The Basics of Telehealth Assessment and Treatment

Original Editor - Ashmita Iora Davania Patrao

Top Contributors - Ashmita Patrao, Kim Jackson, Tarina van der Stockt, Wanda van Niekerk, Vidya Acharya and Jess Bell

Introduction

This page aims to guide you through the prerequisites of a telehealth assessment. It discusses the effectiveness of telehealth for different conditions and provides various telehealth treatment principles that may be helpful when performing a consultation via digital technology.

Telehealth services are either real-time virtual visits (i.e. synchronous), store-and-forward (asynchronous) or remote patient monitoring.

Types of Platforms

Tele-rehabilitation requires a strong platform that offers competent technical and technological services. They may fall under the following categories

Video conferencing: This is on a continuous online platform that permits dynamic interaction between the client and therapist. This may include platforms like skype, zoom, google duo, Whatsapp etc

Image transfer: This includes the transfer of select images for the purpose of treatment.

Data transfer: This includes the transfer of information through non-image or video methods like emailing medical records, exercise plans etc

Technical Support

Technical support needed for a consultation includes:

• Audio conference equipment
• Video conference equipment
• Computer networking (WANs and LANs)
• Broadband networks
• Satellite television which provides interaction

More information on these technical aspects is given in the page, Practical Considerations in Telehealth

Recommendations for Consultations

It is always considered better to conduct mock consultations to evaluate any technical glitches that may occur and evaluate network strength

Before the Consultation	Consider a pre-call questionnaire (Self-rating such as VAS or Body chart) Ask the client if they would like a partner or family member to be present during the consultation Schedule the consultation based on whom you need to see on a priority basis (Clinical triaging considerations for Telehealth) Confirm if a video graphic consultation is clinically appropriate. Use a room that is private and well lit Make sure the patient's phone number is ready, in case the video call link gives trouble Keep the patient's clinical records ready and preferably on another screen Prior to the session test the technology to check that it is working as it is supposed to.
Start of the consultation	Initiate the consultation Check the connectivity and clarity by asking the subject if they can see and hear you A formal introduction to the patient is a must Verbal consent must be taken from the client before the commencement of the assessment In some countries, you have to verify verbally in which state the patient is situated to confirm you are licensed to assess/treat this patient It is always better to look at the camera for the client to make eye contact and ensure his/her faith in you If there are other consultants in the room, they need to be introduced to the client Instruct the patient on what to do or how to reconnect if the session ends prematurely or there is a poor internet or audio connection
The consultation	Maintain written records as you would for a face-to-face consultation Be aware that video communication is slightly different in comparison to in-person In case you are preoccupied, making notes or reading medical records, let the patient know and explain this to the patient ahead of time
Closing the consultation	Summarize key points - this is particularly important if there were technical difficulties during the consultation Clarify any doubts the patient might have Confirm that the patient is happy with the video method of telehealth Remind the client not to stop his routine medication in case of any comorbidities present Say goodbye and close the call
After the consultation	Update the records Schedule referrals or follow up appointments Make sure you email any exercises you prescribed/promised A prompt follow up email needs to be sent, summarizing the necessary features of the teleconsultation Any necessary face to face appointments must be scheduled

The following two optional videos provide you with some ideas on how to set up telehealth appointments in a client's home. The first video focuses on the rehabilitation professional setting up a telehealth device in a patient's home and things to consider such as lighting, position of the device and quality of sound. The second video is more directed towards patients and what they can do with their set-up before the appointment.

Plan Your Consultations

The consultant or therapist must always be prepared. The therapist must develop a list of the questions that will have to be asked. The key examination points including active movements, passive movements and special tests must be organised to optimize the best utilization of the session time. Identify if any of the assessment procedures may require assistance by a family member or care giver. These two optional videos provide you with some ideas on how to plan your consultations. The first one is a demonstration of a telehealth session and the second optional video gives you some tips and tricks on how to manage the palpation component of a physical assessment.

