BACKGROUND AND PURPOSE
Telehealth is a broad term encompassing the delivery of health care services via remote patient–clinician exchanges and other services such as the use of patient portals, videoconferencing, and continuing education for clinicians.1 1 2 3,4 5 5
The 2020 COVID-19 pandemic in the United States (referred to as “pandemic” here-forth) presents an unprecedented public health crisis that has impacted nearly every facet of life, including but not limited to the world's economy and welfare.6 7,8 9 9
Therefore, the purpose of this case report is to illustrate the twofold potential benefits of telehealth as (1) a novel clinical education model that emphasizes adaptive learning and develops innovative physical therapists and (2) a flexible care delivery model that has the potential to positively impact patient satisfaction and outcomes.
CASE DESCRIPTION
Telehealth Physical Therapy Clinic Setup and Operations
In response to the immediate need for PT clinic service provision to support full-time Doctor of Physical Therapy (DPT) student clinical education requirements in the face of the pandemic, select faculty and students in the University of Minnesota Division of Physical Therapy Program rapidly established the “telehealth physical therapy clinic (TeleMNPT)” pro bono outpatient telehealth clinic. Virtual PT service provision led by final-year DPT students under the supervision of licensed PT faculty was designed to offer mutual benefit to both community members seeking remote clinic access during the pandemic and to DPT students needing additional clinic time and skill development to meet curricular requirements.
The initial development and pilot of the TeleMNPT clinic involved 2 PT core faculty and 1 final year DPT student. Over the course of 3 weeks, the faculty determined the desired structure of clinic operations and drafted formal clinic policies, quickly approved by the University's institutional regulatory bodies. Faculty also drafted client recruitment language and informed consent language that was approved by the Program Director and institutional leadership to ensure consistent messaging during the pandemic. Five secure, university-supported technology platforms were selected and implemented to 1) host virtual synchronous clinic sessions, 2) obtain client intake information electronically, 3) communicate with clients regarding scheduling, 4) document clinic sessions, and 5) disseminate home exercise program information. In consultation with the institution's health information and privacy compliance office, a single-point, Health Insurance Portability and Accountability Act (HIPAA) compliant communication process was developed. Students and faculty created postservice satisfaction surveys for clients for quality improvement purposes. No billing logistics were involved because the clinic was developed to operate free of charge.
One faculty and student piloted PT service provision using known community member volunteers, during which they collaboratively established the roles, responsibilities, and best practices of supervisor and student in the clinical education model. Known community member volunteers included a faculty member, a family member of a faculty member, and a former teaching assistant, all with musculoskeletal conditions and awareness of the newly developing telehealth clinic. Community client recruitment progressed to include email, word-of-mouth, and social media using the institutionally approved messaging, with the aim to support 2 nearly full clinical caseloads. Interested individuals accessed a secure web link embedded in recruitment materials to complete the informed consent and client history intake forms. The supervising PT and students then reviewed the information to determine appropriateness for PT services. Considerations included client impairments and rehabilitation needs, client access to required technology and support, and supervising therapist expertise. If deemed eligible, the students contacted the client to schedule an initial telehealth visit. Most of these patient intake steps were later facilitated by primarily one student, as one of the long-term goals of the clinic was for it to be student run with core faculty support. Following the successful 2-week pilot period, TeleMNPT expanded to include 2 licensed core PT faculty, each supervising 2 DPT students and serving as their primary clinical instructor (CI). Only these 4 students participated in this telehealth experience following the cancellations of their planned final clinical experience due to the pandemic.
Each client telehealth session was conducted via Zoom videoconferencing platform (Zoom Video Communications, Inc, San Jose, CA) (Figure 1 ). The patient's geographical location was verified to ensure their safety should a medical emergency arise and to adhere to local PT practice acts disallowing providing PT services across state lines. One of the 2 SPTs in the educational model took the lead in performing the evaluation or intervention measures while the other student observed. The primary CI was present at all times to modify or enhance service provision with guidance as needed. Depending on the patient's clinical presentation, consultation of faculty with specialty expertise was implemented. In these cases, the expert faculty acted as the main CI for the student to consult; however, the student's primary CI was present in all sessions to observe and facilitate other areas of student growth as needed. The need for additional sessions and/or referrals was determined based on the results of the initial evaluation.
