At two weeks post op from my most recent hip surgery, the state of California announced the first stay at home order in the U.S. which meant I had a dilemma. Up until that point, I was not worried and thought this "pandemic" was in someone else's backyard - certainly not mine. However, I began listening to the news and realized that this is more serious than I thought and because my husband has some health problems, I am opting to do the majority of my PT through video. So far so good!
Jacob Templar, PT, had shared info with Hopeful Hippies a few months back about pain science and I thought that I would reach out to him to see his perspective as I knew, since he is in New York, that he was implementing this with his own patients.
When did you first start off with telehealth for PT? and why?
I personally started doing telewellness via the Strength Guys to serve our athletes. I have had a unique interest in powerlifting and bodybuilding for a while and the skills and knowledge about Physical Therapy (PT) that would allow me to uniquely understand issues they may be dealing with and make adjustments/recommendations for their training to help them continue training. My 9-5 job just started telehealth several weeks ago but myself and a coworker have been interested in telehealth and have followed expert PTs for years.
How can this modality ensure that a patent make progress from surgery/injury?
We can still do many of the most effective things in PT via telehealth. Education about conditions, symptoms, activity and exercises. As well as having people perform exercises to guide them through a program just like we might in person. This allows them to stay active and continue to be motivated to perform rehab activities in a time they may not be as focused on Orthopedic health.
How do you make sure patients are doing the exercises correctly?
Being able to visualize them perform the exercise is helpful to ensure they are doing the exercises correctly and we can watch from multiple angles and make corrections just as we might in person
What type of platform do you use?
Currently I am using the HIPAA compliant Doxy.me which has been around for a while. This platform is also easy to use for patients as they just need a link to a providers virtual waiting room and type their name in, no sign up required. Scheduling and payments are also easy via this platform.
Is there any science/data to support the use of telehealth for PT?
There are several studies that have been performed especially in post surgical situations. Most notably there have been some promising papers done with patients who had hip and knee joint replacements with good overall outcomes and patient satisfaction. There is also a systematic review of literature in Ortho settings with papers ranging in date from 2003-2016. There is not sufficient data to support its use long term as a replacement for in person PT, but there is good evidence to support that people are generally satisfied with services provided and can have good outcomes functionally.
What types of limitations do you see with telehealth? pros/cons?
Most limitations are technology related. Many internet sources are not as reliable and subjective to drops in service and video/audio quality. Especially when everyone is on the internet at once right now. Internets like fiber optic based services have more reliable speed and quality. Not everyone has access to the internet or devices that can be used to benefit from telehealth and may not understand technology enough to use this service to its full potential
What types of skills does a PT have to really develop to be successful with telehealth?
The biggest skill that is needed for this is good communication. Great communicators make great healthcare workers in general. This is because the most reliable and accurate ways to identify patterns of symptoms and presentation is allowing a patient to tell us their story. Many healthcare providers today have forgotten the art of the medical interview and listening, relying more on tests and measures that when scientifically researched are not as good at telling us about someone's condition and how the illness is impacting them, than listening. If at that point we need to identify something or rule out this condition versus that condition more advanced tests are then warranted. Also, specific to PT is the understanding of exercise progression, regression and how to plan exercise, educational skills about pain and medical conditions. Finally, creativity, being creative you can figure out how to perform exercises with minimal or no equipment and how to walk patients through many hands on tests we might perform in the clinic on themselves.
What types of education and/or skills does a patient have to have to be successful with telehealth?
In my opinion the only skills they need to have are the abilities to use basic functions of a smart phone, tablet or laptop. Most of the platforms used for telehealth are simple to use and only require the patient to know how to do a google search, search a web address, check their email, or click a link.
How do you communicate proper positioning of an exercise if you are not there to guide the patient's body? What about any manual therapy needs? For hip patients, many surgeons, to prevent hip capsule contractures, have mobilizations as part of their protocols.
This is one of the great things about movement and exercise. General movement and exercise has always been shown to be a great intervention for pain, improving function, and rehabbing injury. We often get lost in precise specific movements but human movement often is best learned when we have the freedom to move how we want and are encouraged to move in all and any positions. We often want constraints and seek constraints but PTs should be guides more than strict drill instructors when it comes to most exercises patients perform. Personally there are specific movements I want someone to be more precise with but most general exercises I give basic guidelines and allow them to move based on those. Also when it comes to manual therapies evidence does show that these can help to augment effects of exercise but do not replace exercise and self guided movements and stretching. Many stretches that I perform on patients can be replicated at home with towels, belts and other household objects. There are some that are difficult to replicate but for the majority of effects we can teach someone how to do movements and stretches that can have very similar effects.
What about equipment needs for most patients?
This would depend in the person. Some patients in person clinics will never be replaced due to equipment needs for safety, or they may be a high level athlete that needs weights, lots of space etc. But the vast majority of patients just need clothes they would normally do PT in, an open space about the size of a living room or office space, a chair and their body. I have a lot of patients use towels for specific stretches, and we often use things like reusable shopping bags, brooms, buckets and other household objects for weights or implements to perform stretches with.
Does insurance cover it?
As of right now Medicare is covering some aspects of PT but is very grey right now and changing almost daily. At this time many commercial insurance plans are covering it but may vary state by state and plan by plan. It is best for someone to contact their insurance provider and ask specifically if telehealth/medicine is covered by their plan and if that plan specifically covers PT services via telehealth/medicine.
Are you able to serve patients in any states?
This is also a big grey area right now because of certain restrictions being waived in certain states and at a federal level. However, most therapists have been advised to only treat patients that they would normally be able to treat in person. Which is mostly determined by state practice acts and license agreements based on your state or surrounding states.
Note: If you are a patient looking for telehealth in New York state, you can contact Dr. Templar at Physical Therapy Services of Rochester. If you live in the UK or in California, Hopeful Hippies also has multiple contacts who are doing telehealth for PT. Send us a message. If you live in some other geographic area and would like to share your therapist's info or need help finding someone, please reach out through the website!
Be safe, be well, be hopeful.