Modifying Assessment to Fit a Virtual Audience

Observation assessment, when done virtually, will depend on the view and the angulation of the device. Relying on observatory findings may be challenging as it requires proper alignment of the camera with respect to the body segments. Thus, it would be appropriate to ask additional questions to complement your observation. Adaptations of the regular examination and modifications of the special tests and other evaluation methods are essential.

Initial set up: It may at times be necessary to pay a visit to the patient's residence and set up a location for the video device to be placed. This can help with the assessment process and will help with the continuous monitoring of the patient as they perform their exercise session.

Safety is a priority: Before we venture into the technicalities of the section, it is important to understand that the safety of the client is a must and a primary concern of every therapist. In the unlikely event that something goes wrong, a therapist must be able to reach out to the patient or have a system in place. Tests that are not safe to perform should be replaced with another test or additional questioning or rather in-person.

Camera placement for the patient: The placement must give a good view of the client. This can be done by a few trial placement areas tried out. (e.g. on a table, adjusting the tilt of the laptop or placing the iPad on a stand that is aligned to give a good view of the client as they perform what is asked of them.

Camera placement for the therapist: Patients need to see the therapist's whole face when talking. When showing exercises the patient needs to see the therapist's whole body if possible. The therapist should have enough space to move in front of the camera. When moving the camera to show exercises on the floor make sure you have a stable surface to place the camera on so that you don't have to hold the device or put it on the floor.

Adapt instructions: The instructions must be specific, loud and clear. Use of non-medical terminology is always preferred. If the assistance of a family member is required the instructions must be very specific with respect to hand placement and in which direction (toward which part) the movement must occur.

Time for a session: Initial assessments may take more time and the follow-up sessions may take less time. With technical glitches and poor connectivity, the session time may be prolonged.

In this optional video below, best practice for telehealth for rehabilitation professionals are highlighted and valuable advice and tips are shared.

Assessment Practicalities

Make sure you are well prepared for any telehealth consultation, especially for an initial assessment and consider the following assessment practicalities:

• Have a list of questions and tests on hand. When starting with telehealth you might be overwhelmed by the technology and troubleshooting and a list helps you to stay on track
• Think of additional questions to ask the patient. For instance, if you are not able to view the whole patient because of poor set up, when testing forward flexion you can ask them how far they are able to reach down - fingertips to the knees, mid-shin, ankle.
• Consider which orthopedic tests will be valuable to do over telehealth and if they can be independently performed.
• For passive and active range of motion, you need to consider the patient's angle to the camera. Consider different ways of testing if you are unable to measure with a goniometer.
• The therapist could provide a pre-recorded video to the patient ahead of the session to teach them how to perform a specific test while in the consultation. Or to give them guidance on what is needed for the test, for e.g. a chair or bed.
• A family member can be shown how to perform passive range of motion
• Consider which tests cannot be safely or effectively performed without you directly assisting. Are these tests paramount to your clinical reasoning processes with regards to the patient's diagnosis or treatment direction? Can a test be sufficiently replaced by another test or additional questioning? Or do you need to assess the patient in person in order to establish a clear diagnosis?
• A new musculoskeletal assessment framework published in Cureus provides pre-consultation guidance and step-by-step remote examination instructions to musculoskeletal clinicians working in primary care to adapt their assessments based on published evidence, and community-sourced best practice; it also includes patient and clinician resources (patient information leaflet and photographs of examinations). The framework suggests adapting traditional techniques 'look, feel, move' to 'look, point, move' which reflects the increased role of patient participation within virtual consultations.

To learn more click on this link: Remote Musculoskeletal Assessment Framework: A Guide for Primary Care

These two optional videos provide you with some ideas on how to conduct musculoskeletal assessments using telehealth.

Treatment

What Interventions Can You Safely Do as Part of Telehealth

There is a perceived acceptance of telehealth and rehabilitation service in chronic musculoskeletal conditions. Research suggests that physiotherapy in telehealth are effective in the following conditions:

• Chronic joint pain or osteoarthritis (knee osteoarthritis and arthritis of other joints)
• Shoulder hemiarthroplasty
• Total hip replacement
• Non-specific low back pain that is subacute in nature
• Chronic non-specific neck pain
• Total knee arthroplasty
• Lumbar spine stenosis which is degenerative in nature

Telehealth is not suited for interventions like manual therapy, soft tissue techniques or any technique that requires a hands-on approach by the therapist to the client.