Figure 1.: A Screen Capture of a Typical Telehealth Session Using Zoom. The Patient is Viewed in the Large, Main Window, While the Clinical Instructor (CI) and 2 Student Physical Therapists Can be Seen in the 3 Minimized Windows Above. Additionally, an Example of the Text Chat Feature Can be Seen Toward the Right of the Figure, Where the CI and Observing Student Are Able to Discuss the Patient's Presentation Privately
Prior to initiating the experience, students and faculty were familiarized with the novel telehealth format. For students, prior to performing their first evaluation, they observed their peer performing an evaluation and treatment, first via a recorded session, followed by a “live” session. This allowed students some insight on how to sequence an examination, acquire objective data, and provide interventions within the videoconferencing format. After these observations, students and CIs arranged a virtual meeting to set learning goals based on the student's self perceived strengths and areas that would benefit from further development. Because the electronic intake forms were completed well ahead of evaluations, students and CIs were able to discuss the first session's plan in advance. Debriefing with the students about this clinical experience suggests that this process of preplanned sessions with less complex patients early in the clinical experience increased their confidence in being successful in this novel, telehealth format.
A Unique Case of Telehealth Physical Therapy Implementation
The patient in this case report sought care from the TeleMNPT clinic in April 2020. Most of the patient's history was gathered from the online intake form prior to the initial visit with further clarification provided in the subjective portion of the evaluation. From a review of the online intake form, the patient was deemed appropriate for telehealth services because 1) she demonstrated several impairments in body functions, 2) she was not at her prior level of function and demonstrated activity limitations, 3) the patient faced limitations seeking in-person care during the pandemic, and 4) although out of the expertise of the primary CI, another core faculty member with specialty knowledge/skills in the area of the patient's impairments was available for consultation (also a licensed PT). In light of the pandemic and concern of contracting the novel coronavirus, the patient decided to seek telehealth services before resorting to in-person care. The use of telehealth in this unique circumstance was deemed to be both a safe and appropriate option, based on the intake process previously described.
Subjective History
For the initial visit, the patient accessed services using her laptop and Zoom. Although the patient initially had difficulty initiating a Zoom meeting, this barrier was overcome using the HIPAA compliant Zoom “call out” feature to make contact with the patient and provide step-by-step guidance for establishing video and audio connections. This protocol had been established with prior guidance from the university's HIPAA compliance office. Prior to the examination, the clinical team and roles were explained to the patient as the following (names omitted): the leading SPT, the observing SPT, the 2 students' primary CI, and the consulted expert faculty member. All clinical team members showed proof of their roles to the patient via Zoom, in the form of their university identification cards. The patient then verified her geographical location, and to adhere to state practice statutes, all clinical team members were also physically located in the same state.
The patient's online intake form indicated that she was a 68-year-old woman, retired speech language pathologist. In combination, the intake form and subjective history interview indicated that she exercised 5 to 7 times a week; however, most of her activity had been limited in light of the pandemic. Comorbidities included hypertension, heart disease, osteoarthritis, depression, metal implants from a previous ankle fracture, and osteoporosis. She reported 2 previous episodes of vertigo, the first of which occurred 30 years ago after riding a tilt-a-whirl (a spinning fairground ride), and the second occurred about 10 years ago when she was getting out of bed in the morning. Both episodes lasted approximately 2 days. She had not sought care for either episode.
The patient complained of dizziness, nausea, clamminess, lightheadedness, and “scrambling eyes” during mobility and positional changes at home. Her symptoms were most intense with the following movements: getting in and out of bed, cervical extension, left head turns, and lying on her left side. The initial onset of symptoms was described as sudden and began 1 week prior to the initial examination. Duration of symptoms was described as “shorter.” She did indicate that on the third or fourth night after the initial onset, her symptoms peaked at their worst and seemed to last 20 minutes. The patient reported needing to self-limit her head movements, particularly with going from a supine to sit position or vice versa. She reported the 3 greatest problems were difficulty sleeping, feeling weak due to dizziness, and fear of falling, which limited her walking and exercises. She denied any hearing change, neck pain, history of infections (including ear infections), balance impairments, or falls since the onset of symptoms.
