Expected and Unexpected: Preconceptions of Telehealth for Hand Therapy Patients

Introduction

Hand and upper extremity injuries can significantly affect a person’s ability to complete daily living tasks, work, and participate in leisure activities. They may account for up to 50% of all injuries sustained whether traumatic, insidious, or through repetitive stress [9].

Hand therapy entails evaluation and implementation of a tailored intervention program to treat diagnoses of varying severity, complexity, and chronicity. Certified hand therapists work closely with surgeons and physicians to carry out conservative rehabilitation treatment as well as postoperative management [9]. Evaluation includes patient history and assessment of pertinent skeletal, muscular, nervous, vascular, skin and connective tissue, often involving the use of instruments and/or palpation [4]. Therapists implement a variety of treatment techniques to improve range of motion, dexterity, and hand use in daily activity, with manual techniques, scar management, and edema control cited among the most critical and frequently used interventions [4]. The centrality of therapeutic touch to hand therapy lends itself to face-to-face encounters, close proximity, and direct contact. These were necessarily limited when the Hospital for Special Surgery Department of Rehabilitation undertook protective measures in response to rising rates of COVID-19 in New York City in March 2020. Shelter-in-place orders mandated a translation of best practices into new formats.

The Rehabilitation Department rapidly optimized its telehealth capacity to provide continuity of care. Only patients with emergent, postoperative needs continued to receive onsite therapy. The remaining patients were discharged with a home program, when appropriate, or offered to receive therapy via telehealth. This shift included the Hand Therapy Section, comprised of 4 physical therapists and 6 occupational therapists, none of whom had used telehealth before. Therapists had varying degrees of confidence as to how telehealth would work for their patients.

Only a few studies existed that described the use of telehealth with the hand therapy population. One study used telehealth for hand therapy in a rural area, demonstrating effectiveness of telemonitoring to support home-based hand rehabilitation exercise programs using visual and audio feedback [9]. Therapists were able to monitor outcomes, and patients who participated in video monitoring showed greater improvement in grip and pinch strength than those who performed self-directed practice alone [9]. In contrast, the use of telehealth for patients with other conditions has been studied extensively. Cottrell et al [2] performed a systematic review suggesting that telerehabilitation was effective and comparable with standard practice in a variety of musculoskeletal conditions requiring physical therapy. In general, studies largely emphasized selective use of telehealth to provide broader or more convenient access to rehabilitation (ie, those living in remote areas, or unable to take time from work or school to attend in-person appointments) [3]. Despite evidence suggesting telehealth provision of rehabilitation is broadly accepted by consumers, and more than 80% of primary care clinicians reported satisfaction of service quality through telemedicine, questions remain regarding perceived treatment outcomes by hand specialists [1,6].

Telehealth services are still not generally viewed as a substitute for face-to-face care, and few papers have examined therapist perceptions of the care provided. Joy MacDermid, in highlighting how hand therapists are expert educators in guiding patients and teaching skills for self-management, emphasized that hand therapists would need to adapt to alternative formats to continue caring for patients during the pandemic and that this evolving change in service delivery would challenge us to provide accurate evaluation and effective treatment [7].

In this clinical commentary, we share our preconceptions about delivering hand therapy via telehealth, actual experiences, illustrative examples, and next steps.

Preconceptions: Therapist’s Expectations for Delivering Hand Therapy via Telehealth

In late March 2020, the Hand Therapy section learned that it would be included in the department-wide implementation of telehealth care and initial reactions varied. Some therapists felt, “This will never work, it will definitely fail,” and others had no strong expectations whatsoever. One common concern was that clients benefiting from manual techniques or modalities would not be successful with telehealth therapy—that is, those that required extensive stretching, scar care, or edema management. Others felt that telehealth would only work with highly motivated patients or those with lighter therapy needs—such as reinforcement of home exercises. In addition, would patients become frustrated with hand therapy delivered via telehealth, or perhaps would older patients struggle with navigating the technology?

We expressed varying degrees of preparedness to provide care over a virtual platform. Therapists completed a series of training modules, as well as a “rehearsal” session with a colleague to facilitate proficiency using the technology. Training emphasized preservation of patient privacy and technical aspects of testing the microphone/camera. Considerations for how to conduct the treatment itself were less formally addressed. In discussing our perceived level of competency, 1 therapist suggested that hand therapists tend to capitalize on adaptability, reasoning skills, and problem solving when addressing clinical challenges. She suggested, despite the lack of experience, hand therapists, may be particularly suited to adjust to a different mode of care delivery and would even thrive. Some of us were more concerned about prospective technological hiccups.

Experiences Delivering Hand Therapy via Telehealth

When reflecting on clients we had treated with telehealth during the past 7 months, we were pleasantly surprised by the many successful outcomes. As of September 30, 2020, a total of 1285 visits were carried out by the 5 authors of this commentary, and 2251 total visits by the hand therapy department. In most cases, therapists observed anecdotally that outcomes were similar to those treated with in-person visits. Patients tended to do well with telehealth hand therapy, regaining functional hand use even after extensive injury or challenging postoperative precautions.

