The Spine Telehealth Physical Examination: Strategies for Success

Introduction

The COVID-19 pandemic has placed enormous strain on the delivery of safe and efficacious health care worldwide. Social distancing practices, limitations on non-urgent surgeries, and amendments to traditional clinical workflows have forced both physicians and patients to adopt alternative platforms for providing and receiving care, respectively. Telehealth has rapidly become a widely accepted and effective tool for continuing necessary clinical practices.

Prior to the pandemic, orthopedic surgeons witnessed a steady rise in telehealth as a means to provide consultations, outpatient care, and rehabilitative services, with promising results [14]. However, a unique concern to the virtual assessment of spinal pathologies is the ability to perform a robust physical examination. While the recent surge in telehealth use has introduced various recommended means for performing a virtual physical examination [11,15], best practices for examining the spine via telehealth remain unclear. Recently, members of our study group have published a telehealth physical examination of the spine, acknowledging those aspects of the assessment that are compatible with a virtual setting while recognizing notable special tests that are unable to be assessed [6].

As spine surgeons segue into a seemingly new era of practice management, novel means of evaluating a patient via telehealth must be learned. The aim of this technical note is to provide spine care practitioners with a concise review of our recently published experiences and suggested best practices to perform a physical examination of the spine via telehealth.

Telehealth Requirements: Setup for Success

A complete telehealth examination of the spine has a few essential requirements. The patient will require a device with videoconferencing capabilities; in our experience, a smartphone with front- and rear-facing cameras is a simple, ubiquitous option. A tablet, laptop, or desktop computer may also be used. Access to a videoconferencing application is fundamental. Recently, the Department of Health and Human Services (HHS) has loosened regulations to allow for previously non-HIPAA (Health Insurance Portability and Accountability Act of 1996)–compliant platforms as an option for establishing and performing telehealth visits [13].

From the onset of the visit, it is crucial that physicians be cognizant of their virtual presence, the so-called “webside manner.” Patients are likely to be initially apprehensive of receiving or even initiating care remotely; this apprehension may turn to skepticism if a strong physician-patient relationship is not established [4]. Hence, it is crucial that providers remain vocal throughout the examination, consistently providing verbal cues and demonstrations of the following physical examination maneuvers as necessary.

The examination should be performed in a familiar, quiet setting with adequate space to allow for a global assessment of the patient and a gait evaluation. Typically, an office room or living room works well. The patient should dress comfortably in shorts and a shirt to allow for unimpeded visualization of their extremities. For new patient visits, or when examining older or more disabled individuals, it is often helpful to have another person available to assist with patient or camera positioning as necessary. Similarly, extreme caution must be used directing the aforementioned patients through various examination maneuvers to mitigate any fall risk. Last, the room should contain a standard height chair and bed or table for evaluation in the seated and supine positions as needed.

Global Assessment: Inspection, Range of Motion, Gait

The remote physical examination begins with a global assessment of the patient. The patient is asked to stand 5 to 10 paces away from the camera; here, a head-to-toe inspection is performed, evaluating for any obvious coronal plane deformity, pelvic obliquity, or shoulder asymmetry. The patient is then instructed to turn 90° and a similar sagittal plane assessment is performed, eying for sagittal plane deformity or imbalance. Any evidence of compensation at the hip, knee, or ankle should be scrutinized. From here, range of motion (ROM) of the cervical, thoracic, and lumbar spine is performed sequentially, namely, flexion, extension, rotation in all regions. Continuous verbal cues are essential, specifically inquiring of the patient which movements exacerbate or alleviate their pain. The patient is then asked to turn and face the camera, and lateral bending of all spinal regions is performed.

A gait assessment is then conducted. The patient is asked to take 5 to 10 paces toward the camera, turn 180°, and return to their initial position. This distance should allow the examiner to note any abnormal patterns (eg, antalgic, Trendelenburg, or steppage gait), as well as any asymmetries or imbalances of the stance and swing phases. A tandem gait may also be evaluated; crucial here is to counsel the patient to perform this near a wall for assistance, or with another individual by their side if available.

Examination of the Cervical Spine

Examination of the cervical spine begins with the camera placed on level with the sternum, with the head, neck, shoulders, elbows, and hands easily in view. Focal inspection may demonstrate atrophy of larger muscle groups of the upper torso and extremities. Range of motion of the neck and upper extremities should then be performed. A modified Spurling’s maneuver may be performed: The patient is asked to perform full extension of the neck and flex laterally to both the right and left shoulder [2]. The patient is asked if they experience any radicular symptoms with this maneuver. Active shoulder ROM should be performed, as shoulder pathology may be a contributor to cervical pain [12]. The patient is then asked to move closer to the camera and pronate/supinate the forearm to assess both the dorsal and palmar aspects of the hands, respectively. The examiner should note any asymmetry, atrophy, tremor, or intrinsic wasting. A modern, high-fidelity camera may catch subtle findings, although finer changes are more challenging to appreciate virtually.