The week prior to initial examination, the patient reported seeking information online regarding her complaints, due to both hesitancy and inability to access in-person health care services during the pandemic. In doing so, she discovered Brandt–Daroff exercises for vertigo, which involve sitting on the edge of a bed, rotating the head 45°, quickly lying down on the side away from the rotation, then sitting up quickly and repeating to the opposite side.10
The patient's main goals for PT included full resolution of her symptoms, confirming that the Brandt–Daroff exercises found online were safe and appropriate and to prevent further episodes of vertigo. Because of her symptoms, she reported limitations with sleep, walking, exercises, activities of daily living, and reported feeling fearful of falling due to vertigo during mobility. She rated each of these activities as a 5/10 on the patient-specific functional scale (PSFS), which has been found to be reliable, responsive, and valid for patients with low back pain and is commonly used in a variety of conditions, including chronic dizziness due to its user-friendliness.11,12
Following the subjective portion of the examination, the patient was placed in a Zoom virtual waiting room. The SPT then consulted privately with the expert faculty member and described her differential diagnoses as benign paroxysmal positional vertigo (BPPV) and, less likely, unilateral vestibular hypofunction, based on the patient's short-duration symptoms elicited by positional changes. The SPT outlined her plan for objective testing, which included a cervical active range of motion (AROM) screen, modified vertebral artery test, and Dix–Hallpike test. The expert faculty member was in agreement with this plan and included guidance for modifications and safety measures to consider for objective testing.
Objective Examination
Through videoconferencing, a forward head posture was evident along with an unwillingness to extend the neck. An AROM screen of the cervical spine was first performed to potentially rule out cervicogenic dizziness and ensure an adequate range of motion for BPPV testing and treatment. No symptoms were elicited when she extended her head/neck and rotated to the left and right. Due to the videoconferencing format and inability to use goniometric measurements, AROM measures were reported as estimates from typically observed norms. All motions were pain free and adequate for testing and intervention of suspected BPPV.
Objective testing for suspected BPPV involved several modifications for adequate viewing and maximizing patient safety in the telehealth setting. Prior to testing for BPPV, although the index of suspicion was low,13 14
Dix–Hallpike testing was performed bilaterally. After a latency of 20 seconds in the left Dix–Hallpike test, the patient described symptoms of dizziness, nausea, and “eyes scrambling” for a duration of less than 1 minute. These signs were interpreted as a positive test for one of the left vertical semicircular canals. The right Dix–Hallpike test was negative. Standard observation of nystagmus was not possible using the patient's laptop camera in this telehealth setting. However, the availability of expert consultation in the area of vestibular disorders allowed the SPT to confidently interpret the patient's response to positional testing and move forward with further clinical decision making.
Student-Led Clinical Decision Making
After completing these measures, the patient was placed in the virtual waiting room a second time. The SPT identified that the signs and symptoms elicited during objective testing and subjective questioning were indeed indicative of BPPV, specifically, vertical canal BPPV in the left ear and suggestive of canalithiasis. The strongest indicators of this suspected diagnosis were the patient's complaints of vertiginous symptoms with positional changes, a positive modified Dix–Hallpike test, and improvements likely occurring from the patient's consistent performance of the Brandt–Daroff exercises. The SPT made the decision to continue treatment with the Epley maneuver via telehealth because of the potential benefit for immediate symptom alleviation often seen with this intervention.15
OUTCOMES
Clinical Outcomes
With 3 guided repetitions of the Epley maneuver, the patient was able to express near full resolution of her symptoms at the end of this initial session. Although she still described feeling “sort of strange,” she no longer was experiencing her usual symptoms. It was determined that she was appropriate for continued telehealth services because of her ability to safely perform the Epley maneuver, her positive response to treatment, and her successful use of the videoconferencing technology. Therefore, a need for referral to another provider for a “hands-on” intervention or further assessment was deemed unnecessary. An additional telehealth visit was scheduled to ensure efficacy of the Epley maneuver. In the follow-up visit 5 days after the initial examination, the patient described full resolution of her symptoms. She reported being able to resume walking her dog, light aerobic activity (dancing for 20 minutes), basic yoga forms, and a modified push-up and sit-up routine. She also reported an improvement in appetite and overall “felt so much better.” Her PSFS ratings changed from an initial rating of 5/10 on all included activities to a rating of 10/10 for her ability to sleep, walk, exercise, and perform activities of daily living (ADLs), and 9/10 for fear of falling (Table 1 ). Ratings for all activities exceeded the minimum clinically important difference commonly described as a 2 to 3 point change.11,12
Table 1. -
Patient Outcomes Using the PSFS
11,12
Activity
PSFS Rating at Initial Evaluation
PSFS Rating at Discharge
Sleeping
5/10
10/10
Walking, exercise
5/10
10/10
Performing activities of daily living
5/10
10/10
Feeling fearful of falling
5/10
9/10
Abbreviation: PSFS = patient-specific functional scale.
A zero on the PSFS indicates unable to perform activity while a 10 indicates able to perform activity at the same level as before injury/condition.
Educational Outcomes
The innovative use of the telehealth platform to allow DPT students to engage in full-time clinical education during the COVID-19 pandemic proved to offer high-quality education with excellent educational outcomes. The student clinical performance assessment tool utilized for this rotation was the same as that typically completed during in-person clinical experiences: the Clinical Internship Evaluation Tool.16
The CI comments included mention of the telehealth format only once, in the examination section regarding the student's ability to successfully perform examination measures using verbal instructions to guide the client through the required steps. All other CI comments reflected performance and growth akin to that typically seen in final performance assessments of in-person clinical experiences. The student was noted to particularly excel in her ability to evaluate the client's presentation and examination measures to make clinical decisions, with the increased access to expert clinician guidance for the patient in this case study enhancing this development. The CI commented, “Seeking mentorship to enhance patient care in this case indicates self awareness and desire to learn and improve outcomes.” Another area of significant growth in this experience was the student's skill in providing effective interventions. With 3 prior in-person clinical rotations in the inpatient setting and no past experience in the outpatient setting, the student flourished in the telehealth environment, and according to the CI, the student became “quite adept at recognizing faulty movement patterns and trying a variety of strategies to improve the intervention,” which the student also demonstrated when observing the other student. Finally, the positive relationship formed between the student and CI in the innovative telehealth clinical environment served to enhance the student's development further, as the CI noted that the student “sets herself apart from many students in her ability to receive feedback and adapt to her practice.”
DISCUSSION AND CONCLUSION
This unique approach for providing PT services in an educational setting via telehealth was rapidly developed in response to the education and service provisions shortages produced by the COVID-19 pandemic. The outcomes of this case report successfully demonstrate its twofold purpose in that (1) both the lead and observing SPT were able to build adaptive clinical knowledge and skill with the guidance of expert faculty and (2) the patient was able to regain function and improved quality of life.
The hands-off nature and technological constraints of the telehealth format challenged the student and provided opportunities for growth across many aspects of clinical performance, such as communication, professional behaviors, and clinical reasoning. For example, the inability to physically perform objective tests or interventions such as the Dix–Hallpike test or the Epley maneuver required that the SPT identify visual cues in the patient's surroundings, such as looking at the patient's laptop camera or a window, to guide the patient through complex and specific positioning for both diagnostic and therapeutic purposes. In doing so, the SPT practiced the skill of adapting communication to a novel situation to accomplish therapeutic goals. The lack of physical proximity during the telehealth session also created safety issues during service provision such as the potential for an emergency or injury during complex and unfamiliar physical movements. The SPT applied learned professional behaviors in safety awareness and risk mitigation by confirming the patient's physical location during the session and modifying her positioning to prevent injury during BPPV testing and treatment. These situations had never been explicitly taught in the SPT's didactic learning experiences, yet she was able to transfer previous learning to an unfamiliar experience. This adaptive learning and decision making in response to challenges encountered in practice is thought to develop “preparedness for future learning” in order to best utilize available resources and problem solve in the clinical environment.17
Although the videoconferencing format provided challenges, it also allowed for unique learning opportunities. Notably, the adaptive learning demonstrated by the SPT in the telehealth environment occurred under the teaching and guidance of a readily available expert faculty member specializing in vertigo and vestibular impairments. The SPT was able to educate the patient about critical aspects of her care, such as appropriate exercises to perform and expected responses following a self-performed Epley maneuver and address the patient's questions using the faculty member's expertise to clarify and interpret unfamiliar critical concepts. The virtual nature of the session, requiring only 1 hour of time with no travel needed, streamlined faculty involvement. Without such ease of access, this educational learning experience likely would not have taken place. Additionally, the second observing SPT was able to actively engage in role modeling in the clinical setting without interrupting the flow of the lead student, a pedagogical strategy supported in medical education by Bandura's social learning theory.18
Another unanticipated educational benefit of the videoconferencing format was the option to record sessions (with the patient's signed consent). Although this option was not used for the patient presented in this case, the recording of evaluations and follow-up sessions for other patients was used by both SPTs and CIs as a way to reflect and critically assess performance retrospectively. The importance of self-assessment is stressed and even defined as the key differentiating factor between a novice and experienced clinician.19 19
Although students benefited from this educational experience, it is important to also consider the potential consequences for the patient had she not sought care via telehealth. Although the patient found partially beneficial exercises for her symptoms online, she also reported discovering a half somersault maneuver to treat BPPV. The exercise requires a patient to bring their head down to the floor in a “half somersault position.”20 https://links.lww.com/JOPTE/A103 21 https://links.lww.com/JOPTE/A103 Table 1 ).
