Virtual Preoperative Physical Therapy: Educating Patients Effectively in the Comfort of Their Homes

Total joint arthroplasty (TJA) is an effective procedure performed to improve the quality of life for patients with pain and functional limitations as a result of end-stage arthritis [10,13]. Patients recovering from TJA have high expectations for pain relief and functional outcomes [5]. Outcomes are improved when information and education on a patient’s upcoming orthopedic surgery is provided in a timely manner [5]. Preoperative education programs are beneficial for TJA patients, especially when compared with postoperative education programs [5,13]. Preoperative patient education empowers patients to be involved in their surgical pathway, sets appropriate expectations for themselves and their families, and allows for decreased anxiety that potentially results in a shorter hospitalization and fewer complications, both in hospital and after discharge home [1,2,9,12,13].

Historically, at our institution, Hospital for Special Surgery (HSS), all patients attend a preoperative group education class taught by a multidisciplinary team consisting of a nurse educator, social worker, and physical therapist (PT) [11]. Research conducted at HSS has further shaped our rehabilitation program for arthroplasty patients, resulting in the creation of a one-on-one preoperative physical therapy education (edPT) appointment that the surgeon has the option to order for each patient. This option of an individual one-on-one edPT appointment was a change from educating patients only in a group setting. The individualized session with a PT is used to preoperatively familiarize patients with the surgeon’s preferences regarding postoperative precautions, as well as to practice postoperative exercises, transfer techniques, and ambulation with an assistive device, both on flat surfaces and on stairs [11]. All patients receive a joint-specific instructional web page with videos (a microsite) and a printed booklet that provides detailed information on the home exercise program, functional home mobility, and activities of daily living through pictures and/or text [11]. Patients are educated on hospital stay expectations, discharge planning, and preparing their homes for their postoperative recovery through home modification suggestions. Soeters et al found that one-on-one preoperative edPT resulted in fewer postoperative inpatient PT visits and greater patient readiness for discharge from PT [11].

Traditionally, the PT department at HSS typically performs 4211 in-person preoperative visits per year. In March 2020, when New York’s shelter-in-place mandate took effect, elective surgery was halted until May 2020 [3]. The American Hospital Association Joint Statement: Roadmap for Maintaining Essential Surgery during COVID-19 Pandemic suggested that institutions “consider use of telemedicine as well as nurse practitioners and physician assistants for components of the preoperative patient evaluation” and “assess preoperative patient education classes vs remote instructions” [7]. Telehealth has demonstrated success in preoperative education [8]. The development of mobile health platforms and telehealth systems for preoperative education has shown to improve patient participation compared with in-person presurgical classes [9]. These innovations may reduce cost while maintaining or even improving patient outcomes [9]. After the start of the COVID-19 pandemic, once surgery resumed in May 2020, the HSS Rehabilitation and Performance department began to offer the option of a virtual one-on-one edPT appointment with the goal of maintaining patient safety and social distancing, while providing essential patient education. These sessions provide the same education as the in-person appointment, while using web-based video applications to observe patients’ functional mobility in their homes. In addition, screen sharing capability is used to review the microsite and booklet. Since May 2020 through September 25, 2020, more than 400 virtual edPT appointments have been completed. This commentary aims to describe the importance and benefits of virtual edPT, the successes and challenges encountered, and the role of virtual edPT in the future.

Importance and Benefits of Virtual Preoperative Physical Therapy

The HSS Rehabilitation and Performance department determined that continuing to provide one-on-one edPT for patients undergoing TJA remained a priority given its demonstrated effectiveness in reducing the amount of time necessary to meet goals for home discharge [11]. The COVID-19 pandemic further emphasized the need for early postoperative independence to allow patients to reduce length of hospital stay once rehabilitation and medical goals are met [6]. While shorter length of stay allows for minimized exposure, it does compact the time rehabilitation providers have to interact with patients postoperatively. This underscores the importance of edPT to educate patients on the recovery proces by setting postoperative expectations and addressing patient/caregiver questions and concerns.

The addition of the virtual edPT method allowed the flexibility to provide care while maintaining and prioritizing patient safety and social distancing. Prior to the pandemic, the in-person edPT appointment was one of multiple appointments during the presurgical day at HSS in New York City (NYC). Patients attended 4 to 6 in-person appointments on 1 day, receiving considerable information in a short time. Currently, to allow for social distancing and avoid overcrowding at the hospital, these in-person edPT appointments are now also being performed at multiple off-site locations that are typically more convenient for patients who live outside of NYC. These off-site locations may or may not have rehabilitation services on site, so having a virtual option for the edPT appointment ensures that all patients can receive the beneficial education prior to their surgical procedure [9], regardless of where their presurgical appointments are performed.