Patient Education

Seventy five percent (75%) of individuals look for an answer online regarding their health condition. It has also been suggested that 40-67% of individuals depend on online platforms including health-related apps to get basic healthcare information. This tells us that telehealth has a huge client base. However, it is important to guide these individuals in the right direction as they may have reservations about it as the primary channel of treatment. Thus, education about telehealth, the general expectations from rehabilitation, the information about the patient-specific condition must be clear and presented in a concise fashion. Patients can be asked to register on the online interface portal and post their questions when necessary. It would be ideal to organize patient education sessions at regular time frames. Many patients often consider telehealth appropriate for follow up sessions rather than initial assessments. Thus, the therapist needs to educate the client/patients as to how the system works and assist and reassure him/her with respect to any difficulties faced.

Exercise Therapy 

There are multiple ways to teach a patient a particular exercise and continually monitor as it is done in a face to face rehabilitation session. These methods can be followed with family members assisting whenever required

• Prerecorded video
• Online video demonstration
• Display of visual feedback
• Video conferencing
• Sensors embedded in task devices if they are available can track and relay information to the therapist
• Family member to assist if needed like with passive ROM video

Functional Rehabilitation

Functional goals have to be individually tailored. In fact, most patients with chronic illnesses preferred telehealth to normal rehabilitation as it was cost-effective and time-saving and reduced sickness absenteeism. Websites and apps can be used instead of telephone and video methods of communication to permit monitoring of exercises and continually record progress. This method has proven more effective for exercise adherence. Thus telerehabilitation is a well-suited method for rehabilitation concerning

• Educating the patient about the condition
• Advising the patient on the self-management techniques
• Prescription of exercises
• Advice regarding Physical activity and individualized planning
• Monitoring progress and follow up

The following optional video provides you with some great tips and tricks for rehabilitation exercises and it is useful if you want to learn more.

Recommendations to the Organizers

Some recommendations for organisers of telehealth services to consider include the following:

• Telehealth networks must be established, preferably using standardized software or systems
• Consulting and referring sites must be made available, for immediate consultation when required
• Standardized, goal-oriented and time-driven protocols must be in place for the efficient delivery of rehabilitation services especially in the acute phase
• Continuing education and mock simulation conditions are suggested to continually train and update professionals offering services. A recent study by Luke Davies et al. developed an international core capability framework for physiotherapists to deliver quality care via videoconferencing. This framework outlines 60 specific capabilities mapped across the seven domains that will help:
  • guide knowledge and skills needed by physiotherapists to deliver quality care via videoconferencing
  • train physiotherapists in the digital environment &
  • inform future development of physiotherapy curricula and professional development initiatives in the delivery of telehealth.
• Telerehabilitation includes one mode of communication. In fact to optimize results and to evaluate adherence, multiple modes of communication may be necessary, like video conferencing, telephone, desktop video phones, messaging devices, online chat sessions, video recordings, email.

Patient Guide

These guidelines are valuable for patients to have to ensure a successful teleheath consultation.

1. Decide what type of consultation you would like or need (telephone consultation works well if a video isn't necessary). Video consultations are more reassuring due to visual feedback.
2. Ensure your details last updated at the hospital are your current details (email id, phone number). locate a quiet place, with good connectivity to the internet. Test the device you will be using prior to the consultation. Make sure the Physical Therapist has your credential details to know it is you and to respond timely. Login to the connection a few minutes prior to the consultation
3. During the consultation, you can look at the screen, it isn't mandatory to look at the camera as this may be difficult. Any questions that require verification can be clarified. If the connection is disrupted in between, reconnect the call
4. Make sure to follow up on anything you have agreed to.

Additional Resources

• International Core Capability Framework for Physiotherapists - Melbourne School of Health Sciences