I'm here with, hi, welcome to our talk on virtual spasticity assessments. My name is Dr. Mary Russell and I'm here with Dr. Natasha Romanosky and we are, and Dr. Monica Verdusco-Gutierrez and we're going to share with you some tips and stories that we have had through the pandemic and trying to navigate that. So some disclosures, I'm on the Speakers Bureau for Allergan and have previously been a consultant for MERS. So some objectives, we're going to identify the history of telemedicine and medical communications and identify three early sources of telehealth that has paved the way for telemedicine as we know it today. So in the beginning, there were three Ts. So the three Ts is the telegraph, the telephone and the television