To maintain social distancing during in-person edPT appointments, functionally independent patients are not permitted to have family members present. Performing the virtual edPT appointment allows for additional family members or caregivers to be present. Patients are encouraged to choose a date and time that is most convenient for them and their families. The goal is to schedule these appointments at least 2 weeks before surgery to allow patients to have sufficient time for discharge planning, including obtaining any suggested equipment or making home or discharge location modifications. Family members or caregivers can better assist patients postoperatively if they have the necessary equipment and understand the postoperative recovery course.

The virtual edPT appointment is encouraged to be performed in the patient’s planned discharge environment. This allows for accurate assessment of the location and the ability to identify potential functional challenges in advance. Traditionally, during in-person appointments, patients describe their expected discharge location to the therapist and practice mobility skills in a limited clinical setting. The virtual edPT appointment is advantageous as there is visualization and simulation of postoperative tasks in the discharge environment which facilitates a more accurate discharge plan. The PT can troubleshoot any modifications that are needed to improve safety and patient comfort by seeing the actual discharge environment. The clinician can also assess the patient’s ability to perform functional mobility within their discharge location, including stair mobility and shower/tub transfers.

The virtual edPT may also assist with the patient’s ability to recall the shared information, as the appointment is often completed in the comfort of their own home or a familiar environment. An electronic device with a camera, microphone, and Internet capability is required for virtual edPT. Dallimore et al compared patient education via paper booklets or with iPads and found patient recall and satisfaction were higher in patients educated via iPad; therefore, the use of virtual technology may be a more effective means of patient education [4]. Elderly participants were able to use an iPad effectively, suggesting the use of technology would not be a barrier for this patient population [4].

Virtual Preoperative Physical Therapy—Success Despite Challenges

While many benefits have been associated with virtual edPT appointments, we experienced a few challenges, including PT licensure, availability and use of technology, and lack of gait training equipment. The treating clinician must have licensure in the state where the patient is located at the time of the appointment. Due to the COVID-19 pandemic, several states allowed for emergency license reciprocity or waivers for telehealth purposes. However, not all states extended this opportunity, and some states placed limits on how long a temporary license would be valid. To maximize the number of patients eligible for virtual edPT, HSS clinicians obtained licensure in states other than New York, both formally and through reciprocity. Due to state licensure restrictions, not all patients were eligible to participate in the virtual program. Those patients were subsequently scheduled for an in-person appointment.

A few patients expressed being uncomfortable with using technology or lacked the necessary device needed for the virtual appointment. To assist with use of the web-based video applications, patients were given instructions and IT support prior to their visit. Application tip sheets that contained step-by-step instructions with screenshots for better visualization were created and emailed to patients to help with any troubleshooting issues. Despite these efforts, the clinician would often need to contact the patient during the scheduled visit via telephone to assist with technological issues with audio, video, or poor WiFi signal strength. If the audio connection was unsuccessful, the clinician would speak to the patient over the phone to review the microsite and booklet on the computer screen. If the patient’s video capability was impaired, the clinician could not observe the patient’s discharge environment or their functional mobility. Thus, the clinician asked detailed questions and encouraged the patient to take photographs of their discharge location, including any stairs within the home to be reviewed with the treating acute care therapist postoperatively. Despite the patient’s impaired video capability, the patient would still be able to see the clinician’s screen and the education portion of the session could proceed as normal. While overcoming these troubleshooting issues would often allow the session to run as planned, this consequently decreased the amount of time available for the virtual edPT. Therefore, a certain level of comfort with using technology and web-based applications is preferred when participating in virtual edPT.

Gait training with an appropriate assistive device proved to be an additional challenge. A component of in-person edPT is gait training with a rolling walker and/or cane. Unless a patient has already undergone orthopedic surgery or has a family member who uses an assistive device, it is uncommon for patients to have these devices within their home. If an assistive device is unavailable during the virtual edPT appointment, the clinician would review video clips demonstrating its proper use on the HSS microsite. While this may not be as beneficial as a patient physically performing the task, reviewing the information prior to surgery does help prepare patients for appropriate postoperative expectations. The goal is to have the patient knowledgeable of the postoperative equipment that may be used in the hospital, as well as suggesting prepurchasing any needed activity of daily living (ADL) equipment to be prepared for a smooth transition into their discharge environment.

Virtual Preoperative Physical Therapy: An Asset for the Future

As a result of the COVID-19 pandemic, the use of virtual health care has been accelerated worldwide. At HSS, the creation and the implementation of a virtual edPT program allowed for the continuation of patient education in advance of TJA while maintaining patient and clinician safety. The added benefits of patient convenience and real-world application of education in the patient’s discharge environment make virtual visits advantageous compared with in-person visits. Given the current climate, virtual appointments remain a viable option for preoperative education. Further study of which patients may benefit most from virtual versus in-person edPT appointments would help determine the best way to meet each patients’ education needs.