The purpose of this study was to investigate the concordance (agreement), of diagnostic and management recommendations arising from three assessment groups: PT_alone, NP_alone and PT/NP_team (PT joining with telehealth).

In the interprofessional assessment, NPs brought significant advantages to the team: rapport and trust with the patient, and knowledge of medical comorbidities as well as pain management approaches already tried. The consulting PT contributed consultative skills on neuromusculoskeletal assessment techniques, as well as clinical reasoning on the intricacies and management approaches for CBD.

The two PTs (PT_alone and PT_team) were trained and practiced in the same setting with similar experience in spinal triage, and were accustomed to a similar assessment format. The PT/NP_team went through pre-assessment interprofessional training to standardize their assessment. The NP_alone followed their traditional assessment approach. The NP_alone and NP working with the PT in a team had different practice settings and years of experience. The differences in clinical practice may have contributed to overall findings, however the most likely reason for differences is the presence of the PT on the interprofessional team.

The present study noted strong agreement between PT_alone and NP_alone, as well as PT_alone and PT/NP_team with respect to “overall diagnoses” and management decisions such as “need for urgent surgical referral” and “follow up PT”. Although concern has been expressed that elements of a conventional face-to-face physical examination require the PT to be “hands-on” with the patient, ¹⁸ in the present study adapting a neuromusculoskeletal assessment to an interprofessional approach of the NP/PT_team resulted in similar outcomes for “overall diagnosis” and “management recommendations” as an in-person PT assessment.

PT_alone and NP_alone comparisons had ‘good’ agreement on the management recommendation for “urgent surgical referral”, and ‘moderate’ strength in agreement for “overall categorization of diagnosis”. NP_alone and NP/PT_team had 85.2% agreement for identification of “the back” as the primary source of the participant's problem, but had lower agreement on overall diagnosis or recommendation for “urgent surgical management”. PT_alone and PT/NP_team were 92.6% in agreement that the back was the source of participants’ problems, and ‘strong’ agreement was noted for “urgent surgical referral”, and “recommendation of any PT follow up”.

Participants spent a mean of 13.1 min with the NP_alone, 36 min with the PT_alone, and 31 min with the PT/NP_team. NP_alone assessment durations were significantly less than both PT_alone and NP/PT_team. This may be an important factor in the consideration of a new model of care. The increased length of assessment durations noted with the NP/PT_team compared to NP_alone would come with increased cost for the healthcare system. However, this refers only to the cost of clinician time, without reference to travel or time patient cost, which are important future considerations since they may represent cost savings to the patient. The present study did not collect information on direct cost savings to the patient which may have been realized due to the team model, for example time and travel already noted, as well as the potential cost savings due to identification of referral needs in the case of medically complex patients, which occurred in the team model and is discussed in detail below. The systematic review by Wade et al. found that medical and specialist care models using telehealth for rural outpatient services also identified studies where telehealth was determined more expensive than the control (in terms of costs of health care services). ³⁷ To the best of our knowledge, there are no cost analyses for PT involvement in an interprofessional care model using videoconferencing.

In terms of longer assessment times on the NP/PT_team, there were three outliers out of 22 (71, 65 and 55 min), which may provide valuable cases to demonstrate the enhanced effectiveness of a team approach. In these cases, the NP/PT_team identified complex medical concerns. In the first case, they referred to geriatric assessment unit for medical review, occupational therapy and PT for reconditioning and treatment for mechanical degenerative pain (of the lumbar spine). PT_alone recommended that individual treatment by a lone practitioner would not likely be effective, and that the patient required a team approach to care. NP_alone recommended return to physician for workup, and noted the importance of social connections and psychological treatments to be ongoing. In the second outlier, NP/PT_team recommended full cardiac, neurological and metabolic workups with the primary provider due to reported: excessive thirst, diminished bilateral foot sensation, noted dyspnea/wheeze, deconditioning, diaphoresis, history of syncope, and diminished memory. NP_alone recommended “referral back to primary provider” due to concerns of generalized weakness, proprioceptive and sensory difficulties. PT_alone recommended possible candidate for facet injection. In the third outlier case, the NP/PT_team reported widespread irritable capsular restrictions including bilateral hips and cervical spine and recommended PT follow-up. NP_alone recommended self-care with videos on posture, as well as continued exercises given by the patient's own PT. PT_alone recommended PT follow-up and self-care for the lumbar pain. However, the third case was more likely indicative of osteoarthritic flare up and involved screening of hips and cervical spine to confirm; this additional screening required a greater length of time.

The present study examined a full, comprehensive neuromusculoskeletal assessment process and clinical reasoning process for the management of CBD. Previous research using telehealth for back pain has focused on specific assessment techniques, or portions of assessments.^38,39 Other studies have examined a single case of neuromusculoskeletal assessment ²⁰ and have focused on experience of patients and practitioners with this type of care. ²¹ No previous studies have examined the concordance, or level of agreement, of a full neuromuscular assessment for CBD and associated clinical decision-making in comparison to a reference standard of in-person PT assessment.

Reduced access to PT in rural and remote regions is a known healthcare disparity. Bath and Janzen found that patients appreciated the expertise and education provided by an in-person PT for their back pain, but that this did not solve the problem of limited rural access to PT. ¹⁵ Briggs et al. interviewed rural Australian people with CBD. They found that some of the participants expressed dissatisfaction with limited access to both interdisciplinary care and practitioners with experience managing pain. Participants raised the idea of telehealth technologies for improving care. ⁴⁰ The present study demonstrates the feasibility of bringing a PT consultant to a rural team for CBD assessments using telehealth, which could improve access to PT in rural areas. The NP/PT_team decisions about overall diagnosis, referral to surgeon and referral for PT showed adequate agreement with the decisions of a PT_alone, which means similar decisions were made through the team assessment over telehealth, as would have been made if a PT_alone assessed the participants.