by Jiten B. Bhatt, Francisco De La Cruz, Ernie Linares, and Nicole Lovett
Jiten B. Bhatt
The onset of a worldwide pandemic has affected the lives of millions of people. Regarding healthcare, countries' systems have been pushed to the brink of collapse as various providers have worked feverishly on the front lines to save the lives of patients stricken with COVID 19. Being a healthcare provider, lots of changes have occurred in medicine; from the utilization of protective equipment, social distancing, and the incorporation of telehealth. In this blog, our faculty will share observations as to how our knowledge of functional movement exam skills has been of benefit during our telehealth sessions.
In April, Medicare passed emergency measures allowing for the use of telehealth for physical and occupational therapists. Finding myself in a new space, I began the process of navigating a patient exam through telephone or video visits. How did this look for me? The subjective exam was very similar to what I encounter in person. The main difference was what wasn't perceived in a regular face to face session - body language and movement. Here, I felt I lacked being able to see certain mannerisms of how a patient would walk in, sit, or communicate. These non-verbal cues are valuable in gaining clues as to how the patient uses their body, but overall, a check and pass for the telehealth area.
Concerning the objective exam, this is where my functional movement skills were invaluable. In assessing a shoulder pain patient, I realized I was going to be bypassing some of the critical elements of an exam I usually engage in - end feel, assessing muscle length, and looking at joint mobility. However, in working with my patient, I had enough subjective information to develop a primary hypothesis of subacromial pain syndrome. I had the patient perform some directed quick tests and was able to rule out a possible tear. The patient then performed a ROM exam, and I noted no signs of adhesive capsulitis. As a result, I was able to determine the source of her pain as possibly being subacromial, and the cause being restricted posterior structures length in the cuff or capsule (through assessment of having scapula fixed at a wall, and having the patient move into horizontal adduction). With a clinical picture coming into better view, I was able to focus on providing some treatment options.
How about other cases? They all couldn't have gone smoothly. For this, I will agree. I had a patient who had severe chronic back pain and didn't respond as well to the care I provided. To this end, I asked the patient to come in for a closer look via an in-person visit. Another client with back pain improved rapidly with just 1-2 video visits using my movement skills to determine that he had an extension rotation syndrome. After education on bracing and improving quad and TFL length, the patient's low back symptoms reduced considerably. Overall, the utilization of my movement skills have been incredibly useful during the pandemic and will hopefully improve with more cases and adaptations without the use of my hands.
Francisco Dela Cruz
The sudden health crisis our country has experienced in the past few months has dramatically changed the way we practice as PTs. The tools that we had before to evaluate and treat patients in the clinic, such as manual therapy, modalities, tools for kinematics/kinetics analysis, has been sidelined for now. Now, we are using our visual observation of static and dynamic posture/functional activities, clinical reasoning/clinical patterns to connect the dots for our patients to provide the best possible treatment.
My experiences with telehealth have mostly been positive. My practice in outpatient orthopedics before the COVID pandemic primarily revolved around looking at movement patterns, static/dynamic postures, functional activities, assessing muscle length/strength, and muscle/joint palpation. Treatments were based on inhibition/facilitation of specific muscles and exercises to improve muscle recruitment and movement patterns/functional activities.
Fast-forward to the new norm for our healthcare as providers, "Telehealth". As I reflect on the changes I had to make in the way I practice, I realized it wasn't as drastic as I thought. I still look at movement patterns, static/dynamic postures, functional activities, and assessing muscle length/strength. The main change now is no more muscle/joint assessment via palpation.
I now evaluate muscle length/strength through functional activity. For example, I use sitting knee extension to assess ankle DF ROM, hamstring length, and L/S directional susceptibility to motion. I will ask the patient to perform a squat to assess ankle DF ROM, knee/hip flexion AROM, quadriceps strength, foot/knee/hip movement pattern, etc. Correcting movement patterns might require asking patients to look at a mirror for feedback or using their own hands to touch a muscle to facilitate it. I think, when combined with sound clinical reasoning, I can still provide the best option for treatment, whether it's exercise or management strategies to allow for optimal tissue healing.
Now, of course, there are challenges that I have also faced. The two main obstacles are technology and giving instructions. The clarity of the video visit is essential to optimize the analysis of visual information from the patient's movement. The instructions have to be concise, and you might have to keep switching between internal vs external cueing to get the right movement pattern and muscle recruitment. Overall, using the different movement science concepts of looking at movement patterns, static/dynamic postures, assessing muscle length/strength, facilitation of muscles has made a challenging transition to telehealth not as daunting.
Having a background in movement science has most definitely prepared me for the challenge of performing telemedicine. I feel confident in what I can observe and functionally test; will give me the information necessary to create the best intervention or movement strategy for my patients. On reflection, the most important skill/tool that has helped me is knowing what "normal" movement looks like. The great part about that knowing normal is that I can then ask myself "So do you like what you see?" and then ask the patient "Can you fix it?" or "make it not hurt?" and observe what they do. For myself, this observation gives lots of information about the patients' body awareness which is paramount when one is trying to incorporate interventional movement strategies in a virtual environment. It helps me understand which verbal and visual cues my patient may need; in the absence of tactile cues. It has been a challenge to cover all facets of the patient encounter but at the same time a good form of stimulation to think differently and utilize our movement analysis skills to help link the movement to the possible impairment. I see it as a great opportunity to practice a most valuable skill. Keep practicing!
At Kaiser Permanente, telehealth has become more popular in recent years. Our organization has used video visits through this pandemic as an option for a patient to receive evaluation and treatment for musculoskeletal pain. So far, I have found video visits to be quite useful. With my movement specialist background, I have to rely on my observation and movement analysis skills versus my hands-on skills. The new environment has challenged me to work on my external cueing. Overall, I have had a good experience and will continue to offer video visits to my patients as another option.
Jiten (“Jay”), Francisco, Ernest (“Ernie”), and Nicole, are Movement Links Instructors and hold various clinical specialist and senior roles in the department of physical therapy at Kaiser Permanente Medical Center in Southern California. They each will lead upcoming course series as we transition out of the tight restrictions of COVID-19. Follow along with us!