Telehealth

As a manual therapist, I never thought I would be writing about Telehealth let alone offering it but thanks to the coronavirus, here we are. I started offering virtual appointments because there was simply no other choice. Even though physical therapy is part of the essential list, I had to reflect on whether it was absolutely essential and furthermore, whether seeing people in my gym was mandatory in providing effective care. I started to research the efficacy of virtual physical therapy and was surprised to find that the results are just as positive if not more effective in some patient populations. Then I started seeing patients virtually and got to have first hand experience of what research indicates. I figured that if I needed convincing Telehealth was a viable option for physical therapy, I’m sure my current patients and even prospective ones are hesitant as well. So here is what research and my own experience says about virtual physical therapy. In a nutshell, don’t knock it before you try it and it’s worth giving it a try. A virtual visit will, more likely than not, help and it is guaranteed to be better than not doing physical therapy at all.

Before I started providing Telehealth appointments, I had two major concerns: 1) how was I going to be able to properly evaluate, assess and diagnose without being able to perform most special tests or palpate? and 2) how was I going to be effective in treating my patients if manual therapy wasn’t an option?

I was happy to find a lot of research regarding my first concern. In a typical evaluation, a physical therapist starts with what we call a subjective interview. This is when we ask very targeted questions almost like a detective to understand the nature and behavior of a person’s pain. From this we generate a hypothesis (or a few) and then we use special tests and movement assessments (referred to as the objective exam) to confirm or deny our hypotheses. I would add that I double confirm through treatment and reassessment. So what does research say? First off, it shows that special tests are not specific or sensitive in provoking the tissues or structures that they are said to. This means that they aren’t accurate enough to rule in or rule out much of anything. In fact, 50% of the time a therapist changed their diagnosis to the wrong one after performing the objective exam. With that said, a physical therapist was able to accurately diagnose 7 out of 8 patients with just their subjective exam. Upon reflection, I have to agree from my clinical experience as well. I very rarely change my hypothesis after my subjective interview. And when I do, its because of the response to treatment rather than any objective measurement or special test. Palpation should also be included in this. The consensus is that palpation is not reliable (regardless of experience level) unless it is pain provoking which has been shown to be clinically significant. The good news: I can direct a patient to self palpate for pain and any use of palpation for further diagnostics isn’t shown to be useful whether it was me or my patient doing the palpating so we can be ok with just skipping it.

  • Somerville, Lyndsay E., et al. “Diagnostic Validity of Patient-Reported History for Shoulder Pathology.” The Surgery Journal 3.2 (2017): e79.
  • Cuthbert, S. C., & Goodheart, G. J. (2007). On the reliability and validity of manual muscle testing: a literature review. Chiropractic & osteopathy, 15(1), 4. 
  • Seffinger, M. A., Najm, W. I., Mishra, S. I., Adams, A., Dickerson, V. M., Murphy, L. S., & Reinsch, S. (2004). Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine, 29(19), E413-E425. 
  • Stochkendahl, M. J., Christensen, H. W., Hartvigsen, J., Vach, W., Haas, M., Hestbaek, L., … & Bronfort, G. (2006). Manual examination of the spine: a systematic critical literature review of reproducibility. Journal of manipulative and physiological therapeutics, 29(6), 475-485.

Research regarding my second concern is a bit more complicated. Most of the research provided by Telehealth proponents is all about disproving manual therapy as being an effective modality but I am not out to undermine the value of hands on treatment that has clinically worked for my patients thus far. If you look at ALL of the research regarding manual therapy, these are the conclusions that have been made:

  1. Manual therapy, as a stand alone treatment, provides short term pain relief, improved range of motion and marginal functional gains when compared to exercise based therapy.
  2. There is little explanation for why manual therapy actually works. Some theorize placebo or patient expectation.
  3. The most effective physical therapy for pain and function involves both manual therapy and exercise.
  4. In some patient populations (research looks mostly at post-operative), a patient-guided home exercise program has been shown to be more effective than a supervised rehabilitation program.

