Sarah Gallagher on Telehealth, Vestibular Therapy for Concussion
Sarah Gallagher, PT, DPT, NCS is the owner of South Valley Physical Therapy and is a member of the Vestibular Disorders Association, American Physical Therapy Association (APTA), and Academy of Neurology. She summarizes literature for the Vestibular Rehabilitation Special Interest Group and is the Vestibular Telerehab Task Force chair. Her clinic has offered telehealth for the past three years and specializes in neurologic and vestibular disorders.
Malayka Gormally, Conor Gormally, and Julian Szieff interviewed Sarah Gallagher this spring about the clinic and its work; the interview has been lightly edited for clarity by Srishti (Shelly) Seth.
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Interview Highlights
Overview of Clinic
I'm the owner of South Valley Physical Therapy Clinic, and we have been specializing in neurologic and vestibular disorders for 30 years. I'm not the original owner; it has changed hands several times. It has always been a specialty clinic and with a subspecialty of vestibular disorders, dizziness, and balance. A high percentage of our population is concussions and head injury, so that is a considerable portion of what I have treated in my career. Prior to working in an outpatient setting where I've been for the last eight years, I worked in a hospital and acute setting, focusing on trauma and more severe TBI. So lots of head injury in the acute phase as well.
Covid-19 and telehealth
Before COVID-19, we treated patients with a limited number of insurance companies reimbursing us for telehealth services. But what you can do is different from every state, every insurance company, and every insurance plan. So just because you have Blue Cross, and one Blue Cross plan says, "Yes, you can do telehealth," that doesn't mean that another Blue Cross plan also says "yes." There's a lot of background work that goes into our planning of telehealth sessions prior to them actually happening.
I've been working closely with the APTA, the American Physical Therapy Association, and specifically the health policy section. The APTA has been a strong advocate for telehealth for a long time, trying to lobby for Medicare reimbursement well before COVID-19 came, and demonstrating the necessity of telehealth. We submitted a paper for advocacy of telehealth to be published to a physical therapy health policy journal. We are also disseminating patient satisfaction surveys to patients so that we can collect data on telehealth, such as what works and potentially what doesn't work. We're also contacting all of our legislators to persuade them to continue telehealth beyond COVID-19.
On the 2020 Clinical Practice Guidelines for Physical Therapists Evaluating and Treating Concussion/mTBI
I think clinical practice guidelines are beneficial for the profession in general because not everybody specializes, so it gives people a roadmap to best practice. I think those of us who practice in high volume, concussion patients are more of our typical patient population, and we know where to modify potentially from the clinical practice guidelines. But the clinical practice guidelines are an excellent evidence-based roadmap that gives providers a direction and helps them with their decision making about how to guide the patient's care. So I am a huge advocate for their creation and adoption.
Telehealth
Formally, we have been using telehealth for the past three years. We started using it through just pay-for-service. So cash pay essentially is when people couldn't find a specialist for dizziness, balance, or concussion. And then we started working on bringing it into our company so that it could be reimbursed by insurance. So it's been about three years that we've been doing it on a formal basis and the past two years for insurance reimbursement.
Right now is very unique because many insurance companies and commercial insurance companies are covering telehealth services. And we're trying to collect a lot of data and be advocates to hold onto this telehealth service. Patients in different locations need different types of providers, or it's difficult for them to get to the clinic, especially if one of their symptoms is dizziness. So we're trying to make sure that this doesn't become a temporary crisis, three months allowance, and instead say, "Telehealth is something that patients actually need long term."
And I just wanted to mention that the whole reason we've started doing telehealth was not because of COVID. We saw a need several years ago to match the right providers with the right patient. That's what the driving force was behind pursuing telehealth. Because it was a lot of work to research to make sure we comply, follow the legislation, and communicate with insurance, practitioners, and patients. So it was a lot of work to get that setup. But the driving force was that the patients could have access to the right provider when they need it. It shouldn't be, "Oh, I just found out about you from a neighbor ten years after my accident, and this has been the most helpful thing I've done in ten years." It should be, "I live in the mountains." Or "I live three hours away from you, I was referred to you, and I can start this right now." Not after not knowing about it or not having access to you, or just going to the person who treats concussion in my region because that was the most convenient. So really, it was to match the right providers to the right patient and the proper diagnosis at the right time when they need it.
We're in Wyoming and Colorado, and we've recently added Florida. And we're open now with COVID-19, and things have opened up with telehealth and people are more accepting of telemedicine. We're open to adding more states as we get approached about it.
