4 Tips for Conducting Successful E-Visits

By Andy Parsons, DPT, OCS

Originally published for MedbridgeEducation.com

Like many of you, I’m trying to navigate the current COVID-19 crisis. My goal is to keep my patients safe while also delivering modified, quality service. E-visits are one option for staying connected with your patients while still providing them with advice so they can continue progressing.

An e-visit is defined as non-face-to-face, patient-initiated communication with a health care provider. Current legislative and reimbursement issues are real barriers to telehealth, so e-visits are a plausible, short-term stopgap solution while the industry works toward full telehealth implementation.

1. E-Visits Must Be Patient-Initiated

An e-visit must be initiated/requested by the patient with their consent and be reflected in your documentation. Therefore, scheduling the visit may be beneficial vs. calling down a list of patients.

Successful reimbursement for e-visits is outside the scope of this specific article, but making sure that e-visits are patient initiated is one necessary step in order to ensure reimbursement. For more information on this topic, refer to MedBridge’s recent webinar, “Updates on E-Visits and Telehealth for Outpatient Therapy Services, Part 1,” as well as the blog post, “FAQ: Providing E-Visits During the COVID-19 Crisis.”

2. Refer to the Chart and Home Exercise Program

Don’t be tempted to speak to your patient utilizing only your memory. Treat the e-visit like you would a regular face-to-face visit. Utilize documentation to improve your recall of prior assessments and home exercise programs (HEP).

Statements like, “I’m comparing your initial assessment to what you’re telling me today,” add value to your visit by indicating you care about their progress. Documentation review also allows for clarification statements like, “You’re reporting the pain has spread to the lower part of your leg when, initially, we discussed that it was isolated to the upper part of the hip. Is that accurate?”

These types of insights allow you to maximize clinical reasoning even at a distance.

Access the most recent version of the assigned HEP and encourage your client to do the same. This way, you both can reference the HEP, which helps to increase clarity in a verbal-only discussion.

Encourage your patient to utilize technology that supports adherence to the HEP. Adherence tends to be better with a remote HEP application versus a paper-only handout anyway.1 As an example, the MedBridge GO app offers reminders to patients to complete their HEP and also provides positive feedback upon completion.

3. The Subjective Interview Is Key

Conducting a thorough interview and actively listening to your patients’ concerns and goals is key during any therapy visit, and that importance is only heightened with an e-visit.

The subjective interview is often more powerful than most clinicians realize. Therapists tend to focus on physical examination methods like special testing, range of motion, and strength testing. But when compared to an MRI, subjective history diagnosis agreed 75% of the time.2 For follow-up treatments, subjective information can give clinicians enough data to make informed decisions about exercise progression, activity modification, and grade return to normal prior level of function.

During your e-visit subjective interview, ask about how the patient has been feeling since their last visit along with how they feel the exercise program has been going. Other strategies you can use include:

• While referencing to your patient’s current home program, ask about the difficulty of specific exercises.

• Use a rated perceived exertion scale. This powerful tool allows you to accurately change and or dose exercise remotely.

• Discuss the severity, nature, and quality of any pain your patient is having in order to get a sense for current irritability levels so you can make informed decisions about interventions.

• Ask about observations you would normally make in the clinic. For example:

  • Are you walking normally or with a limp?

  • Can you walk in a straight line?

  • Are you able to put all of your weight through your affected lower extremity?

  • Have you had any changes in breathing?

  • Have you noticed any skin or wound changes? Has there been drainage?

4. Practice Active Listening

Actively listening allows you to meet your patients’ goals even by phone and will guide changes in intervention during an e-visit. Shared decision making is still a primary goal in this context.

When you’re wrapping up a call, try asking, “What else can I do for you today?” as opposed to “Do you have any other questions?” This subtle difference can lead to more engagement at this point in the e-visit and indicates you’re not in a rush to end the interaction.

