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PT and the Greater Good

Just Phone It In!

Published February 26, 2013 12:45 PM by Dean Metz

A piece of research came out in the British Medical Journal at the end of last month regarding tele-physio. I've been a vocal critic of this practice "development" in this blog and to anyone who will listen. This is an important piece of research. If American PTs are inclined to brush it off as some silly NHS protocol, they'd be wise to contemplate whether or not managed care companies might pay close attention to it!

This is not a bad piece of research, but there are some areas that I think need addressing. The investigators used a large number of participants, but not ethnically diverse with more than 95 percent being Caucasian. The patients allocated to tele-physio were "invited" to call back after the initial telephonic consultation. No mention is made of how many failed to call back. Is it being assumed that they were fully managed with the one call?

The group allocated to tele-physio had 53 percent progress to some face-to-face intervention, with 43 percent being managed by telephone only. These two subgroups are lumped together in the analysis, when in truth, they are deserving of separate analysis! I would really like to see how these two subgroups compared to each other in addition to how the combination compared to "usual treatment."

There are also issues with the timeframe of measurements. If the initial follow-up was at six weeks post-referral, but some people still hadn't seen a physio at that point, then how can one measure impact? Yes, there's a problem with access to physio in the UK, but I don't believe this study truly supports tele-physio as a solution.

I do credit the investigators with a robust discussion on the strengths and limitations of the study. I can see a benefit to a telephonic triage prior to face-to-face interventions that could shorten wait times and initiate action sooner than is current practice. I can see this approach benefiting more rural settings where access is limited. I can't yet see the evidence for this becoming mainstream practice.

Lastly, having seen this practice in action in England, I take issue with practical applications. The study used senior physios to perform telephonic interventions. In practice I have seen Band 5, new graduates in the role who lack sufficient experience to ensure patient safety. I also question their investigation into adverse events (none?). I personally know of three people who performed a home exercise program that was mailed to them after telephonic consultation. All three performed their exercises incorrectly and two wound up aggravating their presenting conditions.

What are your reactions?



Like I said, send a PTA to the patients home the next day for a follow up.  It would be like writing a goal for HEP and the PTA would ensure the exercises are done correctly.

With digital technology exercises can be sent directly to a patients e-mail address, via computer or phone. The patient could even video tape themselves doing the exercises and send them to you if you needed confirmation.  If the PT is savvy a link to a youtube video will help the patient as well.  

I guess the bottom line is which exercises were given to the patients in your blog.  I have not seen many patients mess up when doing ankle pumps, LAQ, marching, and ab/adduction while seated.  

Jason Marketti February 27, 2013 9:40 PM

Jason, if it is the PT's responsibility to ensure activities are done correctly (and I don't disagree with that), I don't believe that can be done with just a telephone conversation. So often, even after a correct return demo of a home program, the next visit brings some interesting variations on a theme in terms of what patients were originally taught.

What is your idea for ensuring correct performance of activities when there is no face to face or opportunity to observe a return demonstration?


Dean Metz February 27, 2013 8:58 AM

This is a good debate issue.

Telehealth is being done in Wahington State.  It will be questioned for some time until people realize it can decrease costs and improve accessibility.

Supervisory visits for the PTA can easily be accomplished through telehealth.  MD's have been doing telehealth for several years, its just a matter of time before the rest of the healthcare world catches up.  

Exercises performed incorrectly were either too complex for the patient or not explained clearly to the patient, in either case it is the therapists job to ensure the patient understands the activity.  I doubt a therapist will send McKenzie exercises or encourage a family member to perform rhythmic stabilization on a patient through the mail after a telehealth appointment.  Why not send a PTA to follow up the next day to ensure this wouldn't happen in the US.  

Jason Marketti February 26, 2013 10:50 PM

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About this Blog

    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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