Strengths and Limitations
The major strength of this work is the study design: a preregistered RCT with an active comparator group consisting of high-dosage, in-person PT with similar treatment dosage between groups, facilitating comparison of outcomes. The novelty of the digital intervention is another strength, as a fully remote exercise-based PT, supported by real-time biofeedback and embedded in a multimodal intervention including education and CBT. The remote monitoring and ongoing contact with the physical therapist through synchronous and asynchronous communications may also have contributed to the high adherence. Incorporating standardized self-reported outcome measures to assess different health domains represents an additional strength of the study [There are several limitations to this study that warrant discussion. First, this study was undertaken in the context of the COVID-19 pandemic, which may have impacted perceptions, receptivity, and compliance with digital and in-person PT programs. Second, the enrolled cohort was composed of predominantly young, physically active, highly educated individuals residing in urban areas, which may limit generalizability. Third, a relatively small proportion of these individuals were receiving regular analgesic medications and were considering surgery, which again merits caution with extrapolation. Fourth, administration of the CBT and educational components varied between the 2 groups, even if they were similar in concept. Fifth, both investigators and participants were unblinded to group allocation. Last, this study lacked posttreatment follow-up, which prohibits conclusions on long-term benefit and cost-effectiveness. Future research should address these issues, endeavor to identify factors that may influence an individual’s decision to partake in digital, in-person, or hybrid care, and define criteria for appropriate candidate selection. The adoption of these new models of care in routine clinical practice also requires competencies by physical therapists, including important changes in training curricula.