Physical therapy via telehealth: an interview with Joe Mahon PT, DPT, SCS
Joe Mahon PT, DPT, SCS
The following is an interview with Joe Mahon PT, DPT, SCS, Lead Physical Therapist & Owner of Physio2Go. Joe Mahon is offering free physical therapy sessions via telehealth for concussion patients while shelter in place orders are in effect, contact him via his website.
Malayka and Conor Gormally, co-founders of Concussion Alliance, interviewed Joe on March 23rd; the interview has been lightly edited for clarity.
Malayka Gormally
We are working on doing coverage for our newsletter that is sensitive to everybody's situation right now. And so it seems like telemedicine is something we should be discussing. Please start by telling us a bit about yourself and what you're doing.
Joe Mahon
I grew up in New Jersey and North Easten Pennsylvania in the Pocono Mountains. I attended the University of Pittsburgh for my undergraduate degree in Rehab Science. I also completed my Doctor of Physical Therapy Degree at the University of Pittsburgh. I went on to complete a sports residency at the University of Delaware, where in addition to working closely with team sports, I honed in on my passion for rehabilitation of post concussion syndrome.
After my training was complete I began to work in a sports medicine clinic in San Diego. Ultimately, I started my own practice where I drive to homes, offices, and gyms as well as offering virtual PT sessions.
Malayka Gormally
Have you had much response yet to your offer to do free telehealth PT?
Joe Mahon
Yeah, it's starting to pick up. I was doing it with our existing patients when it made sense. Since COVID-19 we have had maybe eight new inquiries, and six of them have been scheduled. And I think that that's a pretty good quick response for a company of our size having just put the word out on Friday.
Malayka Gormally
I was listening to a podcast of physical therapists, one in Minnesota and one in Colorado doing telehealth before COVID-19. They were saying that each state has its own laws, and for example, typically, you can't do telehealth with a person in another state unless you're licensed in that state.
I know that the new Coronavirus Preparedness and Response Supplemental Appropriations Act that was just passed loosened some telehealth regulations for Medicare, but I don't know if that affects telehealth laws for non-Medicare patients. I believe it doesn't even address physical therapy. So I'm wondering if you're legally able to do telehealth for someone outside of California, for example. We have readers from all across the country and Canada.
Joe Mahon
Good question. It is state-by-state, and each state dictates what you can do. In California, if the patient lives in California, you have to have a California license. And that's typically true for most states. There is something called the PT Compact. Where say, you are licensed in Texas, and you're a member of the PT Compact. Then you can treat people in I believe it's twenty other states right now. There are still some restrictions even with the compact. The PT compact was present prior to the COVID-19 pandemic.
Right now, a significant number of states have lifted interstate treatment laws but it is not fully clear what needs to be done, in order to cross those state lines and help. Our viewpoint on it, right now in this current climate, is that we want to help people. We want to keep them indoors, and better to beg for forgiveness than ask for permission in a situation like this. So we're still looking into the full legality of interstate physical therapy sessions. But we're just going to add telehealth in the meantime, which takes some risk on, but something we're willing to do.
Malayka Gormally
So if one of our readers in California contacted you, then it's no problem. If it was somebody in Montana or New Jersey contacting you, you might be taking on some risk, but they would not be. Is that correct?
Joe Mahon
That's correct. They have no risk on their end, as a patient. We have PT’s licenced in Pennsylvania and California. We are building a network of PT’s licensed in other states as well for Telehealth When it comes to other countries, it shouldn't matter. So there are no issues with seeking out somebody in Canada or Spain or anything like that.
Malayka Gormally
Okay, because a fairly good percentage of our readers are Canadian.
Joe Mahon
Yeah. There's no issue there.
Malayka Gormally
Which software platform do you use?
Joe Mahon
We went with Doxy.me. It is really easy to use. We've had a couple of our 70+-year-old patients use it, and it wasn't a problem for them. It just sends you a text or an e-mail, and you click it, and it takes you right in.
