Search Results
Searches identified a total of 1797 records, of which 1602 were unique. A total of 1402 titles and abstracts were eliminated, leaving 200 full-text articles to be considered. Of these, 138 were ineligible for the following reasons: did not include a CAIM (n=58) or did not include telemedicine (n=15), review (n=44), research protocol (n=9), conference abstract (n=5), case study (n=5), commentary (n=1), or letter to editor (n=1), leaving a total of 62 eligible studies which are included in this scoping review. A breakdown of study filtration through the inclusion exclusion process can be found in Figure 1.
Eligible Article Characteristics
Eligible articles were published from 1999 to 2020, and originated from the United States (n=34), Italy (n=4), Korea (n=3), the United Kingdom (n=3), Canada (n=2), China (n=2), Norway (n=2), Taiwan (n=2), Australia (n=2), France (n=1), Germany (n=2), Iceland (n=1), Israel (n=1), and Switzerland (n=1). One article included participants from both the US and the UK, [23] and another study included collaboration between Austria and China [24]. Of the 62 articles included, all were primary research articles focused on development of a telemedicine technology or processes for CAIM (n=11), analysis of the data collected by a telemedicine technology for CAIM (n=26) and/or, analysis of usability, acceptability, or feasibility of existing telemedicine software (n=25). The characteristics of all eligible articles can be found in Tables 2, 3, and 4.
CAIM Characteristics
Of the 62 articles included, the distribution of CAIMs discussed were as follows: mindfulness training (n=11), mind-body exercise (n=7), yoga (n=7), biofeedback (n=4), music therapy (n=4), spiritual care (n=4), dance therapy (n=3), cannabis (n=3), chiropractic manipulation (n=2), guided imagery (n=2), hypnosis (n=2), ketogenic diet (n=2), acupuncture (n=1), auricular acupressure (n=1), Chinese medicine (n=1), exercise (n=1), qigong (n=1), herbal medicine (n=1), meditation (n=1), Mediterranean diet (n=1), play-based therapy (n=1), and vitamin B weight loss (n=1).
Telemedicine Characteristics
Of the 62 articles included, the telemedicine tools used were as follows: videoconferencing (n=16), mobile application (n=7), web- or mobile-based application (n=2), videos (n=10), websites (n=7), telephone (n=7), database/cloud system (n=1), telemedicine centre (n=1), teleconference (n=1), telephone and video (n=1), e-mail (n=1), remote tele-biofeedback (n=1), social media platform (n=1), telephone and portable electromyograph (n=1), videos and chat group (n=1), text messaging (n=1), telephone and videoconferencing (n=1), telephone and mp3 audio (n=1), and website and videoconferencing (n=1).
Findings from Thematic Analysis
In total, three main themes emerged from our analysis and are described below.
Theme 1: Practitioner View of CAIM Telemedicine
1.1: Feasibility of CAIM Telemedicine Interventions
Overall practitioners found it feasible to deliver traditionally in-person CAIM interventions through a telemedicine approach (n=26) [24-51]. Sufficient technology exists to meet the delivery needs of a great number of heterogeneous CAIM interventions. For example, Skype as a videoconferencing platform could be effectively used for hypnotherapy [37], but also for mind-body therapy [25]. Other technologies such as telephones, internet websites, smartphone applications, virtual-reality technology, and even specialized cloud platforms were successfully tailored to the goals of particular CAIM interventions and targeted towards a diverse range of patient populations including older adults [27]. Practitioners found it feasible to implement physical activities such as dance and yoga virtually [28, 47, 52], but also found it was possible to administer more complex CAIM interventions such as hypnosis therapy, or the virtual management and treatment of patients with COVID-19 [39, 53].
The feasibility of the intervention itself was comparable, and in some cases, superior to in-person delivery. One study found that interest in participation and feasibility of a Skype mind-body therapy was superior compared to an in-person pilot test of the same intervention [38], while another study found increased scheduling flexibility and subsequently, greater participation in the telemedicine intervention compared to in-person care delivery [25]. Telemedicine approaches to CAIM were also more inclusive for participants who would usually have been unable to participate due to cost barriers, or travel difficulties such as urinary incontinence [37].
1.2: High Acceptability and Satisfaction of CAIM Telemedicine Interventions
Practitioners readily accepted and reported favourable attitudes towards telemedicine approaches to CAIM (n=21) [23, 35, 39-42, 46, 47, 54-66]. Practitioners did not have major concerns regarding ease of use, appeal to target population, or efficacy of telemedicine CAIM interventions. This held true across the various populations included in this review. For example, clinicians in a cannabis reduction intervention did not have concerns about confidentiality, or application of mobile device technology [65]. Another telephone-adapted delivery format for a mindfulness-based stress reduction was perceived by practitioners as “very positive” [46]. In a dance-therapy session for older adults, student nurse leaders expressed high interest and enjoyment in intervention delivery among study participants [40]. Moreover, practitioners involved with a study by Green et al. [35] found that telehealth enabled continuity of care with patients and was therefore a “valuable” tool.
A common view was that telemedicine is valuable to improve the efficiency of medical resource use, through reducing wait times for patients [39], improving hospital-bed shortage problems [39], and reducing the workload burden of healthcare staff [55-57, 66]. Practitioners were also satisfied with the potential to lower healthcare delivery costs [42, 46, 56, 60, 64, 66], in one case by up to 75% [46]. Practitioners believed telemedicine delivery of CAIM had a high potential for wider scalability in the healthcare system [46, 62, 64, 66]. Although, some studies expressed barriers such as a lack of a tailored approach to goal setting in an internet-based workplace intervention promoting a Mediterranean diet [61], and poor software and hardware usability of an electromyographic audio biofeedback program for telerehabilitation [63].