The unexpected circumstance of replacing traditional in-person clinical experiences with the telehealth format presented itself with unique learning opportunities. The most relevant lesson was realizing telehealth's role in clinical education. Although the involved students were able to focus on and hone skills related to verbal instruction and patient education through telehealth, the inability to physically guide patients limited the opportunity to practice hands-on skills. Although it is currently unknown how significantly the PT profession has changed recently, there is no doubt that the pandemic has become a catalyst for potential future shifts in how PT is practiced and taught. As a result, it would be to the benefit of both future clinicians and the profession to prepare for such changes by implementing a mixture of clinical experiences in both telehealth and in-person settings. By allowing access to both clinic settings, students would have the opportunity to maximize hands-on skills in the traditional in-person clinic, while using telehealth as an efficient means of enhancing communication, adaptability, and self-reflective processes, much like the student did in this case report.
Thus, although the telehealth format was deemed advantageous, the efficacy of telehealth as a mode of care in the context of PT clinical education requires further research and innovation. A single case provided initial evidence of its effectiveness but a comparative study assessing educational outcomes of telehealth versus traditional clinical experiences with a larger sample of SPTs is warranted. A systematic review by Martin et al22 Table 2 ), and the immediate assessment of treatment efficacy often possible when treating patients with BPPV. The most suitable candidates for telehealth PT are likely those who do not require extensive in-person contact for manual therapy, correcting movement deviations, or require manual assistance for safety concerns.
Table 2. -
Prerequisites for a Successful Telehealth Session
Technological Setup
Access to the following:
Ability to independently navigate the device to access shared documents, images, or programs or have a person present who can navigate
Ability to independently troubleshoot technology issues or have a person present who can troubleshoot
Clinical considerations
A type and severity of disorder that does not preclude the client from the benefits of services provided by telehealth
Judgment by the licensed physical therapists providing or supervising services that services provided by telehealth are not of lesser quality than those available in person
Contingency plan
Access to a backup method (e.g. smartphone if initially using a laptop) for services, if videoconferencing technology is not working
Awareness and consent
Awareness of risks associated with transmitting protected health information via videoconferencing software (even compliant with HIPAA) and an agreement to services delivered in this manner
Additionally, for telehealth to be effective both in clinical education and to maximize patient outcomes, dedicated PT telehealth software platform innovations are needed. Innovations such as simple HIPAA-compliant videorecording and immediate playback would be useful for patients and students. Developing methods to objectively measure position and movement and would be helpful for students to identify and document patient progress. Innovations such as on-screen goniometric measurements, and the incorporation of wearable sensors could enhance telehealth's value for patients, PT students, clinicians, educators, and payors.
The COVID-19 pandemic brought the world through uncharted territory, including the PT profession. Adaptation and innovation became a necessity, and with it, new insights were formed regarding the positive role telehealth can play in the development of future physical therapists and the profession's approach to serving patients. This case report serves as a stepping stone for examining the potential role telehealth plays as both a mode of care and an educational tool.
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