Our articles are not designed to replace medical advice. If you have an injury we recommend seeing a qualified health professional. To book an appointment with Tom Goom (AKA ‘The Running Physio’) visit our clinic page. We offer both in-person assessments and online consultations.
The brilliant Maryke Louw joins us today to answer your questions about online consultations. Maryke has been providing video assessments for 6 years and has been running an online-only service since 2019. She’s also a great physio with years of experience and someone I’ve had the pleasure of working with to treat elite athletes. Make sure you follow Maryke on Twitter via @SportPhys and check out her website and youtube channel.
1. How can we do tests that might require closer assessment such as muscle strength or neuro tests?
You can’t do all the tests that you would do in a physical clinic. I always triage my online patients if I feel, from doing their subjective interview, that there is a high likelihood of serious injury or red flags or serious/progressive neural disease.
For all other conditions I tend to get my patients to replicate the test movements actively. You are a bit limited with performing neuro tests, but you can still get a general idea by talking the patient through it. I’ve generally found that if I explain to a patient what I would like to test and why, most of them are really good at making observations.
It becomes a bit more difficult when you have a patient who is catastrophizing because you have to be careful not to increase their level of concern. So make sure you choose your words carefully – too much detail and information could be a very bad thing in those cases. I sometimes even leave certain tests out if I feel that it is safe to do so and that the outcome will likely not change anything in my management but may very likely upset the patient further. I’ll then maybe test it in the second session, once I’ve managed to settle the patient’s levels of anxiety a bit.
Examples of neuro tests you could do include:
• Sensation testing by instructing the patient to touch different parts of their body.
• You can usually test muscle strength to at least 3/5 through active movements and possibly 4 to 5/5 by getting them to lift weights (anything heavy in the house) or use exercise bands etc. It depends on the patient’s level of pain and the site of injury.
• Neurodynamics: Get the patient to do the movement pattern actively. You may not pick up fine differences,but it does allow you to notice large differences. The slump test is very easy to demonstrate and talk people through.
Reflex testing is probably an example of a test that can’t be done remotely. Keep in mind that most of our special tests have very low sensitivity and specificity in any case. Your subjective examination (special attention to mechanism of injury and pain/symptom behaviour) becomes much more important when you do online consultations.
2. Any tips on doing concussion assessment over Telehealth?
You can definitely do all the memory and cognitive tests easily via video call. Same goes for the balance tests. I wouldask the patient to have another person present who can handlethe camera. This will allow the patient to fully concentrate on the tests and help to ensure that you can see the full picture properly.
Cervical palpation is likely best done in person, but if there is no other option I would ask the patient to run their fingers down the knobbly bits that they can feel in the back of their neck and press on each one. Again, the subjective interview and active movements will also help to inform your decision with regards to management.
3. Any ideas around creativity if only able to connect via telephone call?
I tend to replicate the movement on my end while I talk the patient through what I want them to do. Experiencing the movement at the same time helps me to come up with cues to guide the patient better.
4. What is the general response of patients to online consultations?
Very good. I always follow my consultations up with a summary email to the patient and that will often prompt them to write back and thank me for the session. Comments can be grouped in three main categories:
• “I feel so relieved now that I know what is going on” or “You’ve put my mind at ease…”
• “It feels good to have a plan in place…” or “…to know what I should be doing”.
• “I feel so relieved that someone has finally listened to me…”
If I had to analyse why people are so satisfied, I think it’s likely because I only see people who actively searched for an answer online and when they book in with me they really want to see me. They’ve usually already tried lots of other treatment options, including massage and hands-on physio,which hadn’t worked, so they don’t feel that this is a second-best option. I’m not sure that you would get the same response if a person was told that they had to use an online physio and wasn’t allowed to see someone in person.
5. What’s the biggest challenges faced with online consultations, and how “convinced” are patients really with the validity/efficacy of it?
I don’t know what my patients had thought about the validity/efficacy before they booked in, but they have so far all been happy with the outcome and I have had plenty of word-of-mouth referrals and return customers (for different injuries). And these people aren’t living in remote places where they can’t access hands-on physio – they’re from places like London!
