Three Month Automated Messaging Intervention

Patient compliance to their prescribed physical therapy (PT) exercises is reported to be
22-40% in various studies. Further, Vasey et al. found that about 8% of patients do not even
schedule a follow up PT appointment after it is prescribed. Low adherence presents a problem
since long term completion of prescribed home exercises has been correlated with improved
health outcomes. Sluijs et al. found that low adherence to PT exercises can be primarily
attributed to three factors: (1) the barriers patients perceive and encounter, (2) the lack
of positive feedback, and (3) the degree of helplessness. An automated phone/texting system
can help with these three points by increasing positive feedback, increasing compliance, and
monitoring patient progress. The system can continually remind the patient that their end
goal is possible, which will decrease their feeling of helplessness in their condition.

Provide an introduction and background information. Describe past experimental and/or
clinical findings leading to the formulation of the study, if applicable. Investigator
Initiated studies must cite references in the response provided or attach a bibliography.
*?HELP?*

Patient compliance to their prescribed physical therapy (PT) exercises is reported to be
22-40% in various studies [1-4]. Further, Vasey et al. found that about 8% of patients do not
even schedule a follow up PT appointment after it is prescribed [5]. Low adherence presents a
problem since long term completion of prescribed home exercises has been correlated with
improved health outcomes. Sluijs et al. found that low adherence to PT exercises can be
primarily attributed to three factors: (1) the barriers patients perceive and encounter, (2)
the lack of positive feedback, and (3) the degree of helplessness [2]. An automated
phone/texting system can help with these three points by increasing positive feedback,
increasing compliance, and monitoring patient progress. The system can continually remind the
patient that their end goal is possible, which will decrease their feeling of helplessness in
their condition.

The American Shoulder and Elbow Surgeons (ASES) created a survey form that evaluates the
shoulder function of a patient. The survey is scored out of 100 points (100 being best
possible shoulder function and 0 being worst possible shoulder function). The form can be
filled out on an iPad online, and the score recorded by a member of the medical team. This
screening form has been validated by numerous studies, and has been specifically validated
for patients with non-operative rotator cuff pain/abnormalities (the population that this
study is proposing to study).

Telemedicine shows promise in improving the outcomes of orthopedic interventions. Medication
adherence and patient outcomes have been shown to improve in interventions that include
reminders. Also, because the adoption of cell phones is nearly ubiquitous worldwide and the
vast majority of cell phone users text message, a text-message-based intervention seems
particularly promising.

Many studies have shown that SMS text messaging has increased treatment compliance. PT
adherence to prescribed exercises seems to be limited by compliance, so Epharmix along with
several orthopedic surgeons set out to develop an intervention. The result,
EpxPhysicalTherapy (EpxPT), is an automated system that ensures that patients have both
scheduled their physical therapy appointment and have performed their home exercises. It also
sends motivational text messages to the patient to encourage the participant to perform their
exercises since a lack of positive reinforcement has been correlated with decreased
compliance. When a patient identifies that they have been unable to schedule a PT appointment
or have not completed their exercises for multiple days in a row, an alert is sent to the
healthcare team.

The system was designed to deliver either voice or text-based automated messages to patients
in a way that avoids an additional burden on the healthcare team. EpxPT offers numerous
advantages to strictly app-based or text message-based systems in both older and
underprivileged patient populations. Older patients, who may be more comfortable with voice
messages, have that option, and patients without a smartphone will still be able to receive
the intervention.

Patients identified to be eligible for this study and have consented will be randomly
assigned to one of two groups: Group 1 will receive the standard of care alone (control) and
Group 2 will receive the EpxPT intervention. In Group 2, EpxPT will remind the patient to
schedule their first PT appointment. Group 2 patients will also be asked if they have
completed their prescribed PT exercises every other day. They will then be sent a
motivational text messages or voice call in order to highlight the importance of completing
their PT regimen. Group 2 patient compliance will be tracked through the text responses
recorded in the Epharmix database. Both Group 1 and Group 2 patients will be seen at a follow
up appointment once a month for three months. At this appointment, patients in both groups
will be asked about their PT compliance (this will be the measurement of compliance for Group
1), and range of motion and a ASES score will be measured.

- Aim 1: To compare control and intervention group compliance to their prescribed physical
therapy home exercise regimen

- Aim 2: To compare control and intervention group shoulder range of motion after a 3
month intervention

- Aim 3: To compare control and intervention group ASES scores after a 3 month
intervention

Inclusion Criteria:

- Anterior or lateral shoulder tenderness

- Positive clinical signs of rotator cuff impingement

- X-ray with no fractures, glenohumeral arthritis, or dislocation

- Prescribed shoulder PT for their shoulder

Exclusion Criteria: