COVID Lessons Have Broadened Opportunity for Virtual Physical Therapy-The HSB Blog 4/4/22






Our Take:

While the Pandemic forced the adoption of virtual physical therapy and the waiver of certain restrictions, the lessons learned from that experience have created an opportunity to broaden the use of these offerings to improve the quality and efficiency of care for patients. The management and availability of consultations for physical therapies as well as sports-related injuries through telehealth platforms during COVID-19 have aided in discovering quick, effective, accurate, and quality diagnoses and delivery of care. As we begin to move to an endemic phase of the Pandemic, the use of certain technologies deployed during COVID such as telemedicine robots that feature a virtual neurologist could be broadened to not only help to assess athletes’ injuries on-site but extend care to underserved areas.

Key Takeaways:

  • A number of research studies have demonstrated that “the accuracy of telehealth tools to determine pain, swelling, range of motion, strength, balance, and gait has been found to be valid, reliable, and feasible.”

  • As noted in one study, in more than 20K public and private secondary schools in the U.S. 34% of schools had no access to athletic training services or physical therapists, and almost ½ had part-time coverage only.

  • While prior to COVID, telehealth for physical therapy (or telePT/virtual PT) had been widely used in many foreign countries, “utilization and reimbursement in the United States remained mostly limited to different government agencies such as the U.S. Army and Indian Health Service.

  • In northern Canada, approximately 80% of pediatric patients are evaluated through telehealth services.

The Problem:

During COVID the use of physical therapy was difficult due to the social distancing measures enacted during the pandemic and the associated limited access to physical care facilities. As noted in “The Role of Virtual Physical Therapy in a Post-Pandemic World: Pearls, Pitfalls, Challenges, and Adaptations”, while telehealth for physical therapy (or virtual /telePT) had been widely used in many foreign countries, “utilization and reimbursement in the United States remained mostly limited to different government agencies such as the U.S. Army and Indian Health Service.” However, as result, many institutions rapidly shifted in order to determine how to deliver physical therapy via telehealth platforms to reduce the risk of infection through physical contact. In order to facilitate this, in April of 2020, the Centers for Medicare and Medicaid Services (CMS) waived certain regulations thereby allowing providers of physical therapy services via telehealth to offer and collect a bill for the telehealth services that had been provided. In addition, many states eased or waived certain state licensure requirements making the provision of physical therapy services across state lines easier. Nevertheless, even with these changes being implemented there were concerns that patients would forego the necessary follow-up care or implement exercises improperly leading to complications or sub-standard efficacy of procedures. As a result to make sure similar, high-quality care was delivered via telehealth as in the study noted above it was important to ensure “prior to performing telehealth physical therapy visits, clinicians were required to complete all training material to ensure comfortability and confidence.”

The Backdrop:

As noted earlier, prior to COVID the use of telePT was fairly limited and there were concerns about the accuracy of certain measurements given that prior to COVID these were often done in a physician's or physical therapist's office. For example prior to the assignment of exercises or a program clinicians would have patients go through a series of exercises to determine their range of motion, strength, balance, etc. In addition, as noted in “The Role of Virtual Physical Therapy in a Post-Pandemic World”, “The main challenge associated with telehealth physical therapy for the clinician is the inability to use one’s hands or provide tactile cues during the evaluation and treatment.” Depending on the level of technological sophistication of the client or their ability to access broadband technology there may be technological hurdles on the part of patients as well.

While “telehealth physical therapy requires a different set of skills that involve no physical contact and highlight therapists’ use of strong “subjective” questioning, a sound understanding of kinematics and movement patterns, and a systematic process to problem-solve” over time a number of training programs have been developed to aid in the successful application of telePT. In addition, a number of research studies have demonstrated that “the accuracy of telehealth tools to determine pain, swelling, range of motion, strength, balance, and gait has been found to be valid, reliable, and feasible. Also, prior studies have shown there is a high agreement between in-person measurements and virtual evaluation of a range of motion measurements and assessment of function for the shoulder, elbow, hip, and knee.” Nevertheless, the issues of technological competency and access remain. For certain age groups or those who may not be as adept at technology, providers need to ensure adequate user training is put in place to ensure the success of telePT encounters. Clinicians will need to realize that due to technological limitations there may be clients where delivery of telePT is not possible. For example, as Wired Magazine pointed out in “Access to Telemedicine is Hardest for Those Who Need it Most” studies indicate that as much as 41% of Medicare recipients don’t have an internet-capable computer or smartphone at home, with elderly Black and Latinx people the least likely to have access compared to whites. Approximately 13M elderly adults have trouble accessing telemedicine services, and approximately ½ of those people may not be capable of having a telephone call with a physician due to problems with hearing, communications, dementia, or eyesight.

Implications:

While certain technological and access limitations continue to exist and should be addressed as rapidly as possible, telePT services have proven to be effective and high quality and should be expanded. For example, according to “The Role of Virtual Physical Therapy in a Post-Pandemic World” provision of telePT provided patients with “quicker access to care, similar patient satisfaction, and increased geographical outreach compared to in-person care.” The study noted that patients were able to get quicker access to telePT with the ability to get an appointment in approximately 3 days vs. approximately 7 days for in-person care. Assuming workarounds or fixes are found to overcome the technical hurdles noted above, this could be a strong option for individuals looking to age in place or in senior care centers where seniors may have limited mobility or who may no longer be living with family or are unable to successfully complete exercises without direction. Not only would this provide appropriate rehabilitation or maintenance of muscle tone, but it would also help with aspects of social isolation. Moreover, expansion of telePT services could help speed recovery and reduce reinjury for communities where the time and lack of transportation make these services more “expensive”. For example, several studies have found that travel and wait times for appointments can eat up anywhere from ½ an hour to 2 hours, making them prohibitively expensive for those on hourly salaries. By contrast, with telePT travel and wait, time would be eliminated improving the quality of care, reducing potential reinjury and the need for expensive follow-up or corrective treatment. Not only does such care reduce the chance of reinjury, studies indicate that such rehabilitative therapy has persistent and lasting effects. For example, according to “Overview of Telehealth and Its Application to Cardiopulmonary Physical Therapy”, results were encouraging based on improvements in function following 30 one-hour VE [virtual-environment based] treatment sessions [and] most improvements persisted well after physical therapy services were discontinued.”

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