Episode 2: Telehealth Best Practice for Physical Therapy

Richard: Welcome to the second podcast of Agile&Me a PT Leadership Podcast series. I'm your host, Richard Lever, and today we have guest Dan Hiri, who is a PT based out of California. Welcome, Dan.

Dan: Thank you. I appreciate the time to speak.

Richard: Fantastic. So today we're talking about Telehealth best practice, and I would love to really explore your experience with telehealth. But before we do that. I'd love a little bit of background for the listeners about your training and clinical experience.

Dan: Absolutely. So, I've been an outpatient physical therapist since 2012. Early on in my career I was extremely heavy on manual therapy. I've been full body ERT certified. I was Stanley Parish trained and then over the last few years I've evolved to, to try to emphasize much more functional movement patterns and just more of an exercise based clinical approach, which has translated well into telehealth. And then when I was studying for my OCS three years ago, I just spent much more time on patient education, patient empowerment and things like that. So as my career is involved, I've become much more hands off and much more how can I make the patient really of their treatment as opposed to just saying, hey, come in, lie on the table, let me crank on you for 20 minutes and then get up and leave.

Richard: That's interesting that you say that because obviously I'm a therapist as well and McKenzie and CRX certified and trained as well as Maitland orientated. And, you know, during training and early in my career, I thought the manual therapy skills were really the be all end all of therapy. But as my career progressed, I really realized that a lot of it was actually empowerment of the patient and education. That's not to dismiss manual therapy but certainly the education and the exercise component very often is the dominant component.

Dan: Absolutely. It took me a few years to really figure that out. I was the same thing. I spent as many hands-on times as possible with every patient early on and it's just, I've seen so much better carry over and lasting effect by exactly as you said. The more the patient really feels like they are the ones who are participating in their care I think it's just more beneficial. I think data's proven that if you look at the stats and you look at evidence-based research that the manual therapy isn’t the be all end all be all like we used to think it was.

Richard: So, thanks for introducing yourself and telling us a little bit about your background. Obviously, telehealth is really new to physical therapy world. Obviously, it's been around for several years for other types of healthcare providers, but I'd love to know how you started using telehealth as a medium for physical therapy delivery.

Dan: So, for us, it, it was a necessity. We had a strict shelter in place in March in California, and so we just tried to move as quickly as we could into telehealth. There was that grey area of, hey, can we be open? Can we have patients in office? Can we be in close contact with patients? Can we do all that? Just patients were so hesitant to come in because there was so much uncertainty. So, we had known for a little while just following the numbers that, that we were going to have to modify our treatment strategy. We've been having discussions with our patients leading up to it off, you know, we're not exactly sure what we're going to do. We're going to try some sort of telehealth. We didn't, we didn't know how it would work. It had not been anything we'd ever really done. But truthfully, it only took about a week to start seeing patients and we were able to ramp up to about, 40 to 50 telehealth visits by the second week. It started out as primarily existing patients and just like, hey, you know, this is going to be new for you. This is going to be new for me, but let's give it a shot and see. And, and I was pleasantly surprised that, it worked out well. I've had a lot of patients consistently see two times a week. It's convenient for them from a scheduling and time-frame and with the way the world is now, everyone's so used to doing everything on Zoom or Skype or whatnot. So, it's not this foreign odd thing of, whoa, this is weird. It's, it's just becoming a little bit more of a normal thing for a lot of patients.

Richard: 12 months ago, who would've believed we would be having this conversation. Obviously, telehealth was coming, but certainly the COVID pandemic expedited that, and it's, it's amusing. That the older saying, necessity is the mother of invention. That certainly, certainly was the case here, wasn't it?

Dan: Absolutely. I remember an undergrad having an argument with a computer science professor who had told us that within 10 years, all our jobs could be outsourced or automated or going to be done by ai. I had an argument with him of absolutely not. There’s no way you can replace the hands-on aspect. There's no way you can replace the human interaction and hands on touch of PT. Now, it’s like maybe don’t always have to be hands-on. Maybe we can do this without having to do that. I was very wrong on that. I honestly didn't think it would be nearly as effective as it has been. I've been very pleasantly surprised.  

Richard: Back the very beginning, like most therapists, it was a kind of a mad rush or scramble to be able to adopt a certain amount of telehealth within the practice of physical therapy. How did you think it would go right at the beginning, before you started seeing therapists?