Evaluation of upper extremities is inherently limited in the remote setting, as true manual motor testing (MMT) is unrealistic without a provider present. However, surrogate means of assessing strength can be performed. With specific verbal cues and demonstrations as needed, patients should be asked to perform a shoulder shrug (trapezius), shoulder abduction (deltoid), elbow flexion (bicep), overhead elbow extension (triceps), and finger and wrist flexion and extension. Failure to perform these maneuvers suggests clinically significant weakness; similarly, obvious asymmetries in muscle strength are easily appreciated on camera. While a subtle loss of strength (4/5 vs 5/5 on MMT) cannot be scored in the remote setting, the patient can perform these actions with a small 5- to 10-lb common household object mimicking degrees of resistance. Recently, authors from this institution have provided a modified upper extremity testing scale that may aid practitioners in scoring individual muscle groups, as is traditionally performed in the office setting (Supplemental Table 1) [6].

A modified sensory examination can also be performed. Demonstrating sensory dermatomes on themselves, providers should ask the patient to point to any areas of numbness or paresthesias. In general, this is sufficient to discern gross sensory involvement. If another individual is present, they may be helpful in identifying subtle asymmetries in sensation with either the gentle touch of a finger or a toothpick or unfolded paperclip.

Examination of the Lumbar Spine

Examination of the lumbar spine should be performed with the camera at trunk level. General inspection, including ROM, is assessed as above. Similarly, sensory changes along lower extremity dermatomes should be evaluated, particularly distally in the leg, ankle, or foot. Those patients with lower back pain are asked to turn face away from the camera and indicate any areas of point tenderness; this is particularly important in evaluating sacroiliac joint pathology.

Testing of lower extremity strength should be performed beginning proximally; the patient is asked to perform hip flexion (iliopsoas), knee extension (quadriceps), knee flexion (hamstrings), ankle dorsiflexion (tibialis anterior), great toe extension (extensor hallucis longus), and ankle plantarflexion (gastrocnemius-soleus). In lieu of a traditional MMT assessment, our institution previously published a series of “functional” bodyweight movements that may simulate maximal resistance (Supplemental Table 2) [6]. The physician must scrutinize these movements thoroughly, looking for any perceived or reported difficulty, asymmetric weakness, or instability. By moving the camera to knee or ankle height, any foot drop may be appreciated. As in the cervical spine evaluation, any notable findings should be carefully correlated with the presenting history and imaging if available to discern concomitant hip or knee pathology.

Special Testing: Assessing for Myelopathy and Radiculopathy

A major impediment to a complete investigation of spinal pathologies via telehealth is the inability to perform a specific, classical physical examination test. These include assessment for hypo- or hyperreflexia, abnormal reflexes (eg, inverted brachioradialis reflex), sustained clonus, an up-going Babinski sign, and Hoffman’s sign. However, in cases of either suspected myelopathy or radiculopathy, there are certain clinical maneuvers (or modifications thereof) that may be amenable to a remote platform (Supplemental Table 3) [6].

In cases of myelopathy, gait or balance abnormalities may be assessed as above. If the patient is capable, a Romberg test can be performed concomitantly: The patient is counseled to stand with their eyes closed and feet together, with a positive result indicated by the inability to maintain this pose for at least 30 seconds [1].

Regarding special testing for lumbar radiculopathy, there are a few special, functional tests that may be performed remotely (Supplemental Table 3). Of note, an active straight leg raise may identify 2 processes: nerve tension or hip pathology (eg, osteoarthritis). An assistant, if available, may be able to help more deconditioned patients with this test, or if the patient is alone, this may be performed in the seated position.

Discussion

In light of social distancing practices, COVID-19 has forced the widespread adoption of telehealth. Prior to this rapid surge, telehealth had witnessed a steady rise in use, given its convenience, high patient and provider satisfaction, the increasing ubiquity, and performance of videoconferencing services [9,10,14]. Amended regulations in coverage, reimbursements, and provider incentives make telehealth an increasingly promising platform as the pandemic persists [8]. In fact, current market forecasts suggest a global market value exceeding $120 billion by the end of 2030, increased from $21.9 billion in 2019 [3].

As practices segue to a new normal of management, spine surgeons will similarly benefit from the adoption of telehealth. However, a main criticism of telehealth is the unrealistic expectation that it can replace a traditional, in-person physical examination. Both providers and patients alike must recognize that a telehealth examination is not meant to replace the latter. Direct comparisons between telehealth and traditional office examinations are fundamentally flawed. No “gold standard” physical examination exists; more specifically, examinations of spinal pathologies are infamous for high inter-observer variability [5,7]. Rather, the telehealth examination is meant to provide a piece of information, digested critically in conjunction with corresponding history and imaging. The summation of all of these elements should allow the provider to create an overall clinical impression. Moving forward, the ultimate value of telehealth will be whether it can allow spine surgeons to continue to provide the same quality of care, patient satisfaction, and long-term outcomes as an in-person office visit.

In sum, this technical note provides spine care practitioners with concise, specific steps to perform a thorough assessment of a patient via telehealth. While current social distancing guidelines continue to preclude the ability to perform an evidence-based validation of these strategies, physicians from our institution have developed and used this examination with early success. Moving forward, future study will be required to confirm whether spine surgeons can continue to provide the same level of care with remote technologies and evaluations.