So what does all that mean? There are two take aways: 1) palpation and manual therapy are not absolutely necessary for proper diagnosis or effective treatment and 2) in not seeing a patient physically, the patient is required to be independent in their home exercise program thus increasing their self-efficacy and control of their own pain. The research regarding self-efficacy really hit home for me and was ultimately why I started not only being ok with treating virtually but actually excited about the possibilities that might come out of it. Being a manual therapist, I often find it challenging for patients to be compliant and learn to become effective in their home exercise program because they know they can just come see me if they need it to be fixed again. In this respect, I think being forced into Telehealth is actually providing a great opportunity for patients to start being in complete control of their own pain, rehab and health. Having had several virtual appointments under my belt, I can also say that it is challenging me to teach patients manual techniques that I would have previously never considered possible for a patient to do on their own at home. It is opening my eyes to how truly independent patients can be and I will definitely be taking this into my practice even when I start to see patients face-to-face again.

  • Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010;18:3 PubMed PMID: 20184717; PubMed Central PMCID: PMC2841070; eng DOI:10.1186/1746-1340-18-3.
  • Clar C, Tsertsvadze A, Court R, et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropr Man Ther. 2014; March;22(1):12 PubMed PMID: 24679336; PubMed Central PMCID: PMCPMC3997823 DOI:10.1186/2045-709X-22-12. 
  • Bialosky JE, George SZ, Bishop MD. How spinal manipulative therapy works: why ask why? J Orthop Sports Phys Ther. 2008; June;38(6):293–295. PubMed PMID: 18515964; eng DOI:1417 [pii] 10.2519/jospt.2008.0118.
  • Grant, J. A., Mohtadi, N. G., Maitland, M. E., & Zernicke, R. F. (2005). Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. The American journal of sports medicine, 33(9), 1288-1297. 
  • Voogt L, de Vries J, Meeus M, et al. Analgesic effects of manual therapy in patients with musculoskeletal pain: a systematic review. Man Ther. 2015; April;20(2):250–256. PubMed PMID: 25282440 DOI:10.1016/j.math.2014.09.001. 
  • Fredin, K., & Lorås, H. (2017). Manual therapy, exercise therapy or combined treatment in the management of adult neck pain–A systematic review and meta-analysis. Musculoskeletal Science and Practice, 31, 62-71. 
  • Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory. Journal of social and clinical psychology, 4(3), 359-373. 

At this point I can say that I provide virtual physical therapy not only because I have to, but also because I am confident I can deliver an effective service that results in a reduction of pain, improved functional outcomes and long term benefit for my patients. Sooooooo, “see” you soon?


Need to hear if from someone else?

“Jenny is amazing. I was in urgent need of a Physical Therapist for a sudden hip issue. A friend recommended Jenny, so I reached out. I had never met her, but I emailed her on Friday. By Sunday morning, she and I had a fabulous online session (she said I was her first client over the internet, but she made the whole session so clear and visible that I felt like I was right there with her.) She remembered everything that we talked about and followed up with an email summary and videos showing me everything I needed to do. I have already recommended Jenny to so many of my friends because I have never met any Physical Therapist so in tune and dedicated. She not only saw the most current situation with my hip, but she also found underlying issues and causes that I would never have imagined. I am looking forward to our next online session for continued strengthening help and advice. I started out afraid that I would need a hip replacement at age 55. I left with my spirits high, hopeful and excited.”

– New Patient

“I think the Telehealth video experience worked well with Jenny Putt.  We were able to identify new areas to address on my tibia/fibula/ankle issue.  Jenny was able to instruct me by example on her leg and the skeleton to manipulate my bone area in the front of my leg related to ankle/tibia/knee tracking.  We then used a small ball to work on the  inflammation issues on the outside and inside of my lower leg to ankle.  Her instructions were clear and I felt that a lot was accomplished.  I would recommend working with Jenny through Telehealth to continue to work on issues during the Coronavirus shelter in place and beyond.  Thank you Jenny!”

– Existing Patient

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