Implementation of rural telehealth physical therapy for chronic low back pain: qualitative findings informing a randomized clinical trial aimed at decreasing opioid use

Background Low back pain (LBP), the most expensive health condition in the United States, accounts for over $134.5 billion in federal spending. As a leading cause of disability worldwide, LBP is a common reason for initiating prescription opioid therapy and often requires ongoing multidisciplinary care. In rural settings, where provider shortages, transportation barriers, and geographic constraints limit access to preventive and specialty healthcare for approximately 60 million Americans, telehealth can bring access to nonpharmacologic treatments of LBP, such as physical therapy, to patients. A qualitative analysis was conducted as part of the ARBOR-Telehealth study, a type 1 hybrid effectiveness-implementation of a pragmatic clinical trial, to evaluate a telehealth-delivered physical therapy intervention for adults with chronic LBP in rural Maryland. Methods In partnership with TidalHealth, a rural health system, nine individuals (patients, physical therapists, rural stakeholders) participated in pre-implementation, semi-structured, baseline video interviews. For methodological rigor, qualitative data were analyzed adhering to the trustworthiness parallel to quantitative data. Results Ten overarching themes (access to care, technology, age-related concerns, usefulness, broadband internet, comparison to in-person care, equipment, space, acceptance of telehealth, therapeutic bonds) illuminated challenges that could affect patient engagement and facilitated the co-design of actionable mitigation strategies for implementation. Conclusions This study revealed context-specific insights on the feasibility of delivering guideline-based LBP physical therapy via telehealth in rural communities. It contributes evidence to ongoing National Institutes of Health efforts focused on improving pain management and reducing reliance on opioids in communities disproportionately affected by the overdose crisis.