Telehealth Rehab: Using Virtual Visits To Get Real Results
Telehealth Rehab: Using Virtual Visits To Get Real Results
As of this writing, my sports med & rehab clinic has been temporarily closed for almost 3 weeks, due to the coronavirus pandemic. For context, today the Surgeon General said, “Next week will be our Pearl Harbor moment.” We weren’t forced to close, but I shut it down preemptively, since I didn’t want us to be contributing to the coronavirus (COVID-19) problem.
Even though we maintain strict hygiene and safety standards in-clinic, the risk of asymptomatic (yet infectious) patients passing the virus to others, or taking it home to their families, was just too great.
Once closed, I immediately switched to treating all my patients via telemedicine, and let me just say -- I’ve been very pleasantly surprised with the experience!
Before I explain, let’s go over some of the benefits, and the drawbacks of rehab by telemedicine.
The pros:
Safety during pandemics! Both for the patient, and for you as their doctor. Telemedicine offers 100% protection for both of you. And if you’re in lockdown, telemedicine is literally the only way you can meet with your patients.
Easy access. You and your patient can easily connect through multiple platforms (Zoom, Facetime, GoToMeeting, even voice calls), through multiple devices (phone, tablet, laptop or PC), and it’s easy to use (I just had an 85-year old grandmother as a new patient!). Note: Under our current Covid-19 Nationwide Public Health Emergency, HHS has relaxed HIPAA rules to allow for use of videoconferencing apps (like those listed above), when used in good faith provision of telehealth.
Low overhead. Imagine erasing your office rent each month. That’s a big expense for most docs, and you don’t need an office to deliver telemed rehab.
Location doesn’t matter. With a physical office, you can only treat patients living relatively close to you. With telemed, you could theoretically treat patients all over the planet.
The cons:
You can’t touch the patient! Some physical exam, ortho & neuro tests simply can’t be done, since you’re not there to do them. Same for most manual or manipulative therapies (but certainly not all!).
It’s a less personal experience. It’s harder to develop rapport with a patient when you’re both 2-dimensional (but it definitely can be done!)
I know I’m leaving some other items off both of these lists, but these are probably the most important considerations. So essentially you’re getting critical access to your patients, with some limitations. Obviously spinal manipulation and myofascial work (done by us) are out. But, we still have an arsenal of hugely powerful tools at our disposal when rehabbing a patient via telemedicine. And these interventions can be massively helpful for our patients, advancing them along their recovery path, even though we might not have our entire “toolbox” to work with.
Here’s what I’ve learned from my telehealth adventure so far.
Consult and history are easy! You’ll find that the Q&A session with your patients is very straight-forward, and feels almost exactly the same as with your in-office patients.
Exam is a little more limited, since we can’t palpate or manually mobilize. However, I can easily tell my patient to show me their active ROM (toe touches, Apley’s Scratch test, etc.) and passive ROM with static stretches (heel-to-buttock, hamstring stretch, bicep stretch, etc.). In fact, some research suggests that the diagnostic accuracy of telehealth exams for certain conditions is on par with in-person assessments (Owusu-Akyaw, 2019)
Here are the rehab tools we do have:
Stretches (to increase range of motion where it’s limited)
Exercises (to increase muscular protection of the injured parts)
Self-massage (with foam roller, lacrosse ball or performed by a partner)
Lifestyle modifications (sleep, hydration, posture, nutrition, technique/regimen, pain coaching, etc.)
My rule for stretching: Stretches have one purpose -- to increase ROM where it’s lacking. To tell if you need a particular stretch, do that stretch. If your ROM is normal, you don’t need that stretch. If your ROM is limited, do that stretch daily until ROM is normal, then “touch-up” for life.
I can also show them how to assess their own need for massage, by demonstrating the massage techniques on myself, and having them replicate these movements. My rule for massage: Where it hurts to do it, is where you need it. The spots that hurt the worst are the spots that need it the most. If you find painful spots, perform massage on those spots every 3 days, until that massage technique doesn’t hurt to do. Then “touch-up” for life.
Finally I demonstrate any rehab exercises by performing them myself, while they watch. Then the patient attempts the movement on their own. Clearly, exercises fall on a continuum -- from simple to complex, from easy to difficult. Finding a safe “entry point” onto that continuum is key. I’ll show them an exercise, then have them perform it. If the exercise is “difficult but do-able”, with good form, that’s the exercise I give them.
Once I’ve assembled their treatment plan (charting the whole time we’re talking), I email it to them. I list each rehab drill, with a description and frequency. And here is perhaps the most critical element of telemed rehab:
I include a link to a video demo of each drill, so they can refer back to it if they forget how to do it.
To do this I shot brief (5-minute) clips of all the rehab drills I prescribe, and posted them on my Youtube channel. Then I include a link to the video in my EHR template, attached to the description of that rehab drill. When charting the patient’s plan, I click the drill I want them to do, and it auto-populates with the drill description and the video link. Then I simply copy & paste it into their email. This way, every patient gets a clear visual of each drill, with me verbally cueing them how to do it -- and they own it for life. Patients love this. And it helps ensure that they’re able to do their “rehab homework” correctly, so they get the results we both want.
The responses we’ve gotten from our patients have been overwhelmingly positive -- even though telehealth rehab does have some limitations. They are very appreciative of the quality of care and attention they receive, and grateful to have access to a doctor during this National and global crisis. For rehab professionals considering adding a telehealth component to their practice, I can strongly recommend it, and I’m happy to help any way I can.
If you’d like a PDF outlining the tech I use for telemed, shoot me an email with subject line “Telemed”, and I’ll send you everything I use: dan@bockmanntechnique.com
Also feel free to check out how I set up my Youtube channel -- you can even copy it exactly if you like!
And if you’d like to see a full new patient encounter I had with a telemed patient, you’ll find a video here.
I believe we’re living through historic times right now. And every disaster is an opportunity for us to become better doctors by adapting and improving our efficiency at delivering high-quality care. I’m glad that we’re all on the same team together!
*See what telehealth services your state allows and reimburses for by checking The National Telehealth Policy Resource Center
References:
Owusu-Akyaw, K. A., Hutyra, C. A., Evanson, R. J., Cook, C. E., Reiman, M., & Mather, R. C. (2019). Concurrent validity of a patient self-administered examination and a clinical examination for femoroacetabular impingement syndrome. BMJ open sport & exercise medicine, 5(1), e000574. https://doi.org/10.1136/bmjsem-2019-000574
Daniel Bockmann, DC
Dr. Bockmann owns a sports medicine & rehab clinic in Austin, TX, where he provides pre- and post-op rehab for spine and extremities. He teaches hands-on rehab seminars for the ACA, TCA and TCC, and is a hosting doctor for the University of Texas pre-med student shadowing program. He posts regularly on his Youtube channel at Bockmann Technique, as well as on Instagram @DrDanBockmann, and he moderates the Rehab Professional Forum on Facebook.