Neurological Physical Therapy Specialization
The American Physical Therapy Association determines the specializations, and there are several of them. The largest group is the orthopedic specialization, and then there are also neurologic, women's health, geriatrics, oncology, pediatrics, cardiopulmonary, electrophysiology, and sports physical therapy. For all of those specializations, there are standards for your practice, and how much you have to work with that patient population. You have to demonstrate that you have enough experience in that patient population, and then you study for a board exam. You apply to take the exam, and you put in an application showing that you have enough proficiency to take the exam potentially, and then you take the exam that's given once a year. And then if you pass, you are technically then a specialist.
I did that for neurologic physical therapy, and I'm a huge advocate for creating a subset or another specialization for vestibular physical therapy. Right now, it falls under neurologic, but it is especially important with the concussion population, so vestibular is really its own specialization. We are trying to get vestibular physical therapy approved as a specialization as well. And I think the challenge is not so much that we need to, anybody can be an expert, you don't need to have this board exam, you can be self-driven. I could have done all the work, studied, and not taken the exam and still be just as much an expert practitioner. I think the issue is how the patient finds the best fit of a provider for them.
This specialization allows patients to say, "Oh, okay, this is the right type of provider for my specific issue. This is somebody who really focuses on this population." I think that is the most valuable part of the specialization. Of course, it drives our profession for advanced learning, but you don't have to be a specialist to necessarily be an expert in that care. So it has some standardization across the board, and I think it's great because it elevates our profession. But I think the best thing specialization does is that it helps match patients with the right type of provider.
I think the VeDA search is a useful tool. But to be a part of that search, you have to be a member and listed as a provider with VeDA. So another search tool that I think is excellent is through the Vestibular Special Interest Group of the neurologic section of the APTA. They have a provider map, and I use it all the time because if I have somebody across the country who reaches out to a patient of mine or me says, "Oh, I have a cousin in North Carolina, do you know anyone?" The Vestibular Special Interest Group search tool is a database of active members. A vestibular therapist is going to be your closest match to a concussion specialist. [The APTA also has a Find a PT search tool with a dropdown list for specialists.]
Patient with persistent-post concussion symptoms looking into PT: this section includes dialogue between Malayka, Conor, and Sarah
Why a therapist specializing in vestibular is a great choice for any concussion patient
Malayka:
For someone with persistent concussion symptoms that don't include dizziness, where do they start in looking for a PT?
Sarah:
Well, I think that a vestibular therapist is an excellent choice because vestibular therapists don't just treat the dizziness. They're looking at more sensory integration, and that's one negative of a specialization: it makes it seem like you have to have a specific set of diagnoses, or symptoms, or signs. So I think a vestibular therapist is a perfect person because, as you all probably know well, these concussions usually do not have isolated symptoms. So if a person has one symptom, they likely have several other symptoms, or the symptoms come and go, or this is my most prevalent symptom. And so I think a vestibular therapist treats all of that. The reason why a vestibular therapist, I believe, is more qualified is that if you look at the research, the most complicated or unremitting cases of concussion are those that have dizziness initially. And so vestibular therapists are going to see those patients who are dizzy, which means that they're going to see those most complicated patients. So even if that dizziness goes away, they're the most experienced specialists to treat people.
Conor:
Because I imagine if you do address that kind of dizziness or kind of clear vestibular problems initially, they're still your patient. As you said, concussion symptoms are more likely to be symptom clusters. They're likely to be originating from a lot of different sources. We went to a fantastic talk by Dr. Nathan Zasler on post-traumatic headaches.
And so I imagine that you usually continue to see those patients and have some experience dealing with or helping the resolution of other symptoms. Are there any specialty things from the neurological subspecialty aside from vestibular that you found to be particularly helpful with treating concussions?
About the autonomic nervous system
Conor:
There's a lot of evidence concerning the blunting of the autonomic nervous system following concussions. And then, of course, obviously headaches and fatigue, oculomotor issues, and cognitive problems. I know that you mentioned that neurological physical therapy is a subset of the APTA's group -- it's one of the APTA's subgroups that you can specialize in. But I'm wondering from your specialization outside of vestibular therapy, is there anything that you found to be particularly helpful in potentially treating some of these other symptoms that could be stemming from vestibular issues, cervical spinal, or autonomic nervous system dysfunction?