1.3: Health and Well-being Improvements
Practitioners found that CAIM interventions delivered using telemedicine resulted in health and well-being improvements across a variety of patient populations, comparable to improvements observed in in-person delivery modes (n=35) [23-27, 30, 32, 34, 36, 38, 42, 43, 47-50, 54, 55, 57, 62, 64, 67-80]. This applied not only to physical patient health [76], but also quality of life [26], mental [32, 36, 38, 75] and spiritual [62] health, and aspects of personality such as self-concept and self-esteem [62]. The improvement in health was observed across all age groups, from children and adolescents [62], to older adults [74]. Moreover, the improvements to health manifested across a diverse range of patient groups, including veterans, cancer patients, and individuals with chronic illness. Many of these changes were clinically meaningful, having positively impacted the course of the illness or resulted in visible improvements from the perspective of both patients and clinicians [62, 64, 74]. Positive health changes often persisted longitudinally at various follow-up periods, indicating that telemedicine interventions can produce persistent health benefits [25, 38, 43, 47, 50, 57, 60, 62, 67, 72, 73, 75, 78, 81]. In some cases, health benefits did not remain at follow-up [68], or longitudinal assessment was not reported.
Theme 2: Patient View of CAIM Telemedicine
2.1: The Patient-Practitioner Relationship
Patients felt it was challenging to form meaningful connections with CAIM practitioners employing telemedicine alternatives (n = 10) [23, 28-30, 40, 53, 71, 77, 82-84]. Study participants reported a lack of understanding of the role of the practitioner, difficulty following along with remote-based interventions, and lack of sufficient feedback on their performance from practitioners. For example, participants involved in yoga interventions through video-conferencing technologies identified challenges such as having to continuously “readjust screens,” difficulty “learning and doing poses simultaneously,” a lack of instructor feedback in real-time, and an inability to “bond” with the site [28, 71, 77]. In telephone-based coaching interventions, participants seemed to be unclear of the role of coaches, and found it “difficult to develop a relationship with or trust a stranger on the phone” [82, 83]. Furthermore, according to participants, CAIM interventionists may misinterpret their needs particularly when employing audio-visual or phone-based telemedicine technology [28, 44, 53, 54, 68, 71, 74, 77, 82], for reasons such as being unable to perceive “subtle expressions” of interest, emotion, or physical comfort [28], or as a consequence of ineffective communication between practitioners and participants through digital platforms [71, 77].
2.2: The Impact of Existing Health Conditions and Morbidities on Intervention Outcomes
Existing illness was found to negatively impact participation, patient safety, or retention of patients in CAIM interventions delivered through telemedicine (n=12) [23, 28-31, 38, 40, 42, 46, 48, 70, 71]. In particular, the presence of health conditions were associated with various functional and mobility limitations such as breathing problems and fatigue, that served as a barrier to participation [23, 46, 71]. For example, some individuals with cancer found it difficult to participate in yoga training due to “[cancer] treatment-related fatigue,” and cancer-related overwhelmingness and forgetfulness [28]. Individuals with chronic pain found that their condition interfered with their ability to attend mindfulness-based classes as part of an intervention [70]. However, this issue was acknowledged and the program was lengthened to suit their needs [70]. Other studies noted that attrition was often due to deteriorating health, or health-related responsibilities (e.g., surgery) [30, 38, 42, 46].
2.3: The Benefit of Telemedicine Delivery of CAIM for Traditionally Underserved Populations.
Participants most frequently cited CAIM interventions administered through a telemedicine approach as an accessible alternative to in-person care, that leads to improved health outcomes without any salient consequences (n=21) [26-29, 34, 35, 37, 39, 42, 46, 48, 50, 53, 55, 56, 60, 65, 67, 70, 71, 85]. Virtual care delivery appeared to expand access to care particularly for rural populations [50], or those with chronic health conditions that prevented them from travelling long distances. Many of the included studies also engaged populations that are often neglected such as racial or ethnic minorities [45, 82], or women veterans [50]. Evaluations and feedback are overwhelmingly positive and in support of these health interventions and notice improved accessibility in receiving CAIM in the comfort of their own homes [29, 38]. Previously identified barriers to participation such as high travel costs [29, 37, 46, 55, 67], inability to travel [37, 46, 48, 67], time conflicts [46, 67, 85], and reluctance to participate in a group or associate with other frail individuals [27], among others, were overcome.
Theme 3: The Technological Impacts of CAIM via Telemedicine
Overall, technological issues did not appear to impede the success of CAIM delivered via telemedicine. However, some participants did believe that technological difficulties were a hindrance. Broadly, issues included degradation of audio and visual quality, limited device accessibility, complex user interface, and troubles with downloading content, which are all necessary components in successful telecommunication delivery of CAIM (n=14) [23, 27-30, 37, 38, 41, 49, 56, 68, 71, 82, 85]. For example, an unstable internet connection, especially in rural areas, made it difficult to attend or follow along during CAIM sessions [23, 49]. Even when participants did connect to the telemedicine platform being used, freezing of the video stream, or inconsistent audio made it difficult to engage and maximally benefit from the intervention [23, 29, 41]. Consequently, some participants believed the technological difficulties prevented them from gaining the “full benefit of the teacher’s feedback and interaction” [30]. In some cases, the technological difficulty meant that the therapeutic session had to be rescheduled [29]. Other types of technological barriers included font and video screen sizes in a mobile app study [85]. In contrast, practitioners did not generally find that technological difficulties were a significant barrier to the feasibility of intervention delivery, reporting that they were infrequent [29, 46, 50, 68], and quickly and easily resolved when they did occur [28].