Clinical Triaging Considerations for Telehealth

Telerehabilitation brings with it the boon of being able to access rehabilitation services without stepping outside the house, however, the question always arises as to what patients need it the most.  This page summarizes the clinical triaging principles and answers some important questions of who needs immediate access to telehealth OR what patients should a therapist see-through telehealth.

The American Telemedicine Association states that a Therapist can see patients via telehealth on a

• Case to case basis
• Using clinical judgment
• Making an informed decision based on the Professional Standards of Health

There can be 2 scenarios based on which patients need triaging

1.      A new client/patient who complains of  symptoms OR an old client/patient who complains of new symptoms

2.      An old client/patient who complains of symptoms similar to ones experienced before

The new client or the old client with new symptoms needs to follow an additional step of going through an initial assessment, which could reveal the client's symptom severity, pain patterns that can help to understand the triaging situation. Below are the assessment steps that can be modified to a telerehabilitation situation.

• Histories including past, present and medical history
• Pain and its behavior (Subjective examination reveals most of the assessment data and is key in the diagnosis of a condition)
• Ruling out any RED Flags (explained below)
• Posture examination (this can be examined well through images if clicked properly)
• Movement examination requires a little space and get the patient to move.  Motion analysis tools (kinovea/Tacker/Motion Analysis) may be helpful although not entirely necessary
• Muscle length measurement (through subject maintaining the specific position)
• The subject can move and send the desired movement in a video clipping which may further be analyzed (Privacy and user guidelines are summarized later)
• For example when doing a shoulder joint motion analysis: If the patient has end range restriction and pain it gives us an idea that the underlying condition may be AC joint dysfunction or early adhesive capsulitis. However, if the patient were to have a painful arc (60 to 120degrees) painful then it would be impingement syndrome. If the patient were to have a lowering of the arm painful then it would be attributed to the eccentric control that loads tendons and would be then because of tendonitis. ^2,3
• However, in some patients, a detailed examination would yield no results. In this case, determine whether a face to face examination would be helpful.⁴ However the NHS strongly recommends a face to face examination only in case of emergencies like red flags⁵
• Thus the diagnostic agreement and patient satisfaction is high in telerehabilitation for diagnosis of musculoskeletal problems ⁶

Patient’s Clinical condition and Presentation

• Specific clinical diagnosis or clinical condition. There are no set rules for triaging based on the diagnosis, however, clinical reasoning must help make the decision
• For example, if the patient is a case of Osteoarthritis then he/she will most likely respond to cryotherapy or heat application at home and an appointment can be delayed. However, if the clinical condition is Intervertebral disc prolapse with high irritability and severity then it might not respond to heat or cryotherapy.
• Symptom severity and chronicity are important features to help in the clinical decision making (More severe and chronic cases must be seen sooner)
• The urgency of the Patient to avail rehabilitation services must also be considered.

Presence of red flags/ Serious pathology

When present, serious pathology or red flags should be directly referred to the Physician or medical specialists. Below is the list of red flags that need to be looked out for.

As the pain escalates there is a progressive worsening of symptoms that do not respond to medications or the usual conservative management.

Fever and weight loss or any such Systemic symptoms

Night pain that disturbs and prevents sleep or pain during lying flat

Urgent conditions:

Primary and secondary cancers: The common presentations are night pain, escalating pain, systemic illness.

Insufficiency fracture: Sudden onset pain, most commonly in the thoracolumbar region. This results from low impact trauma.

Spine related neurological symptoms: relatively newer onset weakness that progressively worsens with less than grade 4 in one or more myotome.

Cervical Myelopathy: The rare occurrence of myelopathy from cervical spondylosis in which the patient presents with pain and diminished coordination ability, balance impairments, and possibly loss f bowel and bladder control.

Inflammatory arthritis OR rheumatological conditions:

Persistent synovitis (swollen arm joints) particularly of the small joints of the hand, stiffness that lasts for at least 30 mins in the morning. This would indicate rheumatoid or psoriatic arthritis.

Autoimmune disorders of newer onset like Lupus or scleroderma or vasculitis with non-articular manifestations of rashes, Raynauds disease with bluish/ red discoloration of hand or feet, inflammatory arthritis which presents with mouth ulcers or sicca related symptoms (drying of mouth and eyes)

Any type of myalgia causes due to viral infection or fibromyalgia but showing worse symptoms proximally, ie shoulder or pelvis, associated with 30 mins of stiffness, and an acute raise response (CRP/ESR). This could be polymyalgia rheumatic or Myalgia that require urgent referral to a Rheumatologist.

Headache is of relatively newer onset mainly in the temples which may radiate to the jaw. Also, there will be proximal areas, pelvic and shoulder pain, symptoms of the eye and there will be an acute response with raised ESR and CRP, usually in patients above 50 years. This patient may be a suspect for giant cell arteritis.⁴ 

The severity of the condition, pain, neurological deficits, or severe shortness of breath,

Clinical reasoning tells us that it could be an acute condition or exacerbation of a chronic condition, we could screen him for red flags and refer him to a physician or specialist at the earliest. The presence of neurological signs and symptoms typical of insidious onset need to be addressed as soon as possible.  

The urgency to access care.  Post-operative condition vs non-specific chronic low back pain.

Postoperatively all subjects need immediate care to accelerate or even assist with the normal healing process of that part. Eg: in case of a fracture of the ankle, Range of Motion exercises need to be prescribed at the earliest, soon after cast removal. However an individual with chronic low back pain would already know the basic exercises and in case of triaging, his appointment could be pushed further to a later date. However, in case, the severity of the symptoms was more for the chronic low back pain case then his need demands more attention and must be seen 1^st. Thus triaging needs to be tailored individually.

A study done on telerehabilitation in chronic musculoskeletal conditions proved successful and patients preferred it.  

Triaging

If the patient has access to the available technologies then the following triaging should be considered to determine appropriateness.

●    The patient’s clinical condition or presentation/ diagnosis

●    The severity of the condition, pain, neurological deficits, or severe shortness of breath, how would this impact your decision

●    Potential or actual red flags.

●    The urgency to access care.  Post-operative condition vs non-specific chronic low back pain.

●    Age of patient

●    Presence of other comorbidities or psychological factors

●    Mobility of the patient, physical risk

●    Language barriers

●    Cognition - ability to provide consent and follow instructions

●    What time point of patient care, assessment, review, treatment.  Hybrid model is available, depending on the condition and the patient. 

●    Patient’s physical location.  Their house, friend, GP practice. Geographical location and influence of internet connection barriers. 

●    Who is present during the consult.  Advantage: assistance with tests, or supervision.  Disadvantage: privacy and confidentiality. Privacy of the patient if you need to visualise areas of the patient’s body.  Is it appropriate to ask about certain conditions with someone in the room. 

●    Therapist skill to translate it to telehealth. 

●    Ability to modify tests, ruling out red flags, do you need a local healthcare professional with the patient. 

●    Scope of practice and registration within your state or country

• Reimbursement for telehealth from the patient’s medical insurance or government insurance like medicare.