Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology

Kendall E Bradley, Chad Cook, Emily K Reinke, Emily N Vinson, Richard C Mather 3rd, Jonathan Riboh, Tally Lassiter, Jocelyn R Wittstein, Kendall E Bradley, Chad Cook, Emily K Reinke, Emily N Vinson, Richard C Mather 3rd, Jonathan Riboh, Tally Lassiter, Jocelyn R Wittstein

Abstract

Hypothesis/background: In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE.

Methods: The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test.

Results: We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87).

Conclusion: This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.

Keywords: Shoulder; clinical assessment; diagnostic accuracy; imaging; magnetic resonance; rotator cuff tear; telehealth.

Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Patient enrollment flowchart.
Figure 2
Figure 2
Location of rotator cuff tear on MRI as read by the radiologist. SS, supraspinatus; IS, infraspinatus; SSc, subscapularis.

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