title: High burden of musculoskeletal conditions: a problem that has only recently come to recognition Agreement Between Telerehabilitation and Face-to-Face Clinical Outcome Assessments for Low Back Pain in Primary Care Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. The diagnostic reliability of Internet-based observational kinematic gait analysis 
  Fundamental principles of validation, and reliability: rigorous science for the assessment of surgical education and training
   Can the Internet be used as a medium to evaluate knee angle?
abstract: Objectives : Musculoskeletal conditions have only recently been acknowledged and research on their burden is scarce in the Middle East and North African ( MENA ) region . For the first time , a population based study was conducted in Lebanon to assess the prevalence , level of disability , and health seeking behaviours related to musculoskeletal pain and rheumatic disorders . Methods : A r and om sample of 500 participants aged ≥ 15 years from Southern Lebanon was interviewed using the COPCORD ( Community Oriented Program for Control of Rheumatic Diseases ) question naire . Results : The prevalence of current musculoskeletal pain was 31.2 % [ CI ( 27.0–35.2 % ) ] . Being a female [ OR=1.8 , CI ( 1.2–2.8 ) ] and of advancing age [ OR=1.03 , CI ( 1.01–1.05 ) ] were the only significant factors associated with current musculoskeletal pain . Prevalence of current functional disability was 6.4 % [ CI ( 4.2–8.5 % ) ] . Around quarter ( 26.0 % ) [ CI ( 22.3–30.1 % ) ] of our sample sought some kind of treatment . The overall prevalence rate of rheumatic disease was 17.0 % [ CI ( 13.7–20.3 % ) ] . Discussion : Our findings indicate that musculoskeletal conditions are common in Lebanon . This is a timely public health issue that needs further investigation and solid recognition by health authorities . Community-based interventions should target patients to prompt them to seek early help in order to prevent the development of musculoskeletal pain into disorders Study Design . A descriptive study of repeated measures using a crossover design . Objective . To determine the level of agreement between assessment s obtained via telerehabilitation and those obtained by traditional face-to-face method in a population of individuals with chronic low back pain ( LBP ) in a primary care setting . Summary of Background Data . Musculoskeletal assessment using telerehabilitation has shown adequate inter- and intrarater agreement and concordance with face-to-face clinical assessment in different diseases . There have been no published studies on the reliability of a telerehabilitation system to assess LBP . Methods . Fifteen individuals ( 6 males ; mean age , 37 yr ) with chronic LBP attended a session for a clinical interview , followed by face-to-face and real-time online telerehabilitation evaluations . There was a 30-minute interval between the 2 assessment s , the order of which was r and omly selected for each patient . The telerehabilitation system used an Internet application conducted via Internet connection ( 17 kB/s ) between 2 personal computers . Real-time video connection facilitated communication between the therapist and the subject . Outcome measures included lumbar spine mobility , Sorensen test , anterior straight leg raise test , Oswestry Disability Index , visual analogue scale for pain , 12-Item Short Form Health Survey question naire , and Tampa Kinesiophobia Scale . Results . The & agr ; reliability between face-to-face and telerehabilitation evaluations was more than 0.80 for 7 of the 9 outcome measures . Lowest reliability was for lateral flexion range of motion ( & agr;= 0.75 ) . Very good inter- and intrarater intraclass correlation coefficients ( & rgr ; ) were obtained ( 0.92–0.96 ) . Conclusion . The findings of our pilot study suggest that this telerehabilitation system may be useful to assess individuals with chronic LBP , providing initial support for its implementation in primary care . Level of Evidence : BACKGROUND total knee arthroplasty is an effective means for relieving the symptoms associated with degenerative arthritis of the knee . Rehabilitation is a necessary adjunct to surgery and is important in regaining optimum function . Access to high- quality rehabilitation services is not always possible , especially for those who live in rural or remote areas . The aim of this study was to evaluate the equivalence of an Internet-based telerehabilitation program compared with conventional outpatient physical therapy for patients who have had a total knee arthroplasty . METHODS this investigation was a single-blinded , prospect i ve , r and omized , controlled noninferiority trial . Sixty-five participants were r and omized to receive a six-week program of outpatient physical therapy either in the conventional manner or by means of an Internet-based telerehabilitation program . The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) measured at baseline and six weeks by a blinded independent assessor . Secondary outcomes included the Patient-Specific Functional Scale , the timed up- and -go test , pain intensity , knee flexion and extension , quadriceps muscle strength , limb girth measurements , and an assessment of gait . Noninferiority was assessed through the comparison of group differences with a noninferiority margin and with linear mixed model statistics . RESULTS baseline characteristics between groups were similar , and all participants had significant improvement on all outcome measures with the intervention ( p < 0.01 for all ) . After the six-week intervention , participants in the telerehabilitation group achieved outcomes comparable to those of the conventional rehabilitation group with regard to flexion and extension range of motion , muscle strength , limb girth , pain , timed up- and -go test , quality of life , and clinical gait and WOMAC scores . Better outcomes for the Patient-Specific Functional Scale and the stiffness subscale of the WOMAC were found in the telerehabilitation group ( p < 0.05 ) . The telerehabilitation intervention was well received by participants , who reported a high level of satisfaction with this novel technology . CONCLUSIONS the outcomes achieved via telerehabilitation at six weeks following total knee arthroplasty were comparable with those after conventional rehabilitation . LEVEL OF EVIDENCE therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence summary We investigated the accuracy and reliability of observational kinematic gait assessment s performed via a low-b and width Internet link ( 18 kbit/s ) and a higher-speed Internet link ( 128 kbit/s ) . Twenty-four subjects were r and omized to either b and width group .  