Musculoskeletal (MSK) pain is a pervasive health issue, and disparities in socioeconomic status can significantly impact access to effective treatment and patient outcomes. A recent report highlighted that while most patients seeking care for MSK issues fall into categories of lower social deprivation, a notable percentage experiences high social deprivation index (SDI) scores, mirroring broader socioeconomic patterns within the population. This disparity is crucial because SDI categories have been linked to the severity of baseline disease burden, underscoring the vulnerability of certain subpopulations. Interestingly, geographical proximity to healthcare facilities did not explain these initial scores, as highly deprived individuals were often located closest to these facilities. Beyond SDI, factors such as being female, overweight, or identifying as Black or Hispanic were also associated with increased baseline scores, further emphasizing the complex interplay of demographics and health. These observations underscore the urgent need for healthcare models that are more holistic and patient-centered, like the Digital Care Program (DCP) model discussed herein.
Low socioeconomic status has historically been associated with poorer treatment outcomes. However, findings from a digital care program reveal a different narrative. This program demonstrated consistent recovery paths across all clinical outcomes, irrespective of SDI scores and initial disease severity. This is particularly striking in pain management, where significant and comparable improvements were observed across all SDI categories. This contrasts sharply with previous studies that reported worse pain outcomes for more socially deprived individuals. The improvements seen in this DCP align with the positive results previously documented with in-person physical therapy for chronic pain patients. Furthermore, pain reduction in the DCP was accompanied by a decrease in analgesic consumption, which is a critical benefit considering the potential for early physical therapy to prevent chronic opioid use, a significant public health concern.
Mental health is intrinsically linked to MSK pain management, with comorbidity and feedback loops frequently observed, and these issues are often exacerbated by social determinants of health. The DCP study demonstrated significant improvements in mental health outcomes, and importantly, these improvements were consistent across different SDI categories. This finding further supports the effectiveness of multimodal, biopsychosocial approaches in digital care settings.
While research on the impact of social determinants of health on mental health recovery in MSK conditions remains limited, the improvements observed in this DCP are within the range of the best outcomes reported in studies of both in-person and telerehabilitation interventions. A key indicator of successful pain interventions is the patient’s ability to return to their normal life. MSK pain is a major contributor to lost productivity, both through presenteeism and absenteeism. The DCP study showed significant improvements in both these metrics across all SDI categories, aligning with results reported for other telerehabilitation programs. Notably, within absenteeism, a significant recovery rate was observed even in the highest SDI category, indicating substantial productivity recovery, potentially due to the patient-centered nature of the DCP. These positive outcomes in productivity recovery, especially among socially deprived groups, highlight the economic benefits of digital care, particularly when considering the substantial indirect costs associated with MSK pain.
Access to in-person physical therapy is often limited for people of color, those with lower education and socioeconomic status, and individuals in rural areas. This reduced accessibility is a known contributor to poorer health outcomes. Moreover, low adherence to physical therapy programs is linked to less favorable clinical results. Telehealth has been proposed as a solution to address these access and adherence barriers. However, disparities in telehealth adoption related to social determinants of health have also been reported. While the COVID-19 pandemic may have shifted perceptions and increased the acceptance of telehealth, particularly for overcoming geographical barriers and minimizing in-person contact, opportunities for further improvement remain.
The DCP study demonstrated a high program completion rate, comparable to real-world in-person physical therapy settings. However, dropout rates were observed across all SDI categories, which is also consistent with previous reports in physical therapy interventions.
Current guidelines emphasize personalized approaches to exercise dosage in MSK pain management, taking into account individual patient trajectories. The DCP implemented this personalized approach, and high patient engagement was evident through interactions with digital physical therapists, consumption of educational resources, and participation in exercise sessions. While the number of sessions varied slightly across SDI categories, with higher SDI groups performing fewer sessions, possibly due to demographic factors, similar recovery outcomes were achieved across all groups. This suggests that the level of engagement in the DCP was sufficient to drive clinical improvement, even among the most socially deprived. Patient satisfaction with the program was also consistently high across all SDI categories.
While the study design doesn’t pinpoint the exact features of the DCP responsible for these outcomes, the multimodal approach, incorporating exercise with real-time biofeedback, education, and cognitive behavioral therapy (CBT), along with tailored treatments, are likely contributing factors. Trust in the healthcare provider is crucial for positive patient outcomes, fostering adherence, symptom reduction, and preventative care engagement. Cultural competence in clinical teams plays a vital role in building therapeutic alliance and compassionate rapport. The culturally sensitive nature of the DCP team may have contributed to the observed positive results. Digital interventions, when coupled with effective communication strategies, have been shown to foster therapeutic alliances comparable to, or even exceeding, those in in-person settings. Effective communication within digital programs, including chat, video, and phone calls, is essential not only for logistical practicality but also for establishing respectful and empathetic patient-provider relationships. Ultimately, an effective MSK pain intervention should leverage the therapeutic alliance to empower patients with self-management skills, enabling them to address their pain and improve their overall quality of life.
Given the constraints of healthcare resources and the increasing demand for rehabilitation services, the findings of this DCP study strongly advocate for scalable digital care delivery systems that are sensitive to social determinants of health. However, further research with controlled studies and larger cohorts is necessary to more comprehensively understand the impact of health disparities associated with SDI on digital therapy outcomes. Future research should focus on identifying the most impactful features of DCPs in enhancing access, engagement, and outcomes across diverse socioeconomic contexts. Investigating the role of culturally competent clinical teams in rehabilitation success is also a priority. Developing integrated care models that combine digital, in-person, and hybrid approaches to optimize healthcare delivery for all populations, especially vulnerable groups, is a critical next step. Initiatives to improve internet access, such as providing WiFi hotspots and community hubs, could further facilitate the dissemination of telehealth and should be explored. Finally, long-term follow-up studies and cost-effectiveness analyses are warranted to fully evaluate the sustained benefits and economic impact of DCPs.
This study has limitations, including the lack of a control group, which limits the ability to establish causality. The study population, drawn from employer health benefits beneficiaries, may not fully represent the general U.S. population. The study was also partially conducted during the COVID-19 pandemic, which may have influenced perceptions and acceptance of digital programs. Despite accounting for various socioeconomic factors, the influence of other unmeasured variables cannot be entirely excluded. The study design does not allow for isolating the specific impact of individual DCP components. Finally, the absence of long-term follow-up limits the understanding of the program’s long-term benefits across different SDI categories.
Despite these limitations, the study possesses significant strengths. It utilized a large, real-world cohort across all U.S. states, encompassing the full spectrum of SDI, enhancing the generalizability of the findings. The DCP itself is a strength, designed to address health equity gaps often overlooked in standard care. The use of validated metrics for both physical and psychological outcomes is another advantage, contrasting with some digital interventions. Crucially, this study demonstrates the feasibility and acceptability of digital care programs designed to promote health equity across diverse socioeconomic backgrounds. Investigating social deprivation within a digital program provides a valuable foundation for future research and improvement in this field.
In conclusion, multimodal, patient-centered digital care programs hold significant promise as a solution to address health inequities in MSK pain management. This study, encompassing a wide range of SDI across the U.S., demonstrates consistent and significant improvements in pain, analgesic use, mental health, and productivity, despite the greater disease burden in socioeconomically vulnerable populations. This research highlights the potential of digital care to advance health equity, paving the way for future innovation and research in this critical area.