Following these e-visit strategies will help you maximize clinical reasoning and patient outcomes. Many of these concepts will translate well when you are able to transition to full telehealth visits.

Disclaimer: The information in this blog post is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this Post should be construed as legal advice from MedBridge, Inc., or the individual author, nor is it intended to be a substitute for legal counsel on any subject matter.

5 Tips for Managing Patellofemoral Pain

By Andy Parsons, PT, DP, Board-Certified Orthopedic Specialist

Broadly described as anterior or retropatellar knee pain,1 patellofemoral pain (PFP) has gone through many evolutions in terms of definition, and pathoanatomic causes. While the focus has traditionally been on more anatomical and biomedical factors, recent evidence suggests that psychosocial factors (like depression and fear avoidance) are important to consider when evaluating these patients.2

Specific pathophysiological causes of the pain remain elusive. One model describes a system that prescribes graded and progressive tolerance to load to increase the envelope of function.3, 4 With this context in mind, here are some quick tips for treating PFP.

1. Quads, Quads, Quads

Yes, go after the quads! We are relatively certain that progressive loading and strengthening of the quads is helpful for PFP.

You have many options, including eccentrics, decline single leg squats, and open chain knee extension. A leg extension likely isolates the quad better than any version of squat, but you’re probably better off including both squats and leg extension rather than either one in isolation.

Young, et al., found some improved outcomes comparing eccentric single leg squats on a 25° slant board over a single squat off a 10 centimeter step.5 Importantly, the decline group was encouraged to load the joint up to moderate pain in this study, which could account for some of the difference between groups.5 Arguably, it’s yet to be determined if eccentrics are necessarily superior to progressive loading.

Here are a few quad-focused exercise examples:

Eccentric Single Leg Decline Squat on Slant Board

Single Leg Knee Extension or Single Leg Chair Squat

2. Include the Hips

Some studies seem to indicate hip-plus-knee exercise is superior to knee-focused exercise alone,6 but we can’t say this is true with much certainly, per a recent Cochrane systematic review.7 Meira and Brumitt are more confident in their systematic review that hip abductor and hip ER strength deficits are associated with PFP, however.8

If your assessment finds hip deficits, it’s worth addressing at this time. Here are a few basic exercises (and don’t forget to add resistance as appropriate!):

Sidelying Hip Abduction with ER

Hip Hike on Step & Clamshell

3. Identify Overtraining

Taking a careful history from your patients with PFP may help identify if there have been recent changes in training loads that could be associated with the new onset of pain. If so, temporarily modifying these loads and progressively building the patient back to prior levels of activity (and hopefully beyond!) may be protective and ease PFP.4

4. Just Say No to the VMO

We can’t isolate the vastus medialis oblique (VMO); it’s well established at this time.9 You’re better off ensuring that you’re prescribing resistance activity at a sufficient level of intensity. If you’re spending too much time worrying about the degree that the lower extremity is internally or externally rotated in attempts to isolate VMO, you’re probably not meeting this primary objective.

5. PFP—More Than Meets the Eye

A growing body of research seems to indicate that there are more than just biomechanical factors that influence recovery from PFP syndrome, as psychosocial factors can also contribute to a patient’s prognosis.2, 4 In other words, effective treatment strategies should consider taking a biopsychosocial approach

• Is your patient displaying fear-avoidance behavior?
• Does your patient lack self-efficacy to reach their goals?

Graded, progressive exercise with shared goal-setting is likely to improve outcomes in this scenario. Physical therapy has the potential to improve the outcomes and function of a large population of individuals affected by patellofemoral pain. Exercise appears to be an overall effective intervention; however, we still have much more research to do to maximize the effects of our interventions, including addressing the questions of dosage, intensity, frequency, and duration.

Originally published on MedbridgeEducation.com

References

1. Crossley, K., Bennell, K., Green, S., & McConnell, J. (2001). A systematic review of physical interventions for patellofemoral pain syndrome. Clinical Journal of Sport Medicine, 11(2): 103–110.

2. Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of Rehabilitation Medicine, 41(8): 604–612.

3. Dye, S. F. & Dye, C. C. (2018). An overview of patellofemoral pain—from a tissue homeostasis perspective. Annals of Joint, 3.

4. Willy, R. W. & Meira, E. P. (2016)."Current concepts in biomechanical interventions for patellofemoral pain. International Journal of Sports Physical Therapy, 11(6): 877–890.

5. Young, M., Cook, J., Purdam, C., Kiss, Z., & Alfredson, H. (2005). Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. British Journal of Sports Medicine, 39(2): 102–105.

6. Baldon, Rde. M., Serrão, F. V., Scattone Silva, R., & Piva, S. R. (2014). Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 44(4): 240–251.

7. van der Heijden, R. A., Lankhorst, N. E., van Linschoten, R., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2015). Exercise for treating patellofemoral pain syndrome. Cochrane Database of Systematic Reviews, 20(1): CD010387.

8. Meira, E. P. & Brumitt, J. (2011). Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health, 3(5): 455–465.

9. Smith, T. O., Bowyer, D, Dixon, J., Stephenson, R., Chester, R., & Donell, S. T. (2009). Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. Physiotherapy Theory and Practice, 25(2): 69–98.

My Shoulder Hurts. Now What?

By Andy Parsons, PT, DPT - Board-Certified Orthopedic Specialist

Shoulder pain is a common problem affecting many people across the lifespan.  Lifetime prevalence of shoulder pain is as high as 66% in the general population.  Pain in the shoulder can come from many different sources including arthritis, rotator cuff problems like tears and strains, or issues deep in the joint with the labrum. These are just a few of the potential sources of pain at the shoulder. 

When managing shoulder pain, you have many choices including the wait and see approach, anti-inflammatory medications, steroids, injections, physical therapy, and even surgery.  You can initiate care through your primary care physician, your physical therapist, or your orthopedic surgeon in most cases. Some avenues will require prescriptions and some specialists may require referral.  Treatment should ultimately be chosen based on the diagnosis. Rotator cuff tendinopathy and tears are among the most common problems at the shoulder. In many cases, it makes sense to manage shoulder pain conservatively with a physical therapist prescribing stretching and progressive strengthening/loading strategies.  X-rays and MRI tests are generally not indicated as a first line of assessment unless there was a specific traumatic injury. These tests can lead to false positive results if performed too frequently or too early in care. A good orthopedic exam from your physical therapist or orthopedic surgeon can give you much information and options for management. Working your way from most conservative treatment up to the most invasive is appropriate with most musculoskeletal problems.

In people aged 60-80 years old, 20-30% have rotator cuff tears at any given time. Typically, one third of the tears are symptomatic and two thirds are asymptomatic.  About half of the asymptomatic tears may become painful over time. Recent quality studies show that people with rotator cuff tears that do not undergo surgery get similar results to those that opt for surgery.  This outcome may depend if the tear was traumatic or more chronic in nature. Arthritis in the shoulder generally responds to stretching, hands on manual therapy, and NSAID drugs. Total shoulder replacements are a more invasive option if more conservative measures have failed.  Multiple factors determine what care path you choose including your preferences, diagnosis, and what treatment you have tried in the past. Either way, you have options to improve your condition.

Andy Parsons is a physical therapist at ProMedica Defiance Total Rehab at ProMedica Defiance Regional Hospital. You can call 419-783-6943 for more information.

Images source: CDC [Public domain], via Wikimedia Commons

**  This information is not intended to replace the advice of a physician/ physical therapist.

Dizzy? Physical Therapy can help with Dizziness and Unsteadiness!

