Physical therapy via telehealth: an interview with Justin J Ho PT, DPT, CSCS
Justin H Ho PT, DPT, CSCS
The following is an interview with Justin J Ho PT, DPT, CSCS, a physical therapist specializing in concussions and practicing at Lake Washington Physical Therapy, in Washington State. Justin is also a Concussion Alliance contributor. To reach Justin, send an email to the attention of Justin Ho.
Malayka and Conor Gormally, co-founders of Concussion Alliance, interviewed Justin on March 23rd; the interview has been lightly edited for clarity.
Malayka Gormally
Since we're all locked in our house, suddenly, telemedicine seems like the thing, right? At first, it seems counterintuitive that you could do telehealth for concussions and concussion symptoms. Have you done telehealth for concussion symptoms, or is this all new?
Justin Ho
I actually have an appointment set up for tomorrow. Someone had reached out to me for one of my first telehealth evaluations for concussion. Yes, it is counterintuitive at first. Still, when you realize that what you're trying to do is to provide information first, that's what telemedicine can provide, a purely educational resource for people to get at least their bearings and learn about where they need to go. Of course, there's going to be moments where you have to see certain providers and certain professionals in person. But up until that point, you just don't know where to start. Telemedicine, I think, can be that entry point for that.
Malayka Gormally
Are there some treatments that you foresee that you'll be able to do?
Justin Ho
What I'm anticipating, for example, with my patient tomorrow, is that I want to get their history down first and see what part of physical therapy I can provide for them. If I'm going to provide vestibular rehab, vestibular symptoms being dizziness and imbalance as a result of some dysfunction of the inner ear or the connection between the inner ear and the brain, I can give a lot of exercises through demonstration. I can share my screen with my patient, allowing them to see a video of me or someone else performing the activity that I would like them to try. There is a lot to do with home exercises a patient can do. The idea is that as you do the exercises, you're able to self-train, train yourself to get better. So vestibular rehab has a lot of implications for telemedicine because it's really hands-off, and I'm able to guide them to do the activity that helps the brain adapt.
Malayka Gormally
Would they practice the exercise and you could watch them practice it?
Justin Ho
Yes. Part of it's going to be making sure that they have a pretty good and safe setup and at home. I'll say, "OK, so you see that fridge there? I would like you to stand next to it and use it as support if necessary." We'll be running through balancing activities that we can do. I'll set the patient up in a corner so that they have both walls to their side in case they do happen to lose some balance if they're doing an eyes-closed activity. There's a lot of variabilities; it takes a lot of creativity to make it customized to their home setting, and if it's not appropriate, safety is number one, we'd have to adjust accordingly.
Malayka Gormally
So would they be taking their phone with them as they exercise? You can do Zoom on the phone, right? So they would take their phone and walk over to a corner and then, holding it, get your instructions?
Justin Ho
Yeah. There are many different ways to be flexible with the situation. If they're tethered to a desktop and the desktop camera, then I'll tell them to go attempt what they think is the right form, and then we'll go back and forth if necessary. For example, I'd say, "Conor, head over to the corner and, with your back to the corner, go and try to do this specific activity where you're balancing on one leg with your eyes closed." And then if they try it and they seem to succeed, they'll come back. Then we can have constant feedback from following this process.
Another way demonstrations can be done; I just step into my office wearing wireless headphones. The patient can provide me feedback if my camera needs to be positioned better and adjust accordingly. This way, I can at least demonstrate the activity for them in real-time.
Essentially, I am guiding patients to do their therapy at home and helping them understand what their symptoms mean. Ultimately people just want to get better, and they want to make sure they're not going to screw anything else up, so I address those concerns right away. If we're describing oculomotor activities, I have a couple of worksheets that I'll send to them that they'll print out, or we have to get creative if there's no printer. Together we will work on setting up different depths of vision and help train the eye. Conor, you've probably gone through the Brock string activities?
Conor Gormally
Yep, yeah.
Justin Ho
Right. It's like helping people do a DIY version of the Brock string because not everyone's going to have string and beads at home. Finding different things like that to be creative, to train oculomotor limitations can be a great start until clinics open.
Conor Gormally
Yes, for sure. So we've talked about vestibular therapy and oculomotor therapy, which are non-kinesthetic therapies for which there is not much of a limiting factor. But are there areas where there's a limiting factor of you not being able to be in the room? Are there any kinds of treatments where you see telemedicine as being a weakness? Are you trying to see if you can find a creative solution and maneuver around like the challenges of treating cervical problems or biomechanical issues or things like that?
Justin Ho
That's a great question because cervical spine or neck related problems are very common complaints after concussion. Many therapists are very comfortable using their hands, as I am, to help treat. Obviously, that's going to be entirely off the table. However, research is showing that a lot of manual therapy simply provides temporary and transient therapeutic effects. Sometimes, you can sidestep that using spinal mobility drills, or different exercises that address these impairments. The patient's main concern is that "my neck is hurt, it is painful, and if I do something, I'm worried it's going to break or worsen." As a PT, you can provide safe exercises and activities for them to do that can provide them permission to restore motion.
For example, I trained under the McKenzie Institute, which is a group from Australia, and they are primarily known for hands-off therapy for the spine. They help instruct their patients to go through certain movements, repeating end-range motions to help parts of the body become less painful and more mobile. The end range movements can help decrease nerve-related symptoms that are going down certain limbs. Additionally, the exercises can help desensitize the area in general.
For example, a simple thing that you could give people if they have neck-related pain is going to be a thing called cervical retractions. I call them double chins. During the visit, I would demonstrate, "OK, you're going to be sitting here, and you push back like you're trying to bring the point of your chin back to your neck, under the jaw." For a lot of people, this is painful, but you can help them understand that it is likely not a damaging activity. It actually can help solve problems by getting them to move into places that they're otherwise protected.
