Remote Care: Telemedicine for Knee Pain Management in Singapore
Overview of Knee Pain
The knee joint is made up of bone on bone. The thigh bone, or femur, is the topmost bone in the joint which actually connects to the lower leg bone, tibia, at the knee. The smaller bone running beside the tibia is the fibula. The tip of the fibula forms the joint with the tibia. The surface of these bones, which comes into contact with each other, is coated with articular cartilage. The function of the cartilage is to allow for smooth, pain-free movement of the joint. The ends of the bones are held in place by ligaments, which are strong connective tissues that attach bone to bone. On the tibia, there are two menisci which act as padding between the bones and as shock absorbers. Many of these structures can be injured at some stage, and by doing so, cause pain in the knee joint.
Knee pain is one of the most common musculoskeletal problems, which occurs in one third of all adults. It affects the quality of life and mobility of the affected individual. Knee pain can be traced back to a specific injury or it can develop over time. The manifestation of knee pain in your everyday life points to a likely problem with one of the structures in your knee. These structures are the most commonly affected by knee pain.
Telemedicine Options for Knee Pain Management
One of the most important aspects to consider in the use of telemedicine in knee pain management is the type of service that you want to provide to the patient and the benefit of these services. The approach to care, whether it is through an acute face-to-face consultation or a longitudinal care episode which is more typical of chronic disease management, affects the type of service needed. As arthritis is a chronic disease, the use of telemedicine is more relevant to the long-term management of knee pain rather than acute attacks of inflammation. Telemedicine can be delivered in various forms, the most common being telephone, video (or internet), and email. Email is often used for asynchronous episode management. For example, a GP may ask the patient with a knee problem to email relevant information (history, examination findings, etc.) that will help the GP to decide whether a new complaint is a flare-up of an existing problem or a new problem that requires a face-to-face consultation. Email consultation with specialists has been used in the same way. Telephone and video consultations can be either similar to conventional telephone and office visits, with the exception that the participants are in different locations, or more as a triage-style service. Video conferencing is the closest form of telemedicine to a face-to-face consultation and is usually favored by patients. Telephone and video triage are often used by allied health professionals. For example, a physiotherapist assessing a patient with a new problem would determine whether traditional physiotherapy or a more complex intervention is required and inform the relevant physician and/or patient of the decision.
Benefits of Telemedicine for Knee Pain
Patients with pain from chronic knee osteoarthritis and a healthcare provider in their practice is willing to be randomized. A trained research assistant will obtain verbal consent, assess eligibility, and randomly assign interested patients to the intervention or the control group. After each baseline assessment, the assistant will inform patients of their group assignment and tell intervention group patients that they will be contacted soon after to arrange their first telemedicine visit. We will then attempt to contact these patients by phone to arrange this visit. At the appointment time, the patient will call the study rheumatologist at a prearranged telephone number. The knee pain doctor Singapore will be at his or her usual office, where they will have access to the patient’s medical record. The patient will then be able to start a secure video session with the doctor using a portable equipment kit which we will provide. This will allow live audiovisual interaction and the simultaneous viewing of the medical record. An audio-only option will be available to patients who have inadequate internet bandwidth for the video link. At the time of the visit, the doctor will have already reviewed the medical record and will then conduct a structured interview, a physical examination using an onscreen joint exam guide, and medication reconciliation. Intervention group patients will have a total of 6 of these visits over the 12-month period, each lasting 30 minutes. Control group patients will simply be instructed to continue their usual medical care and will have phone contact for outcome assessments at the same time intervals as the intervention group, but no other interaction with study staff.
Types of Telemedicine Services Available
Remote monitoring can be used in various forms and has a broad spectrum of evidence in the treatment of knee pain. A 2008 study found that the use of email and the internet for home monitoring of knee OA demonstrated significant improvements in WOMAC scores. However, a more advanced form of remote monitoring is through the use of biosensors and smart technology. A 2019 scoping review found that the use of smart sensors in telemonitoring can provide accurate objective measures of activity, the results of which can be used to inform clinical decision making. This is a rapidly evolving field and is likely to become a fundamental aspect of future musculoskeletal healthcare.