By Andy Parsons, PT, DPT, Board-Certified Orthopedic Specialist, Vestibular Rehab Certified

When you look up into the cupboard, wash your hair, roll over in bed, or bend to look into a low cupboard does your world spin around you?   Do you feel more unsteady with walking, or do you feel like you're being pushed over? Is it difficult for you to walk down the aisle of the supermarket? Do you feel like you're intoxicated even though you haven't had any alcohol?   If you had any or some of these experiences, then you might be suffering from an inner ear problem. Dizziness often comes from a portion of the inner ear called the vestibular system. Issues in this area of the ear can cause the above symptoms or many other problems.

In fact, 35% of people forty and older have experienced a vestibular problem at some point in their lives.  Luckily, there are good treatment options for folks that are having inner ear dysfunction. The most common type of inner ear dizziness called benign paroxysmal positional vertigo (BPPV) creates a sensation of spinning when moving from sitting to lying, rolling over, or looking up for example. Some people complain of unsteadiness with this condition as well. One out of ten people 75 years and older have this problem. The gold standard treatment for this condition is a series of specific physical positions that reposition loose calcium particles in the inner ear.  Studies report success rates between 75-90% for this type of treatment. Medication is not generally helpful for this condition. This treatment is supported by the American Neurotology Association, the American Academy of Family Physicians, and the American Physical Therapy Association among others. Physical therapists with additional training often perform these positioning treatments for people with dizziness. This is generally accomplished in between 2-4 sessions.

Alternatively, the inner ear system can lose function from a variety of issues like infections, viruses, or diseases specific to the inner ear. People with these class of conditions may complain of increased unsteadiness, bouncing vision, falls, and slower walking. Vestibular rehabilitation can be very effective for these people to increase balance and stability with walking by training the brain to compensate for the inner ear problem. Guidelines recommend around 6-8 weeks of treatment for this type of vestibular problem.

Dizziness is a complex subject. Not all dizziness comes from the inner ear.  Lightheadedness is the most common issue that is generally not responsive to physical therapy.  Talk to your doctor or physical therapist about whether or not this type of treatment would be appropriate for you.

Andy Parsons is a physical therapist at ProMedica Defiance Total Rehab at ProMedica Defiance Regional Hospital. He is certified in Vestibular Rehabilitation and has nearly 9 years of experience working with “dizzy” patients. You can call 419-783-6943 for more information.

References:

1. BPPV: Experts Update Best Practices for Diagnosis and Treatment. Am. Academy of Otolaryngolgy- Head and Neck Surgery. https://www.entnet.org/content/bppv-experts-update-best-practices-diagnosis-and-treatment

2. Vestibular.org

3. Image source: Pixabay via Kalhh. https://pixabay.com/photos/trees-away-nature-eddy-turn-dizzy-358418/
   

Temporomandibular Disorder: A Bite Size Intro to Management and Classification

By Andy Parsons, PT, DPT, OCS

Originally published on MedBridgeEdcuation.com

Temporomandibular Disorder is defined by the American Dental Association as any pathology that affects the temporomandibular joint, masticatory muscles, or other closely related structures.1 Local jaw pain, limitations in mastication, clicking/popping when opening the mouth, and mandibular deviations are all signs and symptoms of TMD. TMD prevalence in adults has been reported between 25-52%,2 and as high as 16% in children and adolescents.3 However, only 5-10% of the symptomatic populations require or seek treatment for TMD.4

Physical therapists are part of the interdisciplinary team that manages and treats TMD. Recently Anne Harrison, PT, Phd adapted the American Academy of Orofacial Pain’s diagnostic classification scheme in the Journal of Orthopedic and Sports Physical Therapy to help manage this population.5 Below is a brief overview of this classification system and some basic management ideas for TMD.

