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

Bradley, Kendall E.; Cook, Chad; Reinke, Emily K.; Mather, Richard C.; Riboh, Jonathan; Lassiter, Tally; Wittstein, Jocelyn R.

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 COVID 19 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination versus a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against a 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 a 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 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 two separate assessors. We randomized the order of SCE or STE. A blinded reader assessed an MRI, to use as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared diagnostic effectiveness (overall) of SCE and STE with a Mann Whitney U. Results We included sixty-two (62) consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. Diagnostic effectiveness of stand-alone tests were 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 the SCE (p=0.98). 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 to a SCE in detection of rotator cuff tears. Whereas these results are promising, larger studies are needed for further validation of a STE assessment platform.