In the past, the focus on pain centered on tissue damage. For example, if a person has pain, it is likely caused by something like a herniated disc. But pain can exist without an obvious injury, just as injuries may be present but not causing pain at a given time. A herniated disc does not automatically mean debilitating back pain, as many athletes are able to continue their activities despite this condition. At the same time, a person experiencing back pain may do so without an obvious physiological explanation. Pain science education attempts to explain why each person experiences pain in the way they do, despite similar injuries or diagnoses. What patients can be seen in telehealth? Telehealth requires a separate set of therapist skills than in- person evaluation. But can those skills be applied to everyone? Any patient can be evaluated via telehealth but not every patient is an acceptable candidate for being treated via telehealth. The Performing a remote telehealth evaluation Before the exam: About a week before the initial telehealth appointment, the therapist should send an email to the patient explaining some of the basics of what to expect for the first visit. At a minimum, this should include: ● An explanation of necessary equipment. The patient will need to have a phone or camera available and be able to place it so the therapist can see the patient clearly throughout the session.
What does this have to do with telehealth? Once again, in a one-on-one setting that relies so heavily on communication, therapists can relay this information to the patient without interruption or distraction – a situation that may be impossible to recreate inside the clinic. Telehealth provides a unique opportunity to build not only professional but interpersonal trust between therapist and patient, as the therapist can take an enhanced interest in the patient’s personal wellbeing without the numerous distractions that inevitably occur in the clinic. There is more time to explore each issue.
evaluation itself is critical for determining whether a patient is a candidate for ongoing telehealth sessions or whether an individual will require an in-person follow-up.
● An expectation for the session. Explain that you will be asking numerous questions to better understand the symptoms the patient is experiencing and other relevant points. ● An explanation and preparation for a movement evaluation as appropriate for the specific condition. ● Confirmation that the patient has access to the portal you plan to use for the session.
THE EXAM: REVIEWING SUBJECTIVE HISTORY
One of the most difficult, but important, things to understand about telehealth is that the emphasis switches from objective to subjective. In the clinic the emphasis may focus more on the objective portion of the evaluation because the setting allows the therapist to provide a hands-on evaluation. While an objective evaluation can be limited in the telehealth setting, the subjective evaluation can help to fill in the gaps created in the absence of what may be found using a hands-on approach. A thorough evaluation should ask both qualitative and quantitative questions regarding not only patient physical challenges with pain, strength, and movement, but also external challenges that may hinder positive outcomes. Equally important is allowing adequate time for patient response and thorough understanding of the patient’s complaint(s) and goal(s). Questions should be tailored to identify potential issues or problems, whether inside or outside the scope of the problem being treated. These issues can be broken down into the following categories: ● Red flags: As the name would suggest, these are issues that indicate a need for direct follow-up with other providers or outside entities. The knowledge that certain conditions may point to more serious medical issues can lead the therapist to recommend immediate follow-up with an appropriate professional before continuing with any treatment protocol. This can best be summarized as, “You don’t need to see me, you need to see your physician or go to the hospital.” In summary, the goal is to rule out any condition that is outside the scope of therapy practice. ● Yellow flags: These are patients with extreme pain ratings that may not seem to align with their diagnosis. These patients tend to require a greater amount of rest and can present issues with compliance and sticking to a therapy plan. They may report a high intake of medication as well. These patients may require more frequent, in-depth follow- up. Often, the prognosis for these patients is less than ideal. Yellow flags help to determine which patients should do well in treatment, and those who may struggle to show improvement. ● Orange flags: These are mental health and emotional conditions that may play a role or interfere with a therapy plan. Orange flags typically fall outside the scope of practice for physical and occupational therapy, and therapists should not attempt to treat depression or similar issues. However,
understanding these flags can help to identify mental health concerns and aid in the recommendation for further screening or seeking help for those issues before proceeding with a therapy plan. ● Blue flags: These pertain to work-related conditions that are at least somewhat under the control of the patient. Blue flags typically focus on the outlook within the patient’s occupation, job satisfaction, their perception of their employer, stress, and other factors. ● Black flags: These also focus on issues related to employment, but these are matters where the employee has less control. Financial issues and worker’s compensation claims fall within this category. Additionally, black flags are used to evaluate the individual’s home life and support system. Is the family supportive? Does the patient have a spouse, significant other, or parent that influences the individual negatively regarding their place of employment or chosen career? The company may have policies restricting the employee’s access to services they require. The employee may feel social isolation or disconnection from the workplace (an issue we can expect to see increase in current times, with strict stay-at-home mandates in most US states during the COVID-19 pandemic). (Kendall et al., 1997; Leerar et al., 2007; Nicholas et al., 2011; Shaw et al., 2008) Having a thorough understanding of these flags can be especially beneficial for performing telehealth evaluations. Without the type of interaction experienced during in- person visits, the therapist must rely on communication and conversation to resolve issues that may otherwise never surface. Each of the “five flags” represents a potential hurdle to the desired results of therapy. Having these conversations on the front end can save time and money while increasing session productivity, patient satisfaction, and treatment outcomes. Establishing the therapist/patient rapport is an important goal of the subjective evaluation. It starts with asking the right questions in a process called “motivational interviewing” – asking open- ended questions and really listening to the patient’s responses. Motivational interviewing also involves setting therapy goals and objectives that can be successfully achieved. What does the patient hope and expect to gain from this experience (Alperstein & Sharpe, 2016; Chilton et al., 2012; Rochfort et al., 2018)?
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Book Code: PTNY3622B
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