We found it easier to develop a rapport with patients via telehealth than in person during the COVID-19 pandemic. In person, both therapists and patients wore masks with the former wearing additional protection such as a face shield or goggles. In contrast, no masks were worn during telehealth—both therapist and patient could still see each other’s facial expressions. The patient was often in a relaxed environment, and therapists found it beneficial to use household items when exercising or performing functional activities. Therapists focused entirely on the patient without the interruption of a busy clinic environment. Use of telehealth necessitated more digital connectivity between therapist and patient to make appointments, e-mail instructions, and send home programs.

Several therapists noted that telehealth encouraged patients to take initiative in their own recovery while incorporating exercises into their daily routine within their own environment. Patients were motivated to follow exercise instructions carefully and take ownership of their rehabilitation course. Participation was, by necessity, active instead of passive as patients stretched, massaged, and moved themselves. This was true for both simple and complex cases. Ability to progress and improve was contingent on patient involvement and accountability. We observed that patients were encouraged by gains, adding motivation for investment in their own rehabilitation.

Despite these successes, there were several barriers to overcome. Patients’ comfort with technology seemed to inform effective use of telehealth. While many patients, spanning a broad range of ages, were successful in connecting to a session, there were others who could not get the “gist” of how to use the technology successfully. Difficulty accessing the telehealth platform, positioning the device, and angling the camera effectively all impeded constructive participation in the session. Some patients had limited spatial awareness making it difficult to appreciate what elements were in the camera’s view. Patient frustration with technological difficulties also affected therapy sessions.

Some patients did not thrive with hand therapy delivered by telehealth. We originally assumed that patients with complex diagnoses would yield poorer results. Instead, therapists observed that patients who appeared to be distracted during sessions or located in a busy environment did not progress as well. We each had experiences where the patient was “multi-tasking” during therapy. One patient was on a checkout line in the grocery store, another was driving, others texting, and yet another seemed to be working. Anecdotally, these patients were less engaged, less participatory in therapy, and less likely to improve. The following are a selection of cases that individual therapists, writing in the first person from their perspective, felt exceeded their expectations of recovery during telehealth care.

Case 1

A man in his mid-50s sustained a laceration and dislocation to the fifth proximal interphalangeal (PIP) joint of his dominant right hand. He self-reduced his dislocation, managed the wound, and sought medical consultation approximately 1 week later via telehealth. The orthopedic hand surgeon referred the patient for telehealth hand therapy and cleared him for active and passive range of motion. My assumption was that the prognosis would be poor. Clinically, a fifth-digit PIP dislocation is challenging to manage under ideal circumstances, let alone one compounded with a healing volar PIP laceration and remote therapeutic management.

On evaluation, he presented with moderate edema, notable pain (6 of 10), tenderness at his joint, and difficulty typing and writing. The laceration at his volar PIP joint was slightly open with minimal clear drainage. Range of motion measurements using a goniometer against the computer screen yielded 80°, 80°, and 60° of flexion at the metacarpal phalangeal, PIP, and distal interphalangeal joints respectively, and he was able to flex his fingertip to 3 centimeters from his distal palmar crease.

After rapport was established, we began by working on edema management and range of motion exercises, including tendon gliding, place and hold, blocking, and flexing digits over a highlighter with progression to small diameter pens as motion improved. To assist with his exercise program, printouts and self-adherent wrap were mailed to the patient. Once the wound was closed, I instructed the patient in scar massage and mailed a second packet containing gel digit sleeves, therapy putty, and advanced exercise printouts. Sessions emphasized education, coaching, self-massage, stretching, and motion exercises. The patient was receptive and engaged during each session.

The patient was discharged after 9 telehealth visits (6 weeks 5 days post injury). He had full finger extension and flexion, mild edema, and mild tenderness at the PIP joint. His volar scar was mildly raised but steadily remodeling. He reported no functional limitations at this point. His recovery greatly exceeded my expectations.

Case 2

A woman in her mid-60s fell on her right dominant arm while dancing in early 2020, suffering an elbow dislocation with lateral ulnar collateral ligament sprain and distal radius fracture. She underwent a closed reduction of her elbow and an open reduction internal fixation of her distal radius. Good rapport was already established during the 5 therapy sessions she attended in person prior to the COVID-19 outbreak. When she transitioned to telehealth, I was not sure she would ultimately do well. She was showing signs of frozen shoulder, and her elbow, forearm, wrist, and digit motion were limited. It presented a challenge to progress her motion and advance her function without the benefit of a hands-on approach. As a clinician with advanced training in manual techniques including Graston, cupping, and kinesiotaping, I understood that I would have access to none of these strategies when treating via telehealth, and that I would need to progress her without relying on these familiar tools in my therapy armamentarium.

