Objective exam The objective exam can be complicated, because while this portion of the examination is no less important, it is more challenging to perform in the virtual setting. The key point is to give clear and concise instructions to the patient. For example, to evaluate the patient’s feet, they cannot simply point the phone to their feet. The phone or computer must be positioned so most of their body can be seen relative to the feet. This is just one example, but miscommunication or unclear instructions will eat up valuable time and make this portion of the exam even more challenging. For those who use manual therapy and/or utilize modalities liberally, this is the time to start thinking about a different approach to patient care. The objective exam should focus on the following three areas: ● Active range of motion: Have the patient perform repeated movements that focus on the affected area of the body. For example, if the patient presents with low back pain, ask them to perform forward bending movements and ask them to assess their level of discomfort. Next, have them perform that same movement ten times and ask whether the pain Assessment and when is imaging indicated? When seeing patients in the clinic, the therapist usually does not have to determine whether imaging is necessary, because the patient has often come from a doctor who has ordered those images. In the virtual setting this may not be the case. Widely used rules of assessment, such as the Canadian C-spine Rule (CCR), the Ottawa Knee & Ankle Rules, and specific bone tenderness assessments can be used via telehealth to help determine if imaging is warranted. The CCR is used in non-emergency settings to determine whether a patient requires imaging following a traumatic injury. It can be used with patients who are alert and stable following an incident where a cervical spine injury is a potential concern. This typically happens in a direct-access setting where the patient is not fully aware of the extent of their injury, such as neck pain following a minor motor vehicle collision or sports-related injury (Stiell et al., 2001; Stiell et al., 2003). Avoid using the CCR in the following situations: ● Non-trauma cases. ● Patient exhibits unstable vital signs. ● Acute paralysis or known vertebral disease. ● Previous history of cervical spine injury. ● Patient is under 16 years of age. The Ottawa Knee & Ankle Rules determine the need for imaging in patients with acute knee and ankle injuries. For patients with Plan and follow-up after exam With the challenges of establishing a professional rapport over the internet, frequent follow-up is essential. Thus, when visiting with a patient, it is important to plan the next formal session plus 1 or 2 opportunities to check in between sessions to track compliance with home programs. This can be done via email every few days in order to stay in touch with the patient and send reminders about the next session. Technology An effective telehealth session starts with your internet connection. Nothing is more frustrating to the therapist or patient than having to repeat instructions or evaluations because of a poor internet connection. These issues may not be related to the connection but may be caused by other devices on your network that reduce your bandwidth. This can create a lag
level is increasing, decreasing, or remaining steady? Apply this same approach for other movements. ● Flexibility: As the patient performs a stretching exercise, assess their ability to move with and without restriction. For an injured hamstring, ask the patient to lie down and lift the injured leg as far as they can while keeping it straight. Next, ask them to use a strap and see how much farther they can take that movement (while continuing to avoid bending the knee.) ● Use functional movement for strength assessment: Squats, table pushups, planks, etc. Therapists should always treat the individual rather than looking at a list of symptoms and automatically placing a patient into one category or another. Some conditions or symptoms that might indicate the need for in-person follow-up include patients with: ● Recent surgeries. ● Vestibular problems or neurological issues. ● Balance issues. ● Poor coping skills. ● Complex musculoskeletal presentations. knee injuries, meeting ANY of the following criteria indicates the need for a radiograph: ● Age >55 years. ● Isolated patellar tenderness without other bone tenderness. ● Inability to bear weight immediately after injury and in the emergency department (four steps) regardless of limping (Bachmann et al., 2004; Stiell et al., 1997). An ankle X-ray is required only if the patient has pain in the malleolar zone and meets any of the following criteria: 1. Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR 2. Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR 3. An inability to bear weight both immediately and in the emergency department for four steps (Bachmann et al., 2003;Stiell et al., 1994). A foot X-ray series is indicated if the patient has pain in the midfoot zone and meets any of the following criteria: ● Bone tenderness at the base of the fifth metatarsal (for foot injuries). ● Bone tenderness at the navicular bone (for foot injuries). ● An inability to bear weight both immediately and in the emergency department for four steps (Bachmann et al., 2003; Stiell et al., 1994). A monitoring system that allows patients to report compliance can also be used. For example, some telehealth software programs allow the therapist to see if a patient completed their home program. Each exercise is listed and allows the patient to enter the portal and indicate whether or not they completed a specific exercise or set of exercises on a given day. This accomplishes a number of goals: it allows an increase in rapport that may be lost due to the lack of in-person interaction, while tracking progress through a HIPAA-compliant platform. ● Tenderness of the fibular head. ● Inability to flex the knee to 90°.
WHAT THE THERAPIST WILL REQUIRE
and compromise the audio, video, or both on your telehealth session. Reduce bandwidth usage from other sources on the network during sessions. A webcam and microphone are absolute necessities, and they are built in on most laptops and tablets. If you are using a desktop computer, you will likely need an external webcam.
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Book Code: PTNY3622B
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