When I first started working online, my biggest challenge was to make people understand that they didn’t need anyone to touch them in order to recover. Every single person I told (including physios) about what I was doing used to ask, “But how can a physio treat a person without touching them?” I’ve had to do a lot of education on the subject.
An exercise that helped me with my marketing was to write down every reservation I had about online consultations (because these were similar to the ones other people mentioned) and answer them.
Listen to that little voice in the back of your head that is constantly shouting out reasons as to why online consultations can’t work or isn’t good enough. Write them all down and then answer them. Share those answers with your patients and the rest of the world. Don’t try to forcefully convince people or force the service on them, rather just educate them about how the body heals and how remote consultations can provide the support needed to facilitate the process. Take a look at the video below which demonstrates this.
6. How do you manage the logistics: Space and set-up requirements, earbuds vs. not, tablet vs. laptop? Other recommended equipment to have on hand?
Before the appointment:
• I encourage my patients to send a bit of background information through as part of the booking process by having a section titled “Message for your physio”. This is an optional section but everyone has so far filled it in. I’ve left the question vague and open so that patients can share what is most important for them. It’s amazing how that simple question can sometimes result in me receiving a 4-page PDF and other times just a one-liner. This helps me to plan the session a bit and to get an idea of my patient’s personality and their beliefs about their injuries.
• I send my patients an email with my contact details and info about the session e.g. please make sure you have enough space to move and lie down on floor, works best to call from a device you can move around e.g. phone, tablet or laptop…
My Tech:
• These days I use my phone for most consultations because it is very easy to move around and the picture is good. Laptop works well, but can be annoying to move around.
• I’ve got a £10 tripod from Amazon that I would not want to be without. Get yourself a tripod! It makes your life soooooo easy.
• Wireless earphones are a must. It cancels out background noise, prevents any echo and allow you to easily move around the room.
• Room with good light and fair bit of space. I travel a lot and have done consultations from a variety of settings. So far, my niece’s bedroom with lots of fish pictures on the walls has been my patients’ favourite.
• Make sure you draw the curtains or, if they are open, you don’t have any windows behind you as it will make it very difficult for your patient to see you.
• I always have a mat, ball, theraband and chair handy. Weights can be improvised with stuff in a bag etc. A thick book (Lonely Planet Southeast Asia in my case) works well if you want to demonstrate exercises like heel drops and you don’t have access to a step.
7. What do you charge relative to face to face consultations?
I charge exactly the same as what I changed when I worked ‘hands-on’. We shouldn’t undervalue online care as it delivers the key aspects of treatment well.
8. Are there any legal or privacy issues we need to be aware of?
Yes! Data protection is massively important, and you can find clear guidance on the ICO’s website. Make sure you have watertight Terms and Conditions of use and purchase on your website and that it also complies with the consumer law.
I mainly use Zoom, they have a GDPR Statement and Privacy Policy that are worth looking at to see how it fits within your organisation.
9. What special tests can you do with online consultation since you’re not physically able to palpate/ touch your clients?
Think about what happens in the joint etc. when you perform the special test and how you could get the patient to safely replicate that. For meniscus strains you could for example get them to deep squat with their legs in different degrees of rotation or perform Thessaly’s test.
If the mechanism of injury is highly suggestive of a severe ligament injury e.g. ACL tear, I’ll rather refer the patient on without even trying to stress the ligaments in testing as that would very likely not be safe to do.
Here’s a question for you: Do you really have to be able to distinguish between a grade 1 and 2 MCL tear by doing a valgus strain test if you’re in any case going to treat your patient according to his symptoms and his level of strength and control?
10. What’s the optimal duration for online consultation session?
This will depend on the patient and condition. For most of my sports injury patients a 45min initial and 25min follow-ups are perfect. But I find that any patient with a lot of yellow flags and who requires a lot of reassurance needs 45min follow-ups. Also, for conditions like back pain where patients move a bit more slowly and the exercises may require a bit more careful instruction, longer appointments are better.
It also depends on you and how quickly you work. Maybe start with longer appointments and as you get used to the process you can always redesign your offer.
For more from Maryke follow her on Twitter and check out her website.