Dan: To be honest, I was uncertain. I've evolved my practice to the point where I've had quite a few patients anyways, where we would never do any manual therapy. We'd come in, we'd chat, and I'd say, Okay, come on. Let's go move. Let's go see what you're doing. And so, I, I thought that I'd be able to have a positive effect on those patients, but I also still understood that for a lot of patients, they're mindset on what physical therapy was, come in and have a massage and then they'd give me a band and, and do some things. So, I wasn't sure for the people who had had those previous experience with physical therapy that was conducted in that manner, how they would feel about the telehealth. I was pleasantly surprised by how effective it was, how much positive feedback we got from patients. Our review scores were fantastic on it and found out like, hey, you know, patients really can do well with this. And, and it let us really focus on patient function within their home. Some of those things that we couldn't focus on when they come into the clinic. Like I said, I was a little hesitant of, of how is this going to work. But I've had such a positive experience with it, I really do believe it can be effective and I think it's going to continue to be a big part of what we do.

Richard: Yeah. I think the genie's out to the bottle.

We'll continue the conversation after a short advertisement.

Richard: Welcome back to Agile and Me a Physical Therapy Leadership podcast. Pivoting a little bit, would you be able to give a kind of, give us an idea of the patient caseload that's delivered using virtual care.

Dan: So, at this point for me, about a third of my visits are virtual. For the first three months after the shelter in place, I was a hundred percent virtual. Once I made my way back into clinic, I started seeing, more in clinic patients, less virtual, but it still stayed, at least at the bare minimum, kind of 25%, no, I'd say about a third. With the recent uptake in numbers, it's going up a little bit. Some of the patients I had been seeing in clinic, just don't feel comfortable coming in. I'm seeing a lot of those people. The type of patient that tends to be most effective? Honestly, it's varied. I've done a lot of very successful post-ops throughout the entirety of their post-op process. I've gotten a lot of the, the typical, you know, low back pain of, hey, I've been working from home and sitting all the time. So, I'm seeing a very broad caseload. But overall, I'd say a, about a third of my overall patient bases is telehealth right now.

Richard: I assume a proportion of that volume obviously related to patients uncomfortable, as you say, regarding COVID and, and attending bricks and mortar therapy. But I would assume that a proportion of the patients also actually prefer it as a medium.

Dan: Correct. And mainly from a kind of logistical standpoint, I've seen it be very effective. So anywhere I work we'll have patients who will commute 45 minutes to an hour to come to the clinic. And for them, it's hard twice a week to set aside two and a half hours, three hours to, to go through that whole process. But it's a lot easier to maybe once a week or once every two weeks come into the clinic and then to do those other visits via telehealth where they just set aside a, a 30-minute block in their schedule and set it up just like they would a work zoom meeting. And so, for those patients, it's, it's been really, effective.

Richard: I’d like to move on and really understand what components consist of a virtual or telehealth physical therapy visit, Because obviously we can't do the manual therapy. So, I think the listeners would be really interested in what goes into a session. Because I'm sure a lot of people are afraid of, well, you know, if I can't do manual therapy, what can I do? So, I'd love to, to know and understand exactly how you structure a session.

Dan: Absolutely. So, evaluations were a little bit challenging initially. Just taking aside the manual therapy component. So much of we do is strength testing, special tests, different things like that, where it does require us to, to be in proximity or to be in contact with the patient. And so, from an evaluation standpoint, it's just much more dependent upon the subjective, which honestly, like I was, like we were talking about earlier. I mean, patients usually give us the information we need if we ask the right questions, and we go about it the right way. And, and so the subjective becomes much more important. Figuring out the, the patient's goals and their functional goals and especially, you know, functional goals within the home and things like that. But trying to just gain as much information as possible during the subjective. I'll also spend more time there just chatting with them. Like I've talked about before. manual therapy is a lot of times, if nothing else, how we gain our report with a patient. It's how we gain their trust. We perform some sort of release or some sort of mobilization, they feel better when they trust us. And because you don't have that, you know, you sort of develop that more with the education and things like that. So, I always go into a much lengthier subjective, especially on the evaluation. I really make sure that we both understand what's going on. I spend a lot of time educating them as to what tissue's affected or things like that, just so they really understand like, “hey, this person does understand what they're saying and okay, there's a lot I can do about that”. So much more of, of a subjective component to it, especially with the eval. From a day-to-day treatment standpoint, honestly, it's not that different than a lot of my treatments I do in clinic. You check in, How’s everything going? How have the exercises been? What are you doing? How's the mobility? What are the issues? Okay, perfect. Let's start, Let's look at a couple of the extras you've been doing. Let's make sure they look good. Okay. You know, do we regress them? Do we progress them? And, and you try to treat it a as closely as you could. And try to replicate just an in-clinic session would be. Again, the nice thing about being at home is when I hear stuff like, yeah, I just, I was sitting on my couch for a couple hours and then when I try to stand up, my knee was just killing me. Okay, well perfect. Show me the couch. Let's go sit down. Let's go see how did you get up? What position were you in? And so we just try to replicate those things so there's as much functional carryover as you can. And so, the way I look at it is I try to take advantage of the fact that they're in their home as opposed to looking at it as a detriment