Malayka Gormally
Yes, the podcast that I listen to with the physical therapists in Minnesota and Colorado, they both use Doxy.me well, and they spoke highly of it.
Which concussion symptoms are most easily treatable with telehealth and conversely, which concussion symptoms can you just not treat through telehealth, or are difficult to treat?
Joe Mahon
I think that concussion is one of the more treatable telehealth conditions if you think about how your exam is set up. There are limitations but it can be done effectively. I think it's about just shifting your exam to match the video portion of it.
We can still complete a thorough subjective exam, which for concussion is the most important part of the exam. You can complete an oculomotor exam. The brightness of a screen can be a barrier for some people. But you can still get the information you need to treat it. The cervical spine can be assessed as well, but again with some limitations. You can see range of motion but it gets a little bit harder when you're trying to determine their neck strength, or if you usually try to figure out through palpation what structures are bothering them. You're limited there. And then if there's a vestibular piece, you can't do the head thrust test to assess how their vestibular system is functioning. But you can check their balance still, and you can give them other functional tasks; it's just different.
Malayka Gormally
So that's the assessment part, right? And then there's the whole treatment part if you go down the same list, which ones are easier or more difficult to treat?
Joe Mahon
Yeah, the easier ones to treat are going to be to the oculomotor and the vestibular and movement sensitivity pieces because you can show somebody exercises to do one time, and they can get it. They can do it. They're straightforward. When I was in a clinic setting, with those people who only had an oculomotor piece, I would say, look, do these exercises come back in a week. You know, you only have 20 PT visits, I don't need to see you twice a week to do these exercises. Call me if you are having issues with them. And so those oculomotor issues are going to be easy to treat. Then you have the tougher part; anybody who would need some sort of a hands-on approach to their cervical spine because they're having pain that responds favorably to manual therapy. That's the tough part. But you can still give them strengthening exercises, and there's always a battery of things you can do.
Conor Gormally
And I imagine you can't train someone virtually; you can't exactly train a family member or a quarantine buddy to do any kind of manual therapy. That's not a particularly safe practice, right?
Joe Mahon
Yeah, exactly. If there are little things, it's no big deal if the patient has a spot that hurts, you can put your thumb on there, put some pressure if it feels good. You're not going to be virtually teaching people how to do joint mobilizations or any sort of special techniques.
Malayka Gormally
Yeah, that's unfortunate. We were just at the North American Brain Injury Society annual conference. At the conference, Dr. John Leddy said that cervical spine symptoms are one of the things that don't go away on their own, that they usually try to treat early on.
Joe Mahon
Yeah, the manual therapy part of it. But the evidence is mixed. There are lots of people out there who would argue that you can still treat the cervical spine without doing any manual therapy at all. They believe that it comes down to correctly applying force and load to the spine. This is done with strength training and exercise, rather than manual therapy. Some feel that the hands-on piece is just a feel-good part. I'm somewhere in the middle of all those arguments, where I see the value in manual therapy, but definitely, exercise alone can have strong benefits as well.
Malayka Gormally
So the "forces and loads" in layperson's terms, does that mean exercises or what does that mean?
Joe Mahon
Yes, exactly, strength training and movement.
Malayka Gormally
OK.
Joe Mahon
You are referring to Dr. Leddy, who developed the Buffalo Concussion Treadmill Test, correct? The goal is to help people return to exercise and aerobic training safely. You've got to assess the patients symptoms when they're in an exerted state. And it's doable over telehealth, but it's not exactly like everyone has a treadmill in their home or blood pressure and a heart rate monitor. But more and more of those things are easily accessible and relatively cheap.
Malayka Gormally
Dr. Barry Willer, who works closely with Dr. Leddy, sent us a Dropbox with all the information one needs to do these individualized progressive aerobic exercise programs and essentially do your own treadmill test. That's something we're looking at making available, potentially through our website. So you would be working with people to develop an individualized progressive sub-system aggravating aerobic exercise program.
