Physical Therapy telehealth can be done successfully in the right hands

People always ask HOW can you do physical therapy over the internet? Well, first off, other clinicians think that PTs treat only sports medicine and other orthopedic conditions. We do A LOT more than that. Many of us specialize in clients with cardiopulmonary, neurologic (including vestibular and other balance issues), pelvic floor, or pain issues.  Much of what we do is teach. We educate clients in their disease process, how to use their medications as prescribed, pain and edema management techniques, when to call the doctor or go to the ER, compensatory and modification strategies, and so on. We demonstrate a technique or treatment the client will need to practice sessions (home exercise).  We teach caregivers how to safely transfer, assist, or spot the client; how to communicate and work with cognitively impaired clients; how to inspect their feet and position themselves or loved ones to protect their skin and mitigate infections. Physical therapists teach clients how to use their nebulizers and inhalers correctly and sanitize them. We do wound care.

We teach prevention and wellness. We help mitigate the progression of progressive neuromuscular and musculoskeletal disorders We provide home safety modifications, suggest durable medical equipment, braces, prosthetics, and orthotics. We identify and communicate back to the primary physician or specialist involved possible UTIs and other infections, heart failure, pneumonia, COPD exacerbations, ulcerations and wound complications, cognitive issues, safety concerns, potential medication interactions, and so forth. We send clients back to their primary physician when needed, refer clients to other skilled care providers like orthopedists, podiatrists, neurologists, ENT, rheumatologists, pain specialists, prosthetists and orthotists, etc. as well as communicate with their primary doctor with our concerns.

With the client's home monitor systems (blood pressure cuff, pulse oximeter, glucometer) and skilled visual assessment we can determine the appropriate treatment and workload for a client, and when to modify it.  After doing therapy for over 25 years, I can measure a client's ROM with my eyes to almost the same degree accuracy as a goniometer (and even then, there are online goniometry tools).  A simple sit to stand test tells me if there have good hip extensor strength and watching them ambulate tells me what is going on with other hip and knee muscles. If they can't hold certain positions or lift items of various weights in certain ways, I can identify upper extremity and trunk concerns. Having them perform certain tests I can discern whether their balance issue is strength, ROM, somatosensory loss, visual, or vestibular in nature. Listening to the client (and more questions as needed) I can hone done on the primary etiology of their pain, functional concern, or recognize it is out of the scope of this platform. Watching them breathe I can tell if they are dyspneic, using their accessory muscles, splinting, holding their breath. The quality of their movement, or lack thereof, tells me about their tone/spasticity, feedback loop affecting their movement, contractures, clonus, tremors, and more. And so on. I have amassed the tools, both online and in my office, that I need to provide the care I want to offer. I can demonstrate on another full size "human" without violating HIPAA compliance actually better than I could in the clinic. I have all my educational tools right at my fingertips. I can still get a signature on the necessary forms and ensure payment is received. I can send superbills and communicate with other clinicians and maintain HIPAA compliance. I can ever save more trees because I keep an electric copy of whatever I send to the client in a secure cloud file.

I am not saying it is a forum for every client and diagnosis.  If a client needs help for safety, cognition for performance, there needs to be a caregiver present to teach how to spot or help. If there's not, and it's needed, this platform is not the right one for them. If the client needs manual therapy, hands-on assessment or other treatment (and you can't make a home visit), or is too medically fragile to feel comfortable to treat, this platform is not the right one for them. If they are out of your skillset or comfort zone, this platform may still be the right one for them, but it is the clinician's responsibility to decline them or recommend a more appropriate clinician. The client's care is way more important than your ego.

What I am trying to convey is that telephysical therapy (or virtual physical therapy, online physical therapy, whatever you want to call it) is a great platform for much more than people believe. It's also a great avenue to provide the best specialist for that client because location and availability become less of an issue. All clinicians have strengths and weaknesses. I have always been the only clinician with expertise in cardiopulmonary care in some areas since it's a less common subspecialty. I know great pelvic floor and neonatal clinicians, and while I can provide them through my business network, I am not one of them. Many of my clients are too frail or challenged to get out of the house without it being a tremendous effort but have tapped out of all their in-home benefits. I see strokes who have maxed out their insurance coverage but have improved 5 years after their event. Worse, I see way too many clients AFTER the Parkinson's disease, MS, or ALS has affected them to a point of no return. It's very disheartening to come in knowing if had they been educated and treated early in the disease process, some or much of their complications would have been avoided or diminished. I want to see us do more health care, not health repair.

Online physical therapy allows us to record sessions (with client permission) and store them in the client's portal. Having the session at the client's disposal, the client can reflect back on the session as many times as they need or want which improves carryover better than a written HEP for visual learners. Caregivers and loved ones can see what the client is doing in therapy even if they can't attend. Or attend now because they can be in different locations and time zones to participate. It allows us to gamify in a way we can't do in the clinic or home and make the session fun and engaging for all age groups.

Virtual physical therapy gives older clinicians who no longer want to be part of the workforce because of the physical labor, a chance to stay in the profession and provide their valuable clinical expertise honed over years of service. Virtual physical therapy allows us to connect with other clinicians to confer, learn, and teach others who have clients in a remote area without that specialty. Unlike other facilities, I don't even need to recruit. There is no shortage of highly qualified candidates in my sub-industry. I have more clinicians waiting to work for my business all across the US than I can accommodate at this time and could confidently gather many more outside this country as well. Some of the reasons I am told why they are interested in telehealth is they want a new challenge to "think outside the box", or more flexible hours, they are burned out and something new and different, they want to specialize and only see certain client groups. And a big reason is also, they want to do preventative care and wellness too. Wouldn't it be great if we always were excited about our job? The client would only benefit.

While virtual physical therapy sessions can be both live and recorded (store forward), individual or group (video platforms can provide for HIPAA compliance and anonymity to other group members), the clinician should assess what the best delivery (or combination) of treatment(s) should be. The plan of care should still be evidence-based, clinically relevant, and appropriate.  The primary physicians should still be part of the communication loop. We should still be referring and progressing a client to the correct disciplines and platforms when treatment is completed.

We will, and should never, remove the human touch connection. It will never be the right platform for some diagnoses, conditions, or client personalities or emotional needs. But more and more studies are now showing that even those that we thought needed hands-on care are getting better outcomes through online therapy than traditional routes.

I have seen the internet allow socialization, comradery, and comfort to homebound clients or clients with medical issues not prevalent in their locale to join a support group. And I have also found that it has been a great platform for many to receive high quality, accessible health care and provide another option for the client.

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