Richard: Yeah, it's interesting point because obviously when we bring patients into the clinic, it's really an alien environment. The problem is that the patients are experiencing a function related to the home or work environment, or certainly outside the clinic. So, I would imagine that perhaps you even get a better understanding of the functional limitations, and you use the performance of functional activities to give you an idea perhaps of range of motion limitations, strength issues, et cetera.

Dan: Absolutely. And then even with things now, I've been dragged around so many different patients' houses where they'll pick up their tablet and be like, “Okay, here, now let me come show you this. Okay. This is the desk that I sit at. Like, what do you think?” Those things that we just normally don't really get the opportunity to look at when, when they come into clinic and, like you say, when they're in a foreign environment. So, it's, it's nice to see those.

Richard: Obviously there are limitations and difficulties. Could you perhaps expand on that?

Dan: Absolutely. Obviously, there's the technical aspect of it, and the fact of the matter is not everybody is as tech savvy as everybody else. So, for some, sometimes the frustration on the patient's end especially early on while they're trying to figure out how to do it, how do. The camera at this. Can you see me? You know, it has been frustrating at times. Now, at this point, I'm so used to it. It's not a big deal anymore. But early on there was some frustration there feeling like, hey, I spent 20% of the visit just trying to tell them how to point a camera at something. Or they kept disconnecting and I have to have them reconnect, things like that. Again, I'm pretty used to that now but that is at some point an issue, I think. Especially if you're just getting into it for the first time. For me personally, I think the hardest part is the inability to really give a patient tactile cues for those patients that just don't know how their body moves or just have such a hard time figuring out just positional things. So, part of what I've done, the longer I've done this, I've just really simplified a lot of my interventions. It's you're not going to teach an SFMA rolling pattern and you're not going to teach, you know, a DNS plank to a patient via telehealth. There's just too many things going on where you can't, if you can't queue them with your hands, it's going to be hard. And so, for me, it's frustrating sometimes when you see those patients and you're like “Okay, just, you know, pull your shoulder blades back”. And they just shrug straight up in the air. You're like, “No. Not up. Back.” And they just do the same thing again. It's like you just feel like you want to reach through the, the, the camera, through the computer screen and just kind of show them what you mean by a retracting shoulder blade. And so, for me, I think that's the hardest thing is sometimes when what we think of as those simple movements that you could just show somebody or just do a tactile cue in, you know, three seconds, takes three, four minutes. I think that's probably the hardest. But if anything, from a positive standpoint, it just makes you kind of learn how to simplify and learn how to use verbal cues a little better.

Richard: One argument that is often presented particularly with any type of technology solution, the adoption of using a patient app and many clinicians. clinic employees would say, well, you know, so such and such is over a certain age, they, they won't use it. And in fact, the evidence that I saw was counter to that the uptake in group different age groups was similar. What have you found as it pertains to telehealth in the patient population? Have you found that certain age groups or demographics tend to gravitate towards it or is it really a diverse patient population.

Dan: It's really a diverse patient population. Initially, I think I'm in the Bay Area. I work with a lot of tech workers and things like that, and so for them, they have been working from home for a long time already. They've all been doing virtual appointments, virtual meetings and things like that. So, for them, obviously it was a very easy, quick, smooth transition there. Whereas other people just had never heard of Zoom, had never heard of Skype. At this point, I think the world we're in, everybody is using some sort of virtual communication method. And so at this point now I've had success across all different age groups, demographics, because I think it, it's just part of the world now that people accept, and that people expect to utilize. Now, it's very different than it was in March, but now I see no issues from an age demographic or anything like that.

