learning and 2D human pose estimation to assess work-related musculoskeletal disorder (WMSD) risk in repetitive tasks adds a technological dimension to occupational health. The emphasis on efficient risk assessment aligns with the broader goal of preventive healthcare in occupational settings [31]. Lastly, there are many other studies related to ergonomics, injuries and musculoskeletal disorders treatment. Some of them are directly related to telehealth applications, and one of the articles is related to ethical principles in telehealth practices. However, this article is a systematic review [30, 33–45].
When considering the ethical and professional aspects of the issue, the concept that telehealth is merely an alternative means of providing healthcare services becomes prominent. Therefore, it is imperative for clinicians, professional associations, and authorized bodies to define the scope of practice [25].
According to the World Medical Association’s Statement on Telemedicine Ethics, “Face-to-face consultation between physician and patient” is still the gold standard of clinical care. However, telemedicine has become increasingly widespread, especially recently. It should not be forgotten that telemedicine has a very important facilitating role in reducing the distance between the “patient and the doctor”, especially in geographical areas where it is difficult to access medical services or in individuals such as ship crews who are far from settlements [46].
Dizzying developments in healthcare delivery may open new doors for legal, ethical, and other regulations. All these can have a strong impact on decision-makers. Two prominent issues in telemedicine applications are ethics and cost. Patient privacy, informed consent, and the fact that a patient is waiting for healing are the ethical dimensions of the issue. Issues such as the use of technology in telemedicine applications, security, and legality are the topics that increase the cost [26].
The COVID-19 pandemic, which has affected the whole world, has caused a surge in telemedicine applications. This, of course, has brought the issue of telehealth and ethics, which is already being discussed, to the agenda more strongly this time. Regardless of the application area of telehealth, ethical principles such as “autonomy”, “beneficence”, “do no harm” and “justice” should be respected in the same way as “privacy and confidentiality of patient data” [24].
This scoping review has several limitations. Firstly, accessing relevant articles in databases posed a challenge due to the multitude of scientific databases available, making it possible to find valuable articles across different indices. Secondly, the time constraint for searching and evaluating articles within a limited timeframe was a limitation. The rapid turnover of information necessitates swift assessment, as findings may become outdated or irrelevant if not addressed promptly. Another final limitation is the absence of other studies directly related to the subject matter and addressing its ethical dimensions.
Conclusion
In conclusion, the literature concerning ethical considerations in the convergence of telehealth and AI for WRMSDs underscores the multifaceted nature of these concerns. Key themes such as privacy, informed consent, equity, autonomy, and professional accountability demand ongoing attention and collaborative efforts from researchers, policymakers, and healthcare practitioners to ensure the responsible and ethical deployment of these technologies in the management of work-related musculoskeletal disorders.
In our swiftly evolving world, the provision of health services is undergoing rapid development. As in all fields, it is imperative for professionals to come together and make decisions about ethical practices for real-life applications. Another crucial aspect is the continual updating of these practices based on experiences gained. We believe that increasing studies on this subject is of paramount importance.
Furthermore, this compilation of literature provides a comprehensive overview of telehealth and technology applications in the context of musculoskeletal conditions. From the perspectives of healthcare professionals, patients, and technological advancements, the studies collectively contribute to a nuanced understanding of the challenges, opportunities, and ethical considerations in the rapidly evolving landscape of musculoskeletal healthcare. As the field continues to evolve, further research is warranted to enhance the evidence base and guide the ethical, accurate, and cost-effective implementation of telehealth services for musculoskeletal conditions.
Ethical approval
Tehran University of Medical Sciences, IR.TUMS.MEDICINE.REC.1403.133.
Informed consent
Not applicable.
Conflict of interest
None.
Funding
There was no funding for this study.
Editorial for special series
“Advancements in Telehealth: Empowering Occupational Health through Teleconsultation, Telerehabilitation, and Teleexercise for the Prevention and Treatment of Musculoskeletal Disorders across Occupations”.