Joe Mahon
Yeah, I read one of their papers as well, where they talked about treating the exertional component of PCS for athletes with a home program, based on exercise boundaries determined by an examination and follow-up conversations as needed. That's supposed to be the approach while treating the exertion symptoms virtually. I take the role of getting symptom scores from them when they exercise, how hard they exercise, doing a self heart rate check, and then helping them dose further exertion from there.
Malayka Gormally
I'm thinking about the International Consensus Statement on Concussion in Sport, going down the list of treatments that they feel are evidence-based, and you've covered quite a few of them. Do you know where someone might get cognitive behavioral therapy or cognitive behavioral therapy for insomnia in a telehealth setting?
Joe Mahon
Good question. I don't know anybody off the top of my head who does that. But I'd have to imagine anybody who does operate would be willing to move in this direction right now, especially more than ever.
Malayka Gormally
Do you feel like it's OK for people to self refer to you or another telehealth physical therapist? Or do you believe it's essential for them to try to get a telehealth consult with a neurologist or a neuropsychologist to make sure there isn't anything more serious underlying it? How do you talk to people about this issue?
Joe Mahon
When I get any concussion self-referral, my first question is, "have you been screened by a medical doctor?" Ninety-nine percent of the time, I feel comfortable with my assessment not having to send someone to a doctor. But I'm not a medical doctor. So there's comfort and safety in having them be screened by a physician who knows what they're doing with concussion to make sure that there's not an underlying condition.
My recommendation is that they should have been seen by a doctor in almost all cases after their concussion. If there is somebody who's had a concussion and they've been screened by a medical doctor, I'll take them on. And if they have not been screened, I will still do my assessment; I wouldn't turn them away. I'll go ahead and do an evaluation, and then I'll hold off on any treatment until they've been cleared, which I will assist with. There's my typical policy.
Malayka Gormally
OK. So you would meet them via telehealth, do an assessment and then say, "I can't treat you until you see a doctor" in this case. Right now, it's probably finding a telehealth doctor.
Joe Mahon
Yes, exactly. I would say, with fair certainty, in this case, this is likely a concussion. But before we move on with giving you any exercise that might make things worse, it makes sense to be assessed by a doctor. This is your brain; let's make sure there's not a bleed or something else happening in there.
Malayka Gormally
Are you working with any doctors, neurologists, or other professions that are doing telehealth for the initial assessment, and for a referral?
Joe Mahon
No, I'm not right now, most of the doctors that I had any relationships with were doing things in person. And I haven't heard of anyone fully going to telehealth. But right now, I imagine they are. It's been a whirlwind, so I haven't heard from anybody.
Malayka Gormally
I was just struck by USFHP (a division of Tricare) closing their entire PT department due to COVID-19.
Joe Mahon
I think that's happening across the military. We got a couple of phone calls from some military members already across the country. Those were some of the new calls we had earlier this week saying the "the PT department I was going to has closed down," so now we've been offering them telehealth PT for free right now, and just helping out.
Malayka Gormally
I've heard that the VA. is very good at doing telemedicine. Have you had any interactions with VA. physical therapists doing telehealth or learned anything from them if you have?
Joe Mahon
No, I haven't explored that at all. I know the VA is very proactive with telemedicine. I haven't spoken to anybody doing it at all.
Malayka Gormally
Well, I think we covered everything. It sounds excellent, and thank you for doing this. We appreciate it.
Joe Mahon
Yes, if there's anything else I can do, let me know, and I'm happy to be in touch.
Malayka Gormally
Thank you, Joe. Well, I'm sure we'll be in touch.
Joe Mahon
Yeah, no problem, if you guys can think of anything for me to do, let me know.
Malayka Gormally
OK. We will do that. Have a great day, Joe.