By Daniel Bockmann, DC
When the COVID-19 pandemic hit earlier this year, it quickly became clear that we would have to change the way we run our practice, and how we see patients. We weren’t forced to close in Austin, Texas, where my clinic is located, but I shut down my practice for two months beginning in March since I did not want us to contribute to the problem. Even though we maintain strict hygiene and safety standards in-clinic, the risk of asymptomatic (yet infectious) patients passing the virus to others, or taking it home to their families, was just too great.
Once closed, I immediately switched to treating all my patients via telehealth. This change—while challenging—has turned out to be a wonderful experience. We re-opened our practice for in-person visits in May, but I have continued to offer telehealth as an option for all our patients because it has been so well received.
Before I explain, let’s go over some of the benefits, and drawbacks, of rehabilitation by telehealth. This list is likely not complete, but based on my experience it represents some of the major considerations:
The Pros:
Safety during pandemics. Both for the patient, and for you as their doctor. Telehealth offers 100 percent protection for both of you. And if you are in lockdown, telehealth is literally the only way you can meet with your patients.
Easy access. You and your patient can easily connect through multiple platforms (Zoom, Facetime, GoToMeeting, even voice calls), through multiple devices (phone, tablet, laptop or PC), and it’s easy to use (I just had an 85-year old grandmother as a new patient!). Note: Under our current COVID-19 Nationwide Public Health Emergency, HHS has relaxed HIPAA rules to allow for use of videoconferencing apps (such as those listed above), when used in good faith provision of telehealth.
Low overhead. Imagine erasing your office rent each month. That’s a big expense for most doctors, and you don’t need an office to deliver telehealth rehab.
Location doesn’t matter. With a physical office, you can only treat patients living relatively close to you. With telehealth, you could theoretically treat patients all over the planet.
The Cons:
You can’t touch the patient. Some physical exam, orthopedic and neurological tests simply can’t be done since you’re not there to do them. Same for most manual or manipulative therapies (but certainly not all).
It’s a less personal experience. It’s harder to develop rapport with a patient when you’re both two-dimensional (but it definitely can be done).
So essentially, you are getting critical access to your patients, with some limitations.
Obviously spinal manipulation and myofascial work (performed by the doctor) are out. But we still have an arsenal of hugely powerful tools at our disposal when rehabbing a patient via telehealth. And these interventions can be massively helpful for our patients, advancing them along their recovery path even though we might not have our entire “toolbox” available.
Telehealth Toolbox
Here are the treatment tools we do have:
- Stretches to increase range of motion where it’s limited
- Exercises to increase muscular protection of the injured parts
- Self-massage with foam roller, lacrosse ball or performed by a partner, to break up scar tissue/adhesions that limit mobility
- Lifestyle modifications such as sleep, hydration, posture, nutrition, technique/regimen, pain coaching, etc.
Lessons Learned
Here’s what I’ve learned from my telehealth adventure so far:
- Consult and history are easy. You’ll find that the Q&A session with your patients is very straightforward and feels almost exactly the same as with your in-office patients.
- Exam is a little more limited, since we cannot palpate or manually mobilize. However, I can easily tell my patient to show me their active ROM (toe touches, Apley’s Scratch test, etc.) and passive ROM with static stretches (heel-to-buttock, hamstring stretch, bicep stretch, etc.).
- While certain neurologic and orthopedic tests simply are not practical with telehealth, there are workarounds that can still lead us to a confident diagnosis. For example, heel/toe walk is easy to assess for L5/S1 motor deficits, but for upper extremity I may have to rely on observing the patient’s active range of motion (ROM), combined with asking the patient if they are noticing any shooting pain, numbness or weakness. If present, I’ll have them show me the distribution of any radicular symptoms, which can point to neurological suspects.
- My rule for stretching: Stretches have one purpose—to increase ROM where it is lacking. To tell if you need a particular stretch, do that stretch. If your ROM is normal, you don’t need that stretch. If your ROM is limited, do that stretch daily until ROM is normal, then “touch up” for life.
- I can also show them how to assess their own need for massage, by demonstrating the massage techniques on myself, and having them replicate these movements. Based on my experience, my rule for massage is this: Where it hurts to do it, is where you need it. If you find painful spots, perform massage on those areas every three days until the massage technique you are using no longer hurts to do. Then “touch up” for life.
- Finally, I demonstrate any rehab exercises by performing them myself, while the patient watches. Then the patient can attempt the movement on their own. Clearly, exercises fall on a continuum—from simple to complex, from easy to difficult. Finding a safe “entry point” onto that continuum is key. I’ll show a patient an exercise, then have them perform it. If the exercise is “difficult but doable” with good form, that’s the exercise I give them.
Videos Support Treatment Plan
Once I’ve assembled a treatment plan (charting the whole time we are talking), I email it to the patient. I list each rehab drill, along with a description and frequency.
And here is perhaps the most critical element of telehealth rehab: I include a link to a video demonstration of each drill so the patient can refer back to it. Patients love this, and it helps ensure they are able to do their “rehab homework” correctly and get the results we both want.
To do this I shot brief (five-minute) clips of all the rehab drills I prescribe and posted them on my YouTube channel. Then I include a link to the video in my electronic health record (EHR) template, attached to the description of that rehab drill. This way, when charting the patient’s plan, I click the drill I want them to do and it auto-populates with the drill description and the video link. Then I simply copy and paste it into their email.
This way, every patient gets a clear visual of each drill, with me verbally cueing them on how to do it—and they own it for life.
The response we’ve received from our patients has been overwhelmingly positive, even though telehealth rehab does have some limitations. Patients are very appreciative of the quality of care and attention they receive, and grateful to have access to a doctor during this national and global crisis.
If you’re a rehab professional who’s considering adding a telehealth component to your practice, I strongly recommend you do so, and I’m happy to help any way I can.
If you’d like a PDF outlining the technology I use for telehealth, send me an email with subject line “Telemed” and I’ll send you everything I use: [email protected].
Also feel free to check out how I set up my YouTube channel—you can copy it exactly if you like. You’ll find it HERE. And if you’d like to see a full new patient encounter I had with a telehealth patient, you’ll find a video HERE.
Dr. Bockmann owns a sports medicine and rehab clinic in Austin, Texas, where he provides pre- and post-op rehab for spine and extremities. He teaches hands-on rehab seminars for ACA, the Texas Chiropractic Association and Texas Chiropractic College, and is a hosting doctor for the University of Texas pre-med student shadowing program. He posts regularly on his Youtube channel at Bockmann Technique, as well as on Instagram @DrDanBockmann, and he moderates the Rehab Professional Forum on Facebook.
Editor’s Note: Dr. Bockmann presented a webinar on telehealth in April 2020 that is available in ACA’s online learning platform, Learn ACA.
