Telehealth Physical Therapy: Challenge Accepted for Patients and Providers

Before this year, I (Leda) never even considered the possibility that I would be asked to evaluate and treat patients who were not physically in the same room as me. The idea of working with a patient over the computer just did not appeal to me. Part of the reason that I got into orthopedic physical therapy (PT) was the chance to connect with patients: through hands-on assessment and treatment, attentive listening, and individualized cueing for exercise-based treatments. But, fast forward into the midst of the COVID-19 pandemic and I found myself conducting telehealth PT sessions as a routine practice…and really enjoying it! 

If given the option in typical circumstances, I (Rachel) would never choose to sit and look at a computer all day. Documentation is enough screen time for me! I love the hands-on, dynamic work life of a physical therapist and always will, but the other great thing about being a physical therapist is that we get to be creative problem-solvers. Maybe figuring out how to safely deliver PT services during a pandemic wasn’t my idea of a problem I would like to solve, but that’s the challenge that was presented. So, within a short couple of weeks, I was helping people with anything from ankle sprains to concussions to positional vertigo over the computer – and it went surprisingly well.

The purpose of this post is to share some of our experiences with providing Telehealth Physical Therapy services and to offer some resources for other physical therapists that we have found to be valuable. **Please note that the authors of this post, Leda McDaniel, PT, DPT and Rachel Robinson, PT, DPT are currently practicing in Georgia and Oregon respectively and some of the information provided will be specific to these states–we have tried to provide context and notes when this is the case, but please check with your state PT board for rules and regulations regarding the provision of PT Telehealth services before you begin using these evaluation and treatment options for your patients. Reminder that this blog is NOT medical advice and NOT intended to provide legal guidance for medical professionals.  

Dr. Leda McDaniel, PT, DPT

Dr. Leda McDaniel is a practicing Physical Therapist in Atlanta, GA. She earned her Doctorate of Physical Therapy in 2019 from Ohio University and went on to complete Emory University’s Orthopedic Physical Therapy Residency program in July 2020. Leda’s passion for physical therapy is paralleled by an interest in teaching and education and her clinical practice interests include persistent pain management, tendinopathy rehabilitation, and leveraging neuroplasticity principles in orthopedic physical therapy settings.

Dr. Rachel Robinson, PT, DPT

Dr. Rachel Robinson earned her Doctorate of Physical Therapy in 2019 from Ohio University. Following graduation, she began working at Cooperative Performance & Rehabilitation, a vestibular and orthopedic speciality clinic in Eugene, Oregon. Rachel’s clinical interests include running related injury, treating patients post-concussion, and vestibular rehabilitation. Rachel also has research interests within the domain of preventing and rehabilitating running-related injuries, and has participated in multiple research studies regarding the impact of biomechanical factors on running related injury and performance for NCAA Division I cross country athletes. 

Full disclosure, before March of this year (2020), neither of us had ever done telehealth physical therapy. But, as the COVID-19 public health crisis unfolded, it became clear that some of our delivery models for healthcare services were going to have to change and change FAST! In a matter of a few weeks, both of our clinics adopted telehealth to provide services to patients who were unable (or unwilling) to seek out in-person physical therapy.

“Telehealth” is defined as: the provision of healthcare services via phone, email, or video and it can be “real-time” (synchronous) or via stored messages like email (asynchronous). Our governing body as physical therapists (American Physical Therapy Association, APTA) includes telehealth as part of our “scope of practice” meaning that we can legally use telehealth to conduct physical therapy evaluations and treatments.

In figuring out how to provide quality services in this new way, we started reading (A LOT!), talking with colleagues, practicing on each other and willing friends and family; and eventually, we developed a sense and style of how these evaluations and treatment sessions would be conducted. Since then, we (Rachel and Leda) have collectively worked with patients after surgeries, after car accidents, with knee, back, and shoulder pain and we have even worked with patients who have vestibular symptoms (dizziness) all over telehealth. We have learned that, just as the research suggests, many patient populations do very well when treated via telehealth and actually enjoy it! 

Recent research regarding patient satisfaction with “Telerehab” visits during the COVID-19 pandemic seems to agree with our personal experiences. Most patients (> 93%) reported high satisfaction with healthcare services delivered via telehealth and the vast majority (86%) said that they highly valued future telehealth visits (Tenforde, 2020). Furthermore, physical therapy delivered via telehealth seems to be equally effective as in person therapy. Research has shown that it can provide similar outcomes in terms of pain reduction and functional improvement (Cottrell, 2017) as in person therapy and this holds true for a variety of patients; from post-surgical patients (Pastora-Bernal, 2017; van Egmond, 2018) to those with persistent pain (Ademse ,2018). 