For cervical spine issues, I do prefer to do manual work. Still, with a McKenzie Institute toolbox, it's definitely something that I can implement with patients via telehealth, at least to start the process. There are also many stretches and back exercises that you can do by yourself that will ultimately help out a lot with neck complaints.
Conor Gormally
I feel like there's a lot of room, particularly for exercise, exertional physical therapy, via telehealth. I'd like to hear about any particularly interesting or novel ways that you are thinking about implementing that.
Justin Ho
The University at Buffalo concussion team have their published research on the treadmill and the stationary bike; their research validates exertional therapy. From a clinical standpoint, we have to apply it as early as tolerated after the patient's concussion. Telehealth-wise, you have to get creative. But in a time where everyone has a Fitbit or an Apple Watch, it is incredibly possible. It is helpful to have those smart devices to more easily teach exertional therapy with heart rate monitoring.
When the technology is not available, you have to teach people how to take their heart rate during the session. There's going to be limitations to that, but it doesn't have to be perfect every single time. My goal, when working on exertional therapy and applying this for people at home, is to help them understand what they're trying to do—explaining to them that they're essentially trying to find the heart rate threshold where their symptoms are triggered.
I would tell them, "We're going to keep you moving as much as possible while staying under that symptom-exacerbating threshold." If I were to do this tomorrow and the patient has a stationary bike, there is a straight forward protocol to follow to find their sub-symptom threshold. But if they didn't have a stationary bike, I would get them to march in place, see what happens; march with arm swings, see what happens; increase marching rate to a metronome set at 150 beats per minute, and see what happens. It's not perfect, but the patient can get an idea of what their threshold is. I could see this being pretty viable, at least for preliminary data.
Malayka Gormally
That's really interesting.
Where are you with issues about legality, licensure, and insurance, and how does insurance pay for telehealth, have you crossed any of those bridges?
Justin Ho
That's the thing that's changing, what seems like every hour. Pretty much all our organizations within physical therapy are trying hard to get our services covered. We're glued to the television waiting for what our president has to say about lifting all the HIPAA requirements, requirements about state borders, all the different things that have been barring us from telehealth. Telehealth has been a thing for a while, but until now, it's only been viable via cash payments for PT telehealth. In the state of Washington, most insurance companies are giving the green light to PT via telehealth, given the pandemic we are all experiencing.
I'm embracing the unknown right now and trying to be of service to the community. And yes, if a patient's insurance doesn't cover PT via telehealth, and they are not on Medicare, we can charge cash per visit or the minutes for the session. Then it's an agreement with a patient, and they sign some paperwork.
Malayka Gormally
Can you practice with people across state lines?
Justin Ho
Yes and no. Right now, that's a gray area. There's the PT Compact where your license is accepted in other states. Again, not every state is on board with this. I'll be curious to see where things fall there; one of my patients that left town to the East Coast because of the pandemic in Kirkland. And l had to tell them, "I'm not sure if I can provide physical therapy for you, just because the legislation is a little bit different state by state." I'm just hoping that after this all played out and we're all healthy still, that these legislatures will realize it's kind of silly to have state-by-state regulations and open up the doors. So, yeah, it's a very much uncertain situation. And that's the reason why telehealth has been so slow to become a thing; it's largely because it's hard to get paid for it.
Conor Gormally
I'm anticipating that this scenario is going to change a lot of paradigms and is already clear that it's happening. So hopefully, as you said, the result from this is that as many people as possible get out and get healthy after this whole situation. And the result of it is that we can reflect and look back at all of these things that we did as emergency measures but are actually useful.
Malayka Gormally
Well, the Coronavirus Preparedness and Response Supplemental Appropriations act addresses Medicare patients, and does cover different kinds of doctors, nurse practitioners, and social workers, but not physical therapists.
Justin Ho
Physical therapists not being put on the telehealth list approved by the Coronavirus Preparedness and Response Supplemental Appropriations act makes everything different. They have not updated that yet.
On a side note, I think the understanding that getting physical therapy or just seeing a provider early after a concussion is huge. I had been building this kind of telehealth platform, including the paperwork aspect, for the past three months. What I was hoping to create, even before this (COVID-19) happened, is an early telehealth assessment for concussed individuals. I was hoping to be a resource for the local schools, and their staff, so when their students sustain a concussion, they'd be able to get a telehealth visit pretty much right away. And we can rule in or rule out certain things and help direct them to get to the right places for care.
Malayka Gormally
Oh, wow, OK.
Justin Ho
Getting an immediate telehealth visit would be in contrast to, "We're going to wait for a week and see how our symptoms are before you go to your doctor." And then after you see your doctor, you have to wait for another couple of weeks.
Conor Gormally
Yes.
Justin Ho
That's the main thing. It's a time-based thing. And being a physical therapist, I know that the whole exercise portion is huge. And by being able to teach people that they can address their concerns and quarterback them to where they need to go early, I'm hoping that that makes the long term implications not severe.
So that's what I've been working on in terms of a platform. But obviously, this current situation accelerates so many things that may give me an opportunity and put me in a good position to do that.
Conor Gormally
Yes. There's been a lot of research coming out, particularly from doctors Leddy and Willer, who talk about how they really want to get people on the treadmill (or stationary bicycle) as early as possible to establish what kind of impact the injury has had. And so they were telling me that sometimes they're getting subjects on the treadmill (to test their perceived exertion thresholds) the next day after the injury. Sometimes it's the same day, a couple of hours later, after the impact.
Justin Ho
Yeah, it doesn't have to be perfect. The earlier you get the ball rolling, the better, and that's my reasoning behind this. So that's what I'm doing with my COVID-19 time. Thanks for taking the time to sit down and talk with me!