This patient really surprised me. She took the initiative and made sure to move her whole arm. The patient directed which motions she felt needed the most attention for each session. I would regularly e-mail her new exercises, and she would work diligently on everything presented. We tracked progress using a goniometer against the screen to measure range of motion as well as observing functional movements using body landmarks (ie, touching her back, or the back of her head). She achieved full functional motion of the shoulder, elbow, forearm, wrist, and hand, and I discharged her after a total of 25 visits. Her remaining complaint was that her right-side upper extremity motion was not the same as left (lacking ± 5° in each plane of motion).

Helping this patient achieve a successful outcome was a positive experience. The complexity of treating someone with multiple injuries and marked stiffness across several joints could prove challenging under any circumstances. Our use of a treatment plan that emphasized movement and function was effective, and I would implement it in the future with other patients. The patient’s diligence and determination yielded great results—all without hands-on treatment.

Case 3

A male teenager sustained an injury to his dominant hand, lacerating all zone 4 flexor tendons, index zone 1 flexor digitorum profundus tendon, flexor pollicis longus, median nerve, ulnar nerve, and index ulnar digital nerve in August 2020. After an initial visit to an emergency department, he had a surgical repair at the Hospital for Special Surgery and was referred to Hand Therapy on postoperative day 7. The therapist fabricated a forearm-based dorsal blocking splint and instructed the patient in a home exercise program. The patient and his family elected to continue therapy via telehealth.

I was skeptical when I first saw the referral, and thought it must be a mistake for a telehealth case. Treating this type of injury can be challenging enough when 1 tendon is repaired, let alone 10 tendons and 3 nerves. Rehabilitation requires close attention, frequent communication with the physician, and incredible compliance by the patient (and in this case, the patient’s family) to successfully address edema, tendon glide, and scar management, while minimizing risk of rupture.

It was easy to develop good rapport as a great deal of time was spent on patient and family education during telehealth sessions. It was important to convey the severity of the injury and importance of compliance, while developing a trusting therapeutic relationship. As telehealth allows you to connect with patients without wearing a mask, it allowed both the patient and therapist to be able to read and assess reactions and emotions. The patient appeared at greater ease in his home environment, without added stress commuting to the city. Treating the patient at home also helped to establish a routine for incorporating therapy and exercises. The quick connection with telehealth allowed the patient and his family to actively participate in his care.

Therapy followed an early active motion protocol, clearing him for passive flexion of all digits with active extension to the confines of his splint, as well as short arc active motion. It was challenging to evaluate the edema, incision, joint stiffness, and tendon tightness without closely seeing or touching the patient’s hand and wrist. I worked with the patient’s mother to build common language to describe stages of healing and often asked her to take photographs. These helped me to better appreciate the stage of healing and status of the wounds. The patient gradually became more comfortable looking at, and touching his hand, and donning/doffing the splint. Soon after, he was performing scar massage, desensitization, and manual therapy under the guidance of the therapist and his family supports. They remained steadily compliant with the home exercises and demonstrated an excellent understanding of the healing time frames throughout the therapy progression.

The patient has had a total of 11 hand therapy visits and continues to be seen via telehealth twice a week. Through the course of treatment, there were some visits that I remember thinking “How am I going to make this work? How are we going to accomplish this?” With patience, clear communication and thinking outside the box, I often end a treatment session reflecting on the gains he has made. Although I was doubtful when first reading the complex referral, I am so thankful for the opportunity to work with the patient and proud of his progress. Telehealth appeared to facilitate compliance, promote communication, and establish a strong rapport with the patient and family, enhancing his success throughout the rehabilitation process.

Discussion

The experience of treating hand therapy patients during the past 7 months has exceeded our expectations. We found it possible to help patients resume functional upper extremity use in daily activity despite even complex injury and an inability to use any manual techniques. This view is consistent with those of other clinicians, who attributed quality and efficiency to telehealth care [3]. We observed that patients who appeared motivated and demonstrated self-reliant behaviors tended to do well, and that a good rapport was helpful in advancing recovery. This perspective matches those of Kirwan et al [5], who highlighted therapist’s perception of non-compliance to include lack of motivation, and that developing a rapport with patients and gaining understanding of their traits is important. One therapist commented that her patients might not have been open to receiving hand therapy via telehealth prior to COVID, but now that they had tried it, they would be more receptive to using this medium in the future. Concerted efforts to research the effectiveness of telehealth care with the hand therapy population would be needed to provide evidence to support post pandemic use in daily practice [8].

Potential next steps to enhance use of telehealth with hand therapy patients include communication and training. Gaining a clearer understanding of the patient experience when using telehealth may help therapists to better guide setup and maximize usability. Increasing communication to administrators, colleagues, and physicians is advisable to facilitate continuity of care.

Overall, we surmised that therapists felt more confident and more successful with telehealth treatments than originally expected despite complexity of cases, and anxiety regarding technology. We noted that nearly every hand therapy patient could be a good candidate for telehealth. Research is needed to explore the use of telehealth with the hand therapy population, assess outcomes and patient satisfaction, and shape the indications for telehealth use in a post-COVID world.