Telerehabilitation, on the other hand, is a newer, more interactive form of telemedicine. In a randomized controlled trial between telerehabilitation and a traditional outpatient program for knee osteoarthritis, no significant differences were found in measures of knee function between groups. However, the telerehabilitation group attended more frequently. This may have been due to the increased safety perception and confidence of patients in performing exercises at home. Other forms of rehabilitation also include the use of video games and virtual reality. These have been shown to be well tolerated and accepted by patients, in addition to being feasible. A 2011 study by Shih et al found that virtual reality games were effective in improving balance and reducing the risk of falls in patients with knee osteoarthritis.
Remote consultation typically involves a late generation form of communication, such as email, between the patient and their physician. This has been shown to cause some concern amongst patients. A 2005 study conducted in the US showed that a low-income population of knee pain patients were less likely to use a web-based arthritis toolkit when compared to higher-income patients. This may reflect a preference for this generation of technology from certain groups of patients.
There are four main types of telemedicine used in the treatment of knee pain. These include remote consultation, teleassessment, telerehabilitation, and remote monitoring. The vast majority of studies conducted into telemedicine for knee pain have been on knee osteoarthritis, although other pathologies have been researched.
How Telemedicine Works for Knee Pain Management
Telemedicine functions as a standalone initiative that can be accomplished with the patient at home and the physician at a different location. This technological approach to healthcare will provide numerous benefits for both the physician and the patient. At Allied Healthcare, the entire process is designed to be simple and convenient for the patient. The first step will be to complete a patient registration form. After that, telemedicine coordinators will handle the insurance approval process. Once those steps are completed, an in-home assessment will be scheduled with the patient by both a physician and a telemedicine coordinator. This assessment will include a comprehensive musculoskeletal and neurological examination. At this time, patients will also be educated on how to utilize the company’s secure telemedicine applications. These applications include video conferencing with the physician, secure instant messaging, and access to a cloud-based knee pain treatment and exercise program. The video conference will be the main component to each patient encounter. This will allow direct communication with the patient and physician regarding their knee pain. The secure instant messaging is a tool that enables the fast and efficient dispersal of information between patients and their physicians. This can be anything from questions about an exercise in their program to detailing a change in a patient’s medication. Finally, the cloud-based knee pain treatment and exercise program is a user-friendly tool that allows patients to easily access all the information given to them by their physicians. This includes their current medications, detailed descriptions of their current diagnoses, and exercise programs specific to their conditions. Exercises in the program will also have video demonstrations by physical therapists to ensure proper technique and reduce errors in unsupervised home exercise.
Finding a Knee Pain Doctor in Singapore
Making an appointment with a knee pain doctor should be straightforward. Since telemedicine in Singapore involves real-time audio-visual interaction between doctor and patient, it offers a similar opportunity for patient-initiated, on-the-spot interaction. This can be done either through telephone or through the contact form or email. The appointment process should allow an interaction similar to in-office care, to clarify where and when to meet (online), and to discuss fees and payment.
A list of registered telemedicine providers in Singapore is available from the Singapore Ministry of Health. Many of these providers are specialty-specific. For example, if you are seeking a rheumatologist to manage your knee arthritis, the materials available on the provider’s website might facilitate your decision if you want to arrange a consultation. A further source of referral would be to seek an opinion from your primary care physician. Given the relative infancy of telemedicine in Singapore, he/she may not have a ready list of providers and might need to contact them directly. This referral process is similar to offline care, and in this case, the general practitioner would make the referral to the relevant specialist.
Singapore has enjoyed recent development in telemedicine, but choosing and accessing a knee pain doctor through telemedicine involves several processes. These are similar to traditional (in-office) care, but with subtle differences and some potential obstacles.
Researching and Choosing a Telemedicine Provider
You should check out a few different websites to compare services. As e-health is rapidly evolving, some websites may have a mix of outdated and current information so it is important to consider how recently the information was last updated. Look for a provider who offers a wide range of services including consultation, advice on medication and management of your condition, and monitoring of your health. This will ensure that the provider can offer comprehensive healthcare and accommodate changing needs throughout the rest of your life. At this point it is also worthwhile to check if the provider has any involvement with development of e-health policies or resources. This can include projects with government or non-government organisations, universities, or research and will indicate that the provider is up to date with recent e-health initiatives and likely to offer good quality care.
If you are interested in setting up a telemedicine consultation but do not have a knee pain physician, you may wish to consider seeing a telemedicine provider who can both handle your consultation and long run care. They will be able to provide a consultation and advise a plan based on the New Zealand guidelines for management of knee osteoarthritis. This will allow you to take the plan to your local doctor for discussion, or to another physiotherapist or occupational therapist for review, all without leaving your home. Your doctor or specialist might recommend a telemedicine provider, but if not there are a few things you can do to find one. Often the best way to find a telemedicine provider is to look on the internet, using terms such as “telemedicine provider” or “osteoporosis/MCI and telegerontology”.
