https://shoulderphysio.co.nz/auckland-shoulder-clinic-telehealth/Telehealth Reflections from Pradnya Gadkari
I write this blog post from my personal experience of treating patients with shoulder problem via Telehealth in the last one year, and this is really a reflection of my experience. We are now over 7 weeks of lockdown here in Auckland and the uncertainty of when life would return to normalcy has been challenging on a personal level. Sudden unexpected changes can shake our belief that we are in control of our life, and I think COVID-19 pandemic has certainly confirmed that notion for me.
In 2020, when New Zealand first went into level 4 lockdown physiotherapists were not allowed to work face-to-face with our clients. This really shook our profession because like many other allied health professionals, we had never encountered this situation before. I was secretly hoping that in few weeks like other countries, physiotherapists would be considered as frontline workers and allowed to work in clinic, taking appropriate health and safety measures when treating our clients. But as the weeks went by, I had to accept that would not be the case.
Some time later, physiotherapists were informed by the Physiotherapy Board that treatment could be delivered via Telehealth, and I was cautiously optimistic about it. I had heard and read about the emergence of Telehealth in healthcare sector in last few years, but had some trepidation about delivering physiotherapy treatment in Musculoskeletal Practice via Telehealth. My main reason for this being was my belief that I needed to ‘look’, ‘touch’ and ‘move’ my clients to get a clear understanding of their shoulder problem, and only then I could plan an appropriate treatment for them. I questioned how effective the treatment would be if I couldn’t see my clients in person because in my previous clinical practice, I occasionally use manual therapy techniques to mobilise a stiff joint, or soft tissue release to ease muscular tension, in conjunction with exercise prescription to facilitate recovery of my patients. I also was not confident of my clinical expertise in assessing a patient via videoconferencing!
It was a dilemma for me, either I wait and watch until the lockdown levels changed, or I could adopt Telehealth and adapt to implement it effectively.
Is physiotherapy consultation via Telehealth secure?
Our team at Auckland Shoulder Clinic adopted Telehealth quickly last year and have been seeing many clients through the multiple lockdowns that Auckland has been through in the last year. I was pleasantly surprised to see how easy it was to do a video conference call with any device. All one needed was a good internet connection. The IT platform e.g., zoom, and the practice management software that we use included secure messaging, so storage and transmission of data was encrypted. This allayed our fear of conveying sensitive health data via internet, and negated the need to invest high-grade technology for use of Telehealth. If the patients were computer literate or had a smart phone setting up Telehealth, then the consultation is very easy!
Is physiotherapist’s clinical experience and skill set important in Telehealth consult?
Initially, I found Telehealth consults challenging to establish rapport with a patient. But listening carefully to my patients as I interviewed them during the subjective assessment, the communication flow was easier. Research in Telehealth in musculoskeletal physiotherapy reported that one of the barriers for clinicians in adopting this mode of treatment was feeling the “shift in power” from their hands to the patients. The clinicians had to rely more on the information provided by the patients which could be otherwise obtained through ‘hands-on’ examination in the clinic. I think though this holds true to an extent. But expertise in good subjective assessment allows physiotherapists to do the following:
- screen for serious medical conditions,
- recognise certain patterns which guide in making a diagnosis for our patient
- plan what objective assessment should be performed to confirm the diagnosis.
This stepwise method of assessment is not different than how I would work when seeing patients in the clinic.
For most patients, I have been able to assess their shoulder mobility through observation. I had to adapt when assessing their strength by asking patients to apply self-resistance with their healthy side or push against the wall. The use of TheraBand or getting patients to self-test in various positions, to check whether it provokes and reduces their symptoms. Modifying this level of resistance virtually has also been useful in treatment planning. Occasionally with the patient’s permission, a family member has performed the clinical tests with my instructions.
Overall, Telehealth has enabled me to do the following:
- thoroughly assess a shoulder problem via Telehealth,
- educate my patients about their condition
- offer guidance on self-management and
- if needed referred them to other health professionals for further review and management of their shoulder problem.
A recent study from Ghent University in Belgium found that Telehealth assessment of shoulder problems is reliable for estimating range of motion and self-testing for symptom provocation or reduction. This study also highlighted that clear communication was extremely important during the assessment. It was encouraging to see that this study reported that over 80% of the patients were satisfied with Telehealth consultation.
Barriers in implementing and delivering Telehealth physiotherapy:
After one year of using Telehealth in my practice, I think there are few barriers in adopting this method by other clinicians and patients. For musculoskeletal physiotherapists I think a change in perspective about Telehealth is required, perhaps training newly graduated or inexperienced musculoskeletal physiotherapists to familiarize them how assessment can be adapted to deliver via Telehealth and recognizing the appropriate patient cohort for this platform, would be a good start. I think more awareness could be created in our society that Telehealth physiotherapy is a safe and viable option rather than ‘wait and see’ approach. Telehealth consultations allow physiotherapists the following:
- to screen patients for serious conditions,
- identify those who can be managed via telehealth,
- educate them about their condition,
- start their treatment with appropriate exercises and
- if required refer them early on to their GP or orthopedic specialists for further management.
For those living in remote or rural New Zealand and are unable to access physiotherapy treatment, Telehealth is an alternative mode which is cost and time effective. I think COVID-19 pandemic has led to widespread adoption of Telehealth in other areas of healthcare. It can be a viable and effective alternative method that people can safely access physiotherapy services. Let’s face it! COVID-19 is going to linger for a long time. Perhaps it’s time to look at a hybrid model of physiotherapy where some consultations or complex patients can be seen in-person and subsequently can be managed via Telehealth.
I’ve interviewed some of the team at Auckland Shoulder Clinic so they could share their experiences of telehealth. Take a listen below.
Shoulder Physio Online – An interview with Pradnya Gadkari and Alisha McKeown