Classification

Arthralgia

• Pain in preauricular area

• Pain with end-range movements like jaw opening and lateral excursion

• Pain with joint compression or biting on a tongue depression opposite to the site of compression

Disc displacement with reduction

• Clicking with jaw opening and closing during at least 1 of 3 repetitions, or…

• Clicking during lateral excursion or protrusion during 1 of 3 repetitions

Disc displacement without reduction

• History of jaw locking or catching, but without current joint clicks or crepitus

• Range of motion with opening less than 40mm

Capsular adhesions of a single joint

• Possible limited mouth opening of less than 40mm

• Limited contralateral lateral excursion, protrusion with the jaw deflecting towards the affected joint

Osteoarthritis

• Suspect if arthralgia and crepitus are present

Masticatory Muscle Disorder

• Exhibits pain to palpation of masseter or temporalis

• Pain with mouth opening or biting

• May be limited to less than 40mm or less of mouth opening

• Opening range of motion can be normal as well
  

Basic Management Principles

Further study by the reader is required to understand and treat this condition. Some basic ideas are useful for any skill level of clinician. Depending on classification, some basic treatment options are available:

• Behavior modification

  • Teeth should only touch when talking or chewing. A good subjective interview will identify bruxism or habitual grinding during the day. Habitual retraining may be necessary to avoid clenching. A good cue is “teeth apart and breath.”

  • Diet modification (start a soft diet)

• Stress management

• Pain education and neuropsychological pain management

• Joint mobilizations increase Temporomandibular Joint Dysfunction (TMJ) motion

• Sleep hygiene

Exercise

Exercise should be prescribed to address the impairments noted during evaluation. It’s important to note that most exercise evidence and trials are low quality and at high risk for bias. Higher quality studies need to be performed to increase certainty that exercise is effective for TMD.6

That being said, the most well-known group of TMD exercises are the Rocabado Six.7

1. Resting tongue position maintained after making “cluck” sound

2. Scapular retraction

3. Stabilized neck flexion – grasp hands around back of neck and flex neck

4. Axial extension of neck – nod head into OA flexion and retract neck

5. Controlled opening of TMJ – tongue in position one, open jaw slowly with control, palpate in preauricular area with index fingers

6. Rhythmic stabilization of slightly open jaw

   • Tongue in correct position per first exercise

   • Maintain jaw positions with resistance into opening, closing, right, and left

Individualized TMD Treatment Plans

Dr. Harrison and colleagues have adapted this useful classification scheme for identifying and management TMD. Clinicians should be aware of competing diagnoses, such as primary headache, secondary headache, cranial neuralgias, CNS lesions, and central sensitization, to ensure an informed differential diagnosis. Thus, TMD is a more nuanced diagnosis and treatment than previously described in the literature. Behavior change, manual therapy, exercise, and pain science education are all options for individualized TMD treatment plans.

Image source: Henry Gray (1918) Anatomy of the Human Body. Revised by Warren H. Lewis. 20th Edition. Plate 995.

References

1. Griffiths, Robert H. "Report of the president’s conference on the examination, diagnosis, and management of temporomandibular disorders." The Journal of the American Dental Association (1983): 75-77.

2. de Godoi, Daniela Aparecida, et al. "Symptoms of temporomandibular disorders in the population: an epidemiological study." CEP 14801 (2009): 903.

3. da Silva, Cristhiani Giane, et al. "Prevalence of clinical signs of intra-articular temporomandibular disorders in children and adolescents: A systematic review and meta-analysis." The Journal of the American Dental Association1 (2016): 10-18.

4. Okeson, Jeffrey P. Management of temporomandibular disorders and occlusion. Elsevier Health Sciences, 2014.

5. Harrison, Anne L., Jacob N. Thorp, and Pamela D. Ritzline. "A proposed diagnostic classification of patients with temporomandibular disorders: implications for physical therapists." journal of orthopaedic & sports physical therapy3 (2014): 182-197.

6. Armijo-Olivo, Susan, et al. "Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: systematic review and meta-analysis." Physical therapy1 (2016): 9.