Making an Appointment with a Knee Pain Doctor
Making an appointment with a doctor is as easy as making a phone call. Just like a conventional doctor consult, you will need to find a time that is mutually convenient for both you and the doctor. This can be a great time to ask the clinic staff about any preparatory steps that you will need to make prior to your consultation. It is also a good idea to find out if there are any forms or questionnaires that you will need to fill out, as these can be filled out ahead of time and remitted via email. Many telemedicine consultations involving pain management require patients to fill out pain questionnaires or functional status surveys. We will discuss more about such questionnaires in the section on “Preparing for a Telemedicine Consultation”. After scheduling your consultation time, it would be helpful to mark your appointment date and time on a calendar to serve as a reminder. On the day of your consultation, it is important that you are in an environment where you can speak privately and comfortably with your doctor. Make sure that you will not be interrupted during the consultation, and consider having a family member or friend sit in on the consultation for support and in order to help you remember what was discussed. This can be especially helpful when the patient is elderly. Get all of your previous medical records, x-ray reports, or any other documents relevant to your knee condition and have them nearby during the consultation. Finally, if you have any specific questions that you would like to ask your doctor, write them down and have them ready during the consultation.
Preparing for a Telemedicine Consultation
When you are preparing for a telemedicine consultation, you will want to be sure that you are in a comfortable and safe environment that will allow you to speak openly with your healthcare provider. This may require you to arrange a time for your consultation when a friend or family member can be with you. If you would rather be alone, you may want to prepare by writing down a list of things you want to cover during your appointment or questions you have for your healthcare provider to make sure you get the most out of your appointment. Also, be sure to have a working thermometer and a list of your current medications. Finally, be sure that you have a plan on how to seek follow-up care in the case that you are advised to do so from the telemedicine visit. Preparing for a telemedicine consultation requires a little more planning ahead than a traditional office visit, but by being prepared and taking advantage of its comfort and convenience, you will hopefully be able to get the care and answers you need for your knee pain and treatment.
Follow-up and Ongoing Care
In the event that you are unable to continue with the same US-based telemedicine doctor, the Singapore Telemedicine Centre may be able to facilitate a teleconsultation with one of our registered Singapore doctors who will act as a liaison to the telemedicine doctor in providing the relevant information of your case and facilitating in obtaining the treatment plan or advice. Should there be a need to find another doctor, browse the list of knee pain doctors at the American Academy of Orthopedic Surgeons website to find a specialist in your condition.
When you complete your initial telemedicine consultation with a knee pain doctor, the next phase in the process is to follow up with any recommended clinic visits or future telemedicine consultations. If you have been advised to follow up with a clinic visit, request a written summary from the telemedicine doctor outlining his/her examination findings, diagnosis and treatment plan, and bring this to the clinic doctor. This may facilitate in saving you an unnecessary repeated diagnostic procedures and obtain the appropriate treatment from the clinic doctor. If a repeated telemedicine consultation is recommended, please make every effort to follow up with the same knee pain doctor who has knowledge of your case, rather than having to repeat your entire history with a new doctor.
The availability of specialists for knee pain in Singapore is relatively low, while the prevalence is considerable. Findings from this review suggest that patients with knee pain can be helped by lower indirect costs compared to in-office visits, and direct costs reduced to a third of physician-office visits. This is a crucial finding for patients with common healthcare financing concerns in Singapore. Telerehabilitation has also been recommended for patients with actual disabilities. This option has shown to result in high patient satisfaction and ideal functional results through the use of performance-based tests.
In conclusion, this systematic review describes the effectiveness and feasibility of telemedicine in managing knee pain. The seven studies reviewed found that telemedicine consultations are feasible and can be an effective means of caring for some patients with knee pain. The studies showed a high level of patient satisfaction and no reported adverse effects. The quality of care offered by these consultations was determined to be adequate, with lower costs compared to in-person consultations. This can be seen as an effective means for the aging population in Singapore to get further management of their chronic knee pain, as they are less likely to travel because of pain and disability. High patient satisfaction over the mode of consultation is encouraging, as patients with knee pain report lower satisfaction levels with their medical care compared with patients in the general population.
