The Basics of Telehealth Assessment and Treatment

Introduction

This page will be a guide into the prerequisites required for the assessment of a patient through a tele interface, the effectiveness of telerehablitation in different conditions and the treatment principles in telerehabilitation Given below are the guidelines to follow while performing a consultation.

Practice using different 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, watssapp cal etc

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

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

Technical support practice

Technical support needed for a consultation includes

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

More information on these technical aspects of dealing with a teleconsultation 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 like in case of 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 patients phone number is ready, in case the video graphic link gives trouble Keep the patients clinical records ready and preferably on another screen Prior to the session test the technology , if it is works as its supposed to.
Start of the consultation	Always initiate the consultation by calling the patient Check the connectivity and clarity by asking the subject of he/ can see or hear. A formal introduction to the patient is a must A verbal consent must be taken from the client before the commencement of the assessment procedures It is always better to look at the camera for the client to make eye contact and restore the subjects faith in you In case there are other consultants in the room they need to be introduced to the client
The consultation	Maintain written records as you would for a face-to -face consultation. Be aware that the video communication is slightly different in comparison to their In case you are preoccupied, making notes or reading medical records, let the patient know
Closing the consultaion	Summarize key points, incase something went wrong technically this would really help Clarify any doubts the patient might have Confirm i the patient is happy with the video method of telehealth Remind the client not to stop his routine medication in case of any co morbidities present Say goodbye and close the call
After the consultation	Update the records Schedule referrals or follow up appointments Make sure the exercises, if promised in the form of an email are sent Prompt follow up email needs to be sent, summarizing the necessary features of the teleconsultation Face to face appointments in case necessary must be scheduled

Plan your consultations:

The consultant or therapist must always be prepared. The therapist must develop a list of the questions that will have be asked. The key examination points including active movements, passive movements and special tests must be organised to optimize best utilization of the session time. Identify if any of the assessment procedures may require assistance by a family member.

Modifying assessment to fit a virtual audience

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

Initial set up: It may at times be essential to pay a visit to the patients residence and set up a location for the video device to be placed. This can help with the assessment process and will help with continous monitoring of the patient as he performs his exercise session.

Safety is priority: Before we venture into the technicalities of this section it is important to understand that safety f the client is and must be the prime 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. Replace with another test or additional questioning or rather in-person.

Camera placement: The placement must give a good view of the client. This can be done by a few trial placement areas tried out in the subjects vicinity (EG: 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 a he/she performs what is asked of him/her.

Adapt instructions: The instructions must be specific, load 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 to 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 later sessions will take less time. as a therapist gets used to these sessions the time for assessment also will reduce. Also if the location id remote and the connectivity poor, there are likely to be technical glitches which may prolong the session time.

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 even suggests that physiotherapy when given Strong evidence for tele-rehabilitation being effective in the following

• 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

Teleheath isn't 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: 75% of individuals look for an answer online regarding their health condition. It has also been suggested that 40-67% individuals depend on online platforms including health related apps to get basis 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 are expected to have their reservations on it as the primary channel of treatment. Thus education about telehealth, the general expectations from rehabilitation, the information about the patients specific condition must be clear and presented in a concise fashion. Patients can be asked to register on the online interface portal and post in their questions when necessary. It would be ideal to organize patient education sessions at regular time frames. Many patients were of the idea that telehealth would be indeal for follow up sessions rather than a 1st session. 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, infant most patients with chronic illnesses preferred the telehealth system to normal rehabilitation as it was cost effective ans time saving and reduced sickness absenteeism. Websites and apps can be used instead of Telephone and video methods of communication to permit motoring of exercises and continually record progress. This method has proven more effective for exercise adherence. Thus tele-rehabilitation 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

Recommendations to the Organizers

• Telehealth networks must be establishes, preferably standardized software or systems
• Consulting and refereeing sites must be made available , probably like a smaller unit for immediate consultation when required
• Standardized, goal oriented and time driven protocols must be in place for the efficient delivery of rehabilitation services specially in he acute phase
• Continuing education and mock simulation conditions are suggested to continually train and update professionals offering services
• Telerehablitation includes one mode of communication. In fact to optimize results and to evaluate adherence , multiple modes of of communication may be necessary, like video conferencing, telephone, desktop video phones, messaging devices, online chat sessions, video recordings, email.

Patient guide:

1. Decide what type of a consultation you would like or need (telephone consultation works well if a video isn't necessary). Video consultations are more reassuring due to the visual feedback.
2. Ensure your details last updated at the hospital are your current details (email id, phone number). locate a quite 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 process of 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 u on anything you have agreed to.