Sarah:
I think one of the things that have set our practice apart is that we carefully look at that autonomic nervous system and its interplay with the vestibular system, because there's such a close connection between those two neurologically. But then also, especially when symptoms are continuing to be persistent, we find that treating the autonomic nervous system is the key in there. And so maybe the dizziness isn't gone, but that head fog, that heaviness, that pressure, that cognitive fog, headaches, that sluggishness, that heaviness, those ups and downs, tends to be highly autonomic. We're looking at the autonomic nervous system and helping it regulate more regularly automatically. But we are not thinking of it as a dysfunction of the autonomic nervous system, what you might think of for something like POTS [Postural orthostatic tachycardia syndrome, more of a dysregulation.]
But more so thinking of the autonomic nervous system, it doesn't know how to regulate itself. Like when it's appropriate to be more sympathetic, and when it's necessary to come back more down to parasympathetic. And where's that homeostasis? And let's help that patient achieve a baseline equilibrium and go in and out of that as appropriate. So I think that's a huge part of concussion treatment from our perspective. And dizziness definitely has an overplay, that's how the patients end up coming to us. But I think we look at that autonomic nervous system piece of it even more closely than we do dizziness because the dizziness was almost a little bit easier to treat.
How you treat the Autonomic Nervous System (ANS)
Malayka:
What do you do for ANS problems?
Sarah:
We try to look at the patterns of where the person is. So what are their triggers for coming into a high sympathetic drive or like a parasympathetic tanking? Are those appropriate responses to the triggers, or are they having escalated responses to those? And then teaching them how to find that baseline and also recognize when they're either elevated/sympathetic or depressed/parasympathetic and bring it back to that baseline, shoot for that baseline.
So it's a lot of education and training. For example, the parasympathetic system prepares us for activities like resting our bodies and digesting our food. When we have someone exercise, for instance, if they are more parasympathetic, this can lead to symptoms like brain fog and exhaustion, then we want to elicit more of a sympathetic drive. Whereas somebody who might be stuck more in the sympathetic drive and hyper-vigilant, and their nervous system is hyperactive and hyper-responsive, we want to bring that down. And so we use a lot of techniques to teach them how to recognize that and bring them down to a more appropriate level.
I think that the vestibular therapists and neurologic therapists are still at the top of the more expert level practitioner, and it's not as widespread. Like you're not going to see this kind of work in the CPGs, in the clinical practice guidelines. Maybe it's starting to get some attention, and it's presented at national conferences, but it's certainly not mainstream. If you're a regular practitioner and look at the clinical practice guideline, it's not going to give you a lot of information on how to assess and treat this. So I do think vestibular therapy is an excellent start because it has such a strong connection to the autonomic nervous system that most vestibular therapists are familiar with that and do treat that to some degree. But, again, it's practitioner to practitioner.
Malayka:
Are you able to conduct these techniques over telehealth?
Sarah:
Yeah. Oh, definitely.
Malayka:
Do you treat across state lines right now with telehealth?
Sarah:
We are licensed to treat patients located in Colorado, Wyoming, and Florida. The PT compact makes it easier for obtaining licenses in other states that may allow telehealth. We plan to add additional state licenses, especially as telehealth legislation increases to improve access in more states.
Malayka:
The only thing I've seen in that international consensus was that exercise could help with ANS problems. But it sounds like you have a whole toolkit beyond that, is that correct?
Sarah:
Well, I would say that it's customized. For example, to give you a patient case, if I have a patient do an exercise that is supposed to be provocative, meaning elicit symptoms. Let's say I'm having them do a movement that's stimulating their inner ear, and brings on some dizziness, what this potential patient might feel is like, "Oh, my gosh, I just have to lay down and take a nap. I just spun around in a circle one time, and I just feel like all I can do is put my head down and like go to sleep." So that would be an example of parasympathetic tanking, right? Instead of becoming more hyper-vigilant, he's saying, "I got to lay down and let my whole system decompress."
This is not necessarily the appropriate response; that's an extreme response. If it's eliciting that parasympathetic response too much, I would have him do something that elicits a sympathetic response, like an aerobic exercise to bring his heart rate and blood pressure up. Then, for example, I could keep his head still by not having him move his head or run in place. Alternatively, I could have him lift weights very quickly overhead to bring his blood pressure and heart rate up, which would help stimulate a sympathetic response. This sympathetic response would help him have more of a normal response to that initial exercise to counteract the parasympathetic tanking.