Gait was assessed with the Gait Assessment Rating Scale ( GARS ) in the traditional manner , which is from video-recordings , and with repeated measurements via the online method . Online assessment was found to provide as accurate a measure of gait performance as the traditional assessment ( limits of agreement51 GARS point ; intraclass correlation coefficient , ICC= 0.96 ) regardless of the speed of the Internet connection . The online assessment also demonstrated high intra-rater ( ICC= 0.96 ) and inter-rater ( ICC= 0.92 ) reliability . Low-b and width telerehabilitation applications appear to be feasible via the Internet Surgery has always been a dynamic discipline . It has a long history of groundbreaking innovations that dramatically improved the way patients were treated and surgery was practice d. However , nothing could have prepared the surgical community for the revolutionary advances of the last 2 decades . Almost overnight , the traditional open approach to surgery was replaced by a minimally invasive surgery ( MIS ) approach [ 2 ] . Practitioners quickly realized that this novel approach would require new types of training . Suddenly , the directors of surgical residency programs had to deal with faculty members who were question ing the training paradigm that had served surgery well for a century . The traditional Halsteadian method did not seem to be suitable for the new types of skills required for MIS . To make matters worse , the length of time allocated to training residents was contracting . In the European Union in 2001 the European Working time Directive was extended to include physicians in training and this year in the United States of America the m and atory 80 hour work week restriction has been instituted , both dramatically reducing work/training hours for residents . At the same time , the practice of surgery came under scrutiny in another , apparently unrelated area when the value and relevance of surgical research became an issue of controversy . In an unprecedented attack , the editor of the Lancet [ 6 ] publically called into question the quality of current surgical research . In an editorial entitled ‘ ‘ Surgical Research or Comic Opera ? ’ ’ Dr. Horton expressed grave reservations about its utility , validity , and usefulness . Although the editorial was met by the surgical community with the predictable indignant response , Horton did make some valid points . Not necessarily in response to this editorial but certainly contiguous to it , surgical research appears to be moving away from reliance on retrospective data to prospect i ve , r and omized , and —where possible— blinded data . It is our contention that these two issues , i.e. , MIS skills and surgical research , have now converged around the very essence of our surgical heritage — the stringent use of the ‘ ‘ scientific method ’’ and objective assessment . Perhaps this is best exemplified by the relatively new editorial practice of prioritizing prospect i ve , r and omized , blinded surgical trials for publication . Although blinded , r and omized , controlled trial design can be employed to answer definitively many surgical research questions , we must remember that this design is only one of a quiver full of research method ologies , and may not always be the experimental design of choice . The function of good science is to show clear cause- and -effect relationships , and this does not always require a prospect i ve , r and omized , double-blind experimental design . Indeed the optimal method may not even be experimental , but statistical , such as Structural Equation Models [ 3 ] . This methodology will almost certainly be required to answer the question of which fundamental psychological abilities predict MIS skills/performance or what factors predict obesity or treatment outcomes in obesity . In both of these examples the answer will be multifactorial , which precludes the use of traditional experimental design . The control exerted with traditional experimental design will be replaced with the equally powerful ( but method ologically more sophisticated ) ‘ ‘ statistical ’ ’ control . The point we want to make here is that there is no ‘ ‘ magic bullet ’ ’ experimental methodology for surgical research ; instead , there is a range of experimental design s that should be applied appropriately to answer the pertinent research question . Research design should therefore vary depending on the circumstances . An eloquent example can be found in a report form the Dundee MIS group , who used four subjects and , in essence , a single-subject design to evaluate the utility of three-dimensional camera systems [ 5 ] . The research design they used answered the question unequivocally , but Correspondence to : A. G. Gallagher Surg Endosc ( 2003 ) 17 : 1525–1529 DOI : 10.1007/s00464 - 003 - 0035 - Telemedicine promises to revolutionize medical care delivery in rural and remote areas . The ability to accurately evaluate physical impairment via the Internet is important to the possible future provision of Internet-based physiotherapy . This study evaluated the reliability and validity of assessing knee range of motion via the Internet .  Two therapists evaluated  knee angle on a single subject via two methods of assessment : the Internet and the traditional method ( face-to-face ) .  Nine r and om positions of the knee were chosen with the principal examiner performing 20 face-to-face and two sets of 20 Internet measures in each position ( n=540 ) . The secondary therapist performed Internet assessment s only . The Internet connection was established at a readily available speed of 17 kbit/s . The Internet-based goniometer was found to be a valid tool for measuring both knee flexion and extension angles . It was shown to possess both high intra and inter-rater reliability . Difference average plots of the scores verified the consistency of measurement between both modes of assessment . The successful evaluation of the physical outcome measure of knee range of motion via the Internet assists the further development of Internet-based physiotherapy applications
target: The physiotherapy assessment s such as pain , swelling , range of motion , muscle strength , balance , gait and functional assessment demonstrated good concurrent validity .
  Conclusion TR-based physiotherapy assessment was technically feasible with overall good concurrent validity and excellent reliability , except for lumbar spine posture , orthopaedic special tests , neurodynamic testa and scar assessment
background: Purpose The purpose of this review is to systematic ally explore and summarise the validity and reliability of telerehabilitation (TR)-based physiotherapy assessment for musculoskeletal disorders .