Richard: The patients obviously that you have transitioned either transitioned to telehealth or have themselves sought out telehealth platform for physical therapy; have they been either reluctant users or have they been skeptical of this medium themselves?

Dan: Not over the last four or five months. Initially I think there was more just because to the PT community had not gotten into it nearly as much now. No, honestly, most people just sort of accept this is how things are and, and it's like we were talking about before, age and demographics. My last patient before, you know, I got on to do this. He's a 25 year old ACL reconstruction works for Google, and he was just like, hey, can I just do this from home? Like, it's way easier for me if I can do these. And so, it's, it's convenient aspect for them. You know, I was doing jumping single egg squat-based stuff, things like that. And, and so, no, I mean, I think a lot of people are just used to it and embracing it and appreciate the fact they don't have to drive anywhere. They don't have to leave their house and they can just do it from home.

Richard: Correct me if I'm wrong, but what you're saying really, it's not really the patients that are possibly the barrier to providing telehealth. It's the perception and of therapists that this isn't an effective medium, or they're uncomfortable with using this medium and, and placing that idea and transposing that onto the patient.

Dan: To me, it’s a patient education and clinician education issue. I think a lot of patients don't think of physical therapy all that dissimilar than maybe when they've gone to a chiropractor or a massage therapist in the past. They think it'd be absolutely useless without that because they haven't had the education of the profession that, Hey, guess what? There's benefit from the profession where it's, you know, us teaching you and us showing you how to do things. I think as, as patient perception hopefully continues to evolve as our practice evolves I think that's going to go a long way towards that. And then I think it's also on therapists to, to really educate their patients and let them know there's a lot out there that we can do without having to be in the same room. I know in our clinic we've got, I think, 14 total therapists across three locations, and there's a few therapists who, when we brought up the subject of telehealth, there's like, what are you talking about? How could I do that? I can't do that. What do you mean? And, and so I think it's not just patient education, I think it's therapist education. Like, hey, well we'll look at these other things. I hear you talking to your patients. You can talk to them over telehealth the same way that you talk to them in here. I see you showing patients how to do a squat versus a hinge. You can absolutely do that on telehealth. And so, I think change is always hard for people. I think the more people are educated to just how useful it can be just how beneficial it can be, I think as more and more therapists and more and more patients understand, I think that will really be what grows it.

Richard: We will continue the conversation after a short advertisement.

Richard: Welcome back to Agile and Me a Physical Therapy Leadership podcast. When we think of the future, obviously from a technology perspective we have a robust platform for providing virtual care. What do you think will happen as it pertains to consumer demand and insurers attitude towards telehealth and physical therapy?

Dan: So, from an insurance standpoint, I think that's on us to prove efficacy and so I know there's a lot going in there now of basically trying to show via functional outcome skills via pain scales and things like that, that we're still getting good outcomes. I think in the end, the insurance companies will absolutely embrace it because, you know, if there is a lower cost of care to them and, we can figure out how to make this financially viable for everybody, I absolutely think they'll embrace it. And from a PT standpoint, like I said, I think it just comes down to, to therapists really learning to embrace it as well and just understanding the efficacy of it and understanding that if we don't phrase this as you are getting a half as good of a treatment because we can't touch you. But to say this can be the optimal treatment for you. And like I tell a lot of my patients like, hey, for what you have going on anyways, even if you're coming in the clinics, I probably wouldn't put my hands on you at all. And so the more we can convey that, I think that will continue to grow.

Richard: Yes. I think also consumers will become more and more comfortable and understand that there is a significant component of physical therapy that can be done remotely. And for a certain percentage of patients, it can be done wholly using virtual care. Relatively few patients are seen using virtual care or telehealth currently. Overall, when take into account total visit volume nationally for physical therapy, obviously with new clinicians are apprehensive what advice would you give to clinicians who are about to consider using telehealth as a medium for PT delivery that traditionally we haven't done in the past?