7. Mulet, Mariona, et al. "A randomized clinical trial assessing the efficacy of adding 6 x 6 exercises to self-care for the treatment of masticatory myofascial pain." Journal of orofacial pain4 (2007): 318.

Is Surgery Necessary for an ACL Tear? New Findings in ACL Management

By Andy Parsons, PT, DPT, OCS

In 2016, A cochrane systematic review compared conservative management after ACL tear to ACL reconstruction (ACLR).1 The review concluded that ACLR did not show superior outcomes compared to conservative management up to five years after the initial injury.1,2 Prior practice standards indicated ACLR based on age and activity level; younger patients generally had ACLR, and older individuals might forego the procedure. This could be the beginning of a paradigm shift for management of ACL lesions because some active individuals seem to perform well with conservative care alone.

Copers and Non-copers

The new paradigm is based on a subset of individuals with an ACL deficient knee that “cope” without the inherent ligamentous stability of the ACL. The “coper” group likely gets their knee stability “dynamically” from the muscle groups surrounding the knee as neuromuscular activation patterns change to provide stability to the ACL deficient knee. Non-copers do not function well without the passive restraints of the ACL, and surgery would be indicated in this group.

Once a Coper Always a Coper?

The literature is still trying to answer many questions regarding the feasibility of conservative management in this population. Even though we might be able to classify a patient as a coper or non-coper, there is no guarantee that the individual will remain in one discrete group.

In the primary study of conservatively managed ACL ruptures, 39% opted for ACLR by two years and 51% opted for surgery by five years due to knee instability (these groups were randomized and diagnostically selected for surgical or conservative care). However, in another study, 70% of subjects initially classified as non-copers were functioning well without ACLR at one year following non-operative treatment.3

A Shift Towards a New Paradigm?

Proposed criteria for classifying patients as a coper:3

• Hop test of >80% for timed 6m hop test comparing contralaterally

• KOS-ADLS score >80%

• Global rating of function >80

• No more than one episode of knee giving way since injury

A new version of management would include early referral to PT after ACL tear with treatment for about 10 weeks. During that time, the medical team would attempt to classify the patient as a coper or non-coper. Ultimately, If the patient does need ACLR, he/she would potentially improve post-surgical outcome by completing “prehab”.

 

Risks

Interesting, OA rates are actually higher in subjects that had surgery than those who did not.1 There was no difference in rates of meniscus surgery between the ACLR group and the conservative care at five years.2The biggest risk in the “coper” group is opting for ACLR at a later date.

Disclaimer

Non-operative management of highly active individuals remains controversial. The science is “young” on this question. The conservative treatment findings are based on one RCT. Further replication study needs to be completed before we can confirm if a group of “copers” really exist and what complications might arise with opting out of ACLR. Admittedly, Monk et al. describe the current evidence as weak that finds no difference between conservative management and ACLR. The ability to prospectively identify individuals as true copers or non-copers is fairly poor currently.3 One could argue there is significant waste of time, resources and thus potential harm to the patient if incorrect categorization occurs.

The Future of ACL Management

We may be in the middle of a paradigm shift in which a subgroup of active people with ACL ruptures can be managed as effectively with conservative care as they can with ACL reconstruction. Consistently identifying this subgroup is proving problematic, however.3 Categorization is likely fluid and an individual can move groups after initial categorization. Depending on patient goals, a trial of conservative care for the ACL deficient may be warranted.1-4

References

1. Monk, A. Paul, et al. “Surgical versus conservative interventions for treating anterior cruciate ligament injuries.” The Cochrane Library (2016).

2. Frobell, Richard B., et al. “Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial.” Bmj 346 (2013): f232.

3. Moksnes, Håvard, Lynn Snyder-Mackler, and May Arna Risberg. “Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation.” journal of orthopaedic & sports physical therapy 38.10 (2008): 586-595.

4. Snyder-Mackler, Lynn, and May Arna Risberg. “Who needs ACL surgery? An open question.” (2011): 706-707.