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.  

Age of patient

Young patients recover faster than old in most cases probably due to fast healing rates and the presence of comorbidities among older patients.

Presence of other comorbidities or psychological factors

Comorbidities are associated with the risk of musculoskeletal disorders

Diabetes changes the properties of connective tissues and increases the susceptibility to developing adhesive capsulitis and delays healing. Isometric exercises, when held for more than 6 seconds, can increase the peripheral vascular resistance and in turn increase BP which could be fatal. Thyroid disorders are associated with muscles cramps and ache. This list goes on…. Thus individuals with comorbidities need to be seen on priority bases.

Psychological factors affect the functioning of an individual. 

Mobility of the patient, physical risk

Subjects who are frail and immobile will be put ahead on the list as they are at a higher risk of developing complications. 

Language barriers

When language is a barrier, assessment meets a roadblock. Thus telerehabilitation must involve the use of translation softwares

Cognition - ability to provide consent and follow instructions

In case the patient's cognition is altered in case of severe dementia, delirium, etc a caretaker may be necessary to help out with the assessment process. However subjective information obtained from the patient may not be valid and may even take the assessment in the wrong direction. In such cases, it might be more sensible to schedule a face to face examination. However, if cognition is too poor then exercise prescription may not be n option and pain relief modalities could be the solution.

Patient’s physical location

·        In case the patient residing close to a community facility, or the General Practitioners clinic then it would only make sense to schedule appointments with these facilities to unload the system.

·        If there is someone else with the patient, these individuals could assist in the special tests and aid 

·        If the geographical location of the residence of a client has architectural barriers that don’t suit his travel needs then telerehabilitation becomes the obvious choice for him.

·        Influence of internet connection barriers when present puts these clients on a list of cases to be seen in person. 

Cognition - ability to provide consent and follow instructions

In case the patient's cognition is altered in case of severe dementia, delirium, etc a caretaker may be necessary to help out with the assessment process. However subjective information obtained from the patient may not be valid and may even take the assessment in the wrong direction. In such cases, it might be more sensible to schedule a face to face examination. However, if cognition is too poor then exercise prescription may not be n option and pain relief modalities could be the solution. 

Who is present during the consult.

Specific staff need to be established for this purpose or role

The recently retired staff who are at a higher risk of contacting Covid 19

Staff who are self-isolating but can support telerehabilitation clinics

Technology support teams and administrative teams to ensure the maintenance of appointments, notifications, and provide technical assistance.

Advantage: assistance with tests, or supervision. 

Disadvantage: privacy and confidentiality.  

Privacy of the patient if you need to visualize areas of the patient’s body

• The environment should have only the therapist and the client use a private space
• The communication channel needs to be a safe medium to prevent hacking. Thus an end to end encrypted platform is more apt.
• Data information needs to retain in the documentation form and not telephonic or video graphic data
• Also consider individual factors (Some cultures are conservative and are not comfortable exposing certain body parts, especially when being recorded)
• Clinical consultation of pelvic area pain conditions may be awkward for the client.
• The workforce team (each member must maintain the privacy and security of the client)
• The site that is being used as a platform needs to be continually checked for its policies on communication and information technology  

Therapist skill to translate it to telehealth. 

An assessment of telerehabilitation shoulder relies mostly on subjective assessment, posture examination, movement examination. When overpressure is necessary it can be given by the patients in case possible. Special tests performed actively can be carried out. Muscle length examination should be included in If required a visit from the local healthcare provider (Village healthcare provider may help to aid the assessment process.

Scope of practice and registration within your state or country

The telehealth governing rules vary from place to place

AS stated by the APTA Physical therapists are not yet recognized under the scope of telehealth of medicare, thus an e-visit paid to a therapist cannot be reimbursed under Medicare and most insurance companies. However, Tricare offers coverage in case all the criteria are met  Medicare however is providing coverage for a 7-day consultation which involves clinical decision making.⁷

●       The Health Professions Council of South Africa has permitted the practice of telerehabilitation given the COVID 19 situation and applicable to this situation doesn’t resolve. However, this facility is restricted to already established patient-therapistt relationships. New patient consultations are discouraged. Also, Therapists must professionally conduct themselves over these consultations. ⁸

●       The Australian Physiotherapy Association has permitted the practice of telerehabilitation and the Australian Heath Funds will provide benefits to individuals availing telerehabilitation consultation. ⁹