It has not all been positive, however. We have faced challenges in this delivery method, particularly in reimbursement, billing, technology barriers, and of course with the inability to perform some irreplaceable components of hands-on assessments and treatments. Because many insurance companies do not typically cover telehealth physical therapy services, billing and reimbursement procedures were quickly changed to accommodate individuals’ needs during COVID-19 and each insurance provider was unique in their response. In order to ensure we would be reimbursed for telehealth, we had to keep up with these frequent changes (big thanks to our administrative teams!) 

As could be expected, we have also encountered several technology barriers in our telehealth efforts; namely tech literacy and connectivity issues. For those less familiar with videoconferencing, we need to take extra steps to ensure they have a compatible device, good wifi connection, and understand how to download and use the platform. Once set up, most of our patients have adapted really well to using the technology. 

The greatest challenge (but perhaps the most fun) was adapting all of our examination skills and treatment techniques to a completely online format. We both come from an educational background that strongly values manual therapy, so hands-on assessment and treatment is an integral part of our practices. There is also specific equipment that we only have access to in the clinic (i.e. infrared VNG goggles for vestibular exams). However, the great thing about being PT’s is that we are excellent at making modifications! Need to measure shoulder range of motion? Use an online protractor or goniometer app. Test for BPPV? Have the patient hold the camera up to their eyes to view nystagmus patterns. Mobilize the thoracic spine? Teach a patient your favorite self mobilization. It took some trial and error, but within a few concentrated days of practice we were able to collect the information we needed to make an accurate PT diagnosis, and rely on specific therapeutic exercises/activities alone for really effective treatment.

In the end, navigating all of these obstacles was completely worth it. During a time that simply meeting together less than 6 feet apart poses health risks, we have been able to meet our patient’s needs while keeping them safe and healthy. Would we choose to operate via telehealth all the time? Absolutely not. But days behind the screen were worth it for outcomes like this:

One of my (Rachel) favorite experiences was the first time I evaluated and treated a patient with BPPV (Benign Paroxysmal Positional Vertigo) via telehealth. I was a bit skeptical at how well I’d be able to view nystagmus via an iPhone camera, but lucky for me the patient’s subjective report sounded like a straight-forward posterior canalithiasis (the most common form of BPPV and usually very responsive to treatment). After explaining my hypothesis to the patient, performing a quick oculomotor screen, and demonstrating the test and treatment positions, I instructed the patient to hold up her phone camera to her eyes and go back into the test position. Sure enough, her symptoms were reproduced and I could see her torsional upbeating nystagmus fairly well! I talked her through an Epley maneuver which she performed twice, and she re-tested without symptoms. A virtual BPPV test and treatment done in one session?! No way! On top of being relieved that her vertigo was finally gone, the patient loved doing all of this in the comfort of her own home. While not all of our cases were this simple, we had several similar outcomes which was extremely rewarding.

Lastly, we wanted to share some of the resources that we have found most helpful in getting up to speed on providing telehealth services as physical therapists. See below for resources on  how best to provide these services legally and ethically to patients. 

The following  documents are ones that we have created for Sample PT Telehealth Documentation and Tips for how to get the information you need in a PT evaluation over video telehealth:

PT Telehealth Sample Documentation

PT Telehealth Evaluation Tips

Telehealth Resources for Physical Therapists that we have found useful: 

American Physical Therapy Association (APTA)’s Resources:

  • APTA Learning Center (FREE TELEHEALTH CONTENT as an APTA Member)
  • APTA’s Telehealth Page
  • APTA’s TELEHEALTH PRIVATE PAYER UPDATES
  • APTA Vestibular Evaluation Video Demonstration (must be a member of the APTA Academy of Neurologic Physical Therapy to access)

Blog Post References:

Adamse C, Dekker-Van Weering MG, van Etten-Jamaludin FS, Stuiver MM. The effectiveness of exercise-based telemedicine on pain, physical activity and quality of life in the treatment of chronic pain: A systematic review. J Telemed Telecare. 2018;24(8):511-526.

Cottrell MA, Galea OA, O’Leary SP, Hill AJ, Russell TG. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil. 2017;31(5):625-638.

Pastora-Bernal JM, Martín-Valero R, Barón-López, FJ, Estebanez-Pérez, MJ. Evidence of benefit of telerehabitation after orthopedic surgery: a systematic review. J Med Internet Res. 2017. 19: e142.

Tenforde AS, Borgstrom H, Polich G, et al. Outpatient Physical, Occupational, and Speech Therapy Synchronous Telemedicine: A Survey Study of Patient Satisfaction with Virtual Visits During the COVID-19 Pandemic. Am J Phys Med Rehabil. 2020;99(11):977-981.

Turolla A, Rossettini G, Viceconti A, Palese A, Geri T. Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer? Phys Ther. 2020 Aug 12;100(8):1260-1264.

van Egmond MA, van der Schaaf M, Vredeveld T, et al. Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis. Physiotherapy. 2018;104(3):277-298.

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