Orthopedics delivered via telehealth. It sounds counterintuitive: how exactly can an orthopedic practice – think injured knee, lower back pain, rotator cuff tear – work remotely? Historically, during orthopedic appointments, doctors use palpations — the method of feeling with fingers during a physical examination — to hone in on the patient’s area of pain and to identify the underlying issue causing it.
However, necessity is the mother of invention. The pandemic forced many areas of medicine to go virtual, and orthopedics was no exception. Miho Tanaka, an orthopedic surgeon at Massachusetts General Hospital, spoke with MedCity News recently in an interview where she weighed in on how her orthopedic practice not only adapted to telemedicine, but how its success prompted her practice to stick with the technology once the crisis period abated.
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Orthopedic in-person visits typically include front end paperwork, followed by X-rays or MRIs, then a physical exam where the doctor palpates the problem area to identify the root cause, all culminating in a discussion about where to go next. Going virtual means working how to address the physical aspect. In fact, during the pandemic the physical portion was the sticking point practices initially had to finesse.
“X-rays and MRIs can show pathology, but we are locating actual pain and inflammation [with palpations or resistance],” said Tanaka. “[We have transferred these] techniques to a virtual format.”
What’s interesting is that research supports the efficacy of virtually measuring range of motion, which is a major component of the physical portion of the visit. Other research studies also show that even for things like understanding knee angle, a high-speed connection is sufficient.
Tanaka’s practice has implemented several protocols to help virtual visits run smoothly. For example, patients receive directions on how to prepare for the virtual visit, including everything from having adequate high speed internet for a video call to how to prepare the physical space around them so the doctor can assess the patient’s movement (e.g. one needs to be 6 feet back from the camera and have the camera 2 feet off the ground, for a knee injury) to having household items to use as weights on hand (like a water bottle, which is roughly 1 pound, or a stapler, which is approximately 1/2 a pound). If the patient has a knee injury, shorts are necessary so the doctor can properly see the knee. This prep work allows the orthopedist to assess the patient effectively and to help the appointment run smoothly.
In a virtual physical, instead of palpating the area, the orthopedist coaches the patient through certain movements and assesses her mobility or lack there of, especially comparing one side to the other, to see the impact of the injury. This can include self-palpations or resistance work.
“This means being able to assess the patient in terms of how [she] walks, how [her] knee moves, even what [her] strength is in different parts of [her] body and what [her] function is in [her] extremities,” Tanaka said. “And then based on that we can do things like share the screen and go over the X-rays or whatever MRI [the patient has had done] and then have a discussion.”
Tanaka found virtual visits actually offered striking advantages over in-person visits. For example, when on a telehealth video call, the doctor can use 2D measurements to quickly quantify the patient’s range of mobility from, say, the good knee versus the injured one. Such measurements can be done in person, but require more steps and cannot be done down to the millimeter, Tanaka added.
Further, the option for virtual visits really benefits the orthopedic population in particular. Tanaka has several patients out of the area who historically would have traveled to her for assessment and treatment. However, if someone, for example, has a bum knee, she may not easily be able to travel via plane or car, having to use that knee to literally get to the doctor. With virtual visits, the patient can meet with the doctor without leaving the house. There’s also the added advantage of not having to pay for travel costs.
There’s yet another benefit of going virtual: patients can see her face. Current safety protocols for in-person visits include doctors wearing masks and other protective gear. However, those are not necessary for telehealth. And when discussing surgery or recovery timelines, seeing a doctor’s face can be helpful and builds trust, Tanaka added.
Separately, telehealth allows patients to not assume additional exposure risk if the patient or a family member is high risk for Covid, Tanaka mentioned. Additionally, patients do not have the same long wait times with telehealth that can accompany in-person appointments, she added.
Tanaka did have to get additional licenses in other states to treat out-of-state patients, which may deter some orthopedists, she noted.
‘With new patient evaluations and examinations, I think there are still some limitations there [with the palpations and physical], so the approach is to know and state limitations so the patient can decide if [she] wants to start virtual or not,” said Tanaka.
Despite the power of technology and the protocol she has painstakingly developed, if the patient was OK with a physical visit, Tanaka would prefer to do the first visit in person while subsequent events could be done virtually,
Photo: Maria Symchych-Navrotska, Getty Images
