Member Article: Telehealth or Digital Physical Therapy

Telehealth or Digital Physical Therapy

By: Stephanie Wakeman

What is telehealth/telemedicine? Telemedicine is the delivery of a health care service using electronic communications and/or information technology to provide services between a healthcare provider and patient at a different site.  These services must be provided according to state practice act and state laws just like an ‘in person’ visit.

Globally, the term ‘digital practice’ is being used since it is viewed as more encompassing of the range of technologies on current and future practice.  Therefore, the task force of the World Confederation of Physical Therapy has proposed the following definitions:

Digital practice is a term used to describe health care services, support, and information provided remotely via digital communication and devices.

Purpose: The purpose of digital physical therapy practice is to facilitate effective delivery of physical therapy services by improving access to care and information and managing health care resources.

Digital PT has become all the rage with the onset of COVID-19 and people are clamoring to get onboard with this technology.  The purpose of this article is not to advise on how to get started with your own digital PT gig, but if that is your desire there are some great resources out there. Here is a link to a course to get you started by the real guru, Rob Vining.  The resources can guide you on the ‘how’ of establishing a HIPPA compliant platform and scheduling software as well as EMR options.  APTA also has plenty of resources on compliance and insurance matters regarding telehealth including This article which also has links to other resources. Here is another resource to the specifics on how to start a digital practice.  Finally refer to this resource Compiled by HPA section of APTA for more  updates and resources.

NJ is a parity state meaning legislation has been passed that requires private insurance companies to pay for telehealth service rates similar to in person medical care.  However, this does not mean that all insurance companies that you are contracted with WILL reimburse you.  You have to call each insurance company and ask directly and document the conversation.

How to conduct a digital visit:

When conducting a digital visit, keep in mind best practices and evidenced based intervention. It is vitally important that you conduct a thorough evaluation.  This includes a history of the current problem, systems review, past medical history, and review of work and home environment that may be contributing to the problem.  Use of digital PT has an advantage over in person visits in this way because you can visually see the environment in which the patient lives/works and can assess how their daily set up is affecting a particular impairment.  It is vitally important to rule out for yellow and red flags.  Presence of yellow flags may indicate this person is not appropriate for a digital visit but may benefit from a face to face interaction.  Impairments such as falls risk, some neurological impairments, and suspicion of fractures or infections will warrant an in person visit.  Some yellow flag indicators such as high levels of depression or anxiety, complicated co-morbidities, or significant loss of mobility/function may also warrant an in person visit and/or referral to appropriate healthcare provider.  Any presence of red flag indicators is a signal for immediate referral to MD. Providing an accurate diagnosis, prognosis, and comprehensive education is necessary.  Establishing patient goals and developing a plan of care with evidenced based intervention is key to success.  Services provided must be skilled and effective in accordance with APTA guidelines to practice.  Documentation of each visit is required.

Assessment:

You may be wondering how to determine strength of a particular area/muscle.  This is where you need to get creative and think functionally. Here are some tips for functional assessments in a virtual world:

• I like to assess overall lower body strength through squats, single leg squats, single leg heel raises and 5x sit to stand test.  Assess the squat from frontal and sagittal planes and take note of lumbo-pelvic motion in the sagittal plane. Look at heel raises from posterior view and assess for calcaneal varus/valus that can clue you into eversion and posterior tibialis function. 

• Assess singe leg balance/squat and focus on femoral rotation, knee varus/valgus and excessive pronation/supination at the foot for stability. 

• Observe a step up and a step down and assess for movement quality. 

• For the upper extremity look at a tall plank and push-ups from knees or toes.

• Ask the patient to resist their own bicep curl or front/lateral raise or perform these actions as an isometric against a wall and get their input on right/left differences.  

Special tests:  When performed in clusters, special tests can have a higher likelihood ratio and be more efficacious.  Therefore, performing one or two modified tests is not very reliable, but it may give you information on symptom modification with movement.  A patient can self-perform an empty can test and you can ask them to give themselves overpressure for end range flexion for a modified Neers and cue them into a Kennedy Hawkings position.  Asking the patient to move in specific directions and cueing them on nuanced changes may provide helpful information.

Special tests for ligamentous injuries can be more challenging.  This is an example of the need to refer out for to other provider if you suspect a grade IV tear and/or notice excessive instability of the joint especially when combined with a history of trauma.  It is helpful to review Ottawa ankle/knee rules and Canadian C spine rules. 

Wrap Up: Although there is a plethora of resources out there now on how to start digital visits, it’s really not something you can just setup and be ready for tomorrow.  This new frontier of healthcare takes planning, training and preparedness to ensure compliance with all regulations and deal with emergencies should they arise.  I have found digital PT to be very rewarding because it allows for more one on one in a private, undistracted setting.  Digital PT is NOT for everyone or every impairment, but it really works well for the right person who been properly evaluated and screened.  It has allowed for improved connection with someone because you are ‘invited’ into their homes/offices thus making the visit a bit more personal.  This undistracted space allows for more opportunities to have discussions about areas of health such as sleep, nutrition, mental wellness, and overall exercise habits that can greatly contribute to the person’s sense of wellbeing. 

Stephanie DeShano Wakeman is a doctor of physical therapy and licensed in multiple states including NJ. She is a long time member of APTANJ and currently serves as Delegate.  She has over 20 years of experience in multiple settings but is focused on orthopedics and dance medicine. She has been involved in digital physical therapy since December of 2019 working for Physera Physical Therapy. 

https://ptonice.com/rob-vining

http://www.apta.org/PTinMotion/News/2020/03/23/QuestionsToAskAboutTelehealth/

https://www.telehealthpt.com/telehealth-starter

https://www.aptahpa.org/page/COVID19#InteractiveAudio