New approaches can help people grow their resiliency and self-efficacy
Virtual care and other technologies (such as clinician-to-clinician electronic consults, self-care apps and websites, and bio- and behavioral feedback devices such as activity trackers) will enhance the variety and quality of tools and connections that we, as orthopaedic surgeons, can use to help people seeking better musculoskeletal health.

As we reshape our roles as healthcare providers from the standpoint of maximizing patient-centeredness and providing value, the availability of these platforms will become paramount.

Insurers, though, are wary of shifting care away from the typical medical setting. They fear that doing so will add yet another commodity and cost, without improving health.

These concerns are valid, since early evidence suggests that the advent of retail health care (getting care in a pharmacy or department store) has increased costs without increasing health. But several features of musculoskeletal illness suggest it may be responsive to the addition of virtual health, if it is applied within the biopsychosocial paradigm—in other words, if we use it to provide comprehensive care.

Diagnosis and treatment
Diagnosis and treatment of musculoskeletal illnesses are well suited to virtual care.

Many important physical exam findings—such as abnormal gait or limited range of motion—are as easily seen on video as in person. Deployment of physical test devices (for strength testing, for example) may increase the amount of the typical in-person evaluation that can be done virtually.

When imaging is helpful, it is often already available, but it can also be done locally. Discussing the results of diagnostic tests with patients is a good use of electronic platforms.

Along those lines, the primary treatment strategies in musculoskeletal disease are education, restoration of hope and resilience, and noninvasive interventions that can be delivered virtually (such as home exercises or a recommendation for anti-inflammatories). Monitoring or treatment for an asymptomatic or mildly symptomatic patient is rarely indicated, unlike conditions such as diabetes or hypertension. The need for intervention or re-evaluation is instead driven by persistence or progression of symptoms, which can be easily assessed remotely by interview or patient-reported outcome measures.

Discretionary and preference-sensitive
Musculoskeletal care is often discretionary and preference-sensitive. Life's temporary aches and pains (such as low back pain and enthesopathies) and the pains of the normal aging process (including arthritis, tendinopathy, and neuropathy) are quality-of-life issues. Musculoskeletal health is enhanced by choices that are consistent with a person's values and that are not based on misconceptions.

Virtual health and other uses of technology provide an increased number of touch points that can help people clarify their values before they make decisions about tests or treatments.

Misconceptions can be corrected gently and incrementally. This important process helps ensure that patients' treatment choices are consistent with their values and goals.

Addressing psychosocial factors
Psychosocial factors have a strong influence on musculoskeletal illness. Psychosocial stressors and less effective coping strategies (lower resiliency) affect musculoskeletal patient-reported outcomes as much as or more than pathophysiology. Indeed, stress and distress often manifest as increases in musculoskeletal symptoms and limitations.

In other words, the musculoskeletal system is a common focus for psychological distress (a somatic focus). Patients can more easily say "I hurt" than "I'm down" or "I'm worried."

The false mind-body dichotomy and the stigma and shame associated with misconceptions, symptoms of depression or anxiety, and less effective coping strategies are important barriers to addressing musculoskeletal illness in the biopsychosocial paradigm. Attempts to address psychosocial factors can be unwelcome and offensive.

The key to successfully treating musculoskeletal illness comprehensively (biopsychosocially) is to first gain a person's trust by developing a relationship based on taking genuine interest in each individual. This has been called "relationship-centered care." Effective communication strategies can help establish trusting relationships. Techniques such as motivational interviewing can help people consider all the possibilities for getting and staying healthy, even those that involve personal work on healthy eating, health activity, and healthy thoughts, emotions, and behaviors.

Virtual care has been shown to be equivalent to in-person treatment in building therapeutic alliances in the context of behavioral health. Phone, text, email, and video contact may support a more gradual establishment of trust and genuine interest over time. Opportunities for personal growth can arise at each person's preferred pace. Offering increased access is itself a demonstration of empathy and caring. People may take better advantage of the diagnostic and therapeutic power of time if they know they are in "the embrace of care."

In summary
Proper use of virtual care and other technology enhancements can help achieve the following goals:

• Shift the balance of power (as promoted by Don Berwick and the Institute for Healthcare Improvement), by giving patients information, decision-making leverage, and self-care strategies.
• Improve access and reduce disparities.
• Facilitate incremental care, a softer way to help people gain trust in the care team, become aware of their values, correct misconceptions, and ensure their preferences are based on these values rather than those misconceptions.
• Demonstrate compassion via increased and more facile connections with the care team at the patient's convenience—in effect, providing "concierge care for everyone."

Virtual care and other technology enhancements are well suited to musculoskeletal care. Used strategically, new approaches based in technology can help people grow their resiliency (ability to adapt to adversity) and self-efficacy (confidence that one can achieve one's goals).

Improvements in psychologic health and supportive circumstances promise to do more to improve patient-reported outcomes than most biomedical treatments. The opportunity exists to improve value and convenience for people while simultaneously increasing efficiency of clinician time and breadth of impact.

At the Dell Medical School–The University of Texas at Austin, Karl Koenig, MD, is the medical director of the integrated practice unit for musculoskeletal care; David Ring, MD, PhD, is associate dean for comprehensive care; and Andrea Leyton-Mange, BA, is a value-based care research fellow. Dr. Ring is also the chair of the AAOS Patient Safety Committee.

Aspects of Musculoskeletal Care Well Suited to Virtual Health Modalities (PDF)

References:

1. Ashwood JS, Gaynor M, Setodji CM, Reid RO, Weber E, Mehrotra A: Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending. Health Affairs 2016;35: 449–455. doi:10.1377/hlthaff.2015.0995.
2. Dubin A: Managing Osteoarthritis and Other Chronic Musculoskeletal Pain Disorders. Med Clin North Am 2016;100:143–150. doi:10.1016/j.mcna.2015.08.008.
3. Sharma A, Kudesia P, Shi Q, Gandhi R: Anxiety and Depression in Patients with Osteoarthritis: Impact and Management Challenges. Open Access Rheumatol 2016;8:103–113. doi:10.2147/OARRR.S93516.
4. Sucala M, Schnur JB, Constantino MJ, Miller SJ, Brackman EH, Montgomery GH: The Therapeutic Relationship in E-Therapy for Mental Health: A Systematic Review. J Med Internet Res 2012;14(4):e110. https://doi.org/10.2196/jmir.2084