Dan: So, for me it's, it's a cliche, but just don't make the visit about what you can't do but focus on what you can do. And so, to me, it's all in that first visit. How much can you show your value to the patient? And so, the more that they look at it as, oh wow, that was helpful, if you know, hey, that may have even been better than when I go into the clinic. And so, the more to me that you emphasize functional in-home treat. Things that are applicable to them. Things that you know, hey, oh, what kind of exercise equipment do you have? Okay, you've got that over there. Perfect. Well, let's design a program around what you have in your house and things like that. And then I think for me, like I said, it's, it's something that I've been working on for a long time and it's something I'm still working it on. But just try to keep things simple. We all have a million exercises and a million interventions floating around in our heads. One of the things that doing telehealth has forced me to do is to really simplify. You can't show four complex new exercises when you can't have tactile cues. But to be honest, most patients don't want to be taught four complex new exercises. And, and so the more that you just say, hey, you know what, let's really get this one thing right. You're not going to teach someone how to do a Turkish get up you know, or a snatch on on telehealth. But if you just say, hey, you know what, let's just really work on your hinge today and let's just really get this down. Then patients feel like, hey, I accomplished something, not so much I'm overwhelmed because this person showed me all these different things and I need kettle bells and I need a body blade and I need a bosun and everything like that. I think if we just really try to look at. Let's keep it simple. Let's try to focus on just one or two effective things that you can do in your home. And the patient feels, hey, I got something out of this treatment. They'll keep coming back. And, and my telehealth retention's been good. It's not like patients do one visit, say, oh, this is awful, and then, and then quit. It's, it's all about as long as we can express value and show that to them. I think that, that anybody can be successful with this because every therapist educates. Every therapist is doing these things. It's just making them the focus instead of the background noise while you're doing manual therapy.

Richard: I suppose from a satisfaction perspective, we are really delivering care much more on the patient's terms. I'm sure there there's significant reduction in anxiety from the patient perspective because they're in their own environment rather than an alien environment. So, I would imagine the ability to get patients to perform movements, exercises, and engage might even be stronger than perhaps when you're in clinic.

Dan: I've seen that. I've been very pleasantly surprised by how compliant people have been with their home programs. And I do think a part of it is, you know, they don't feel like they got taught these complex things where they need a gym to do it, but they got taught stuff where if you make them do sit-to-stands in their favorite chair there's a better chance that when they sit down there, they will think a little bit about, oh, how did I sit down? They’ll do some more sit-to-stands in their chair

Richard: So, would you say that a lot of the exercise you give are actually functional than perhaps you would give in clinic?

Dan: Yes, I’ve tried. Definitely more functional than I would've, you know, a few years ago. I've tried as much as I can to make everything I do in clinic very functional. But yes, it's much more applicable to the patient because instead of just saying, Okay, well, you know, you can't put this into an overhead cabinet. Well, let's. Let's try to use a medicine ball in a clinic to a location.

It's let's go over to your cabinet. Let's actually take a bowl and let's look at what your thoracic spine's doing as you do this. Let's look at what, you know, your, your shoulder range of motion is as you do this. So, it’s definitely more functional and definitely more applicable to them.

Richard:  Well thank you Dan.  Is there any final words of wisdom or thoughts you have for our listeners before we end the podcast today?

Dan: If anything I’ve learned, be flexible and be patient. We had some visits early on that were ruined by tech issues or patient frustration. Now when it happens, I just laugh it off with the patient. I’ve been doing this for 9 months now I’ve seen this 20 times. No worries. Let’s just get into the treatment. I think if you get too caught up on thinking that every visit has to be perfect and  if something goes wrong “oh no, what’s it going to do”. There’s always things that come up like that. As long as you’re positive. As long as during the visit I think how can I be valuable to the patient. And so I think as long as the patient experience is good, they have a good conversation with you, you’re positive and they feel like they gained some things from there, they won’t look at it as “oh I couldn’t get hands-on work” or “oh, I couldn’t lift a kettlebell the same way I could in the clinic.” They’ll just look at it as a good experience and want to do it again. For me, every single patient not matter what, even if they are more education based, I make every patient move. Period. Just because we know people feel better when they move. Even in patients that just want to sit there and chat, it could be as simple as let’s just stand up and do some balance or slow marches. As long as patients move every visit they get that same kind of benefit and endorphin response that they would get in clinic and that same positive feeling coming out of the visit.

Richard: Well, thank you Dan. I've really appreciated the time today. You have great insight into telehealth or virtual physical therapy and hopefully there's lots of lessons learned by our guests today. So, thank you.

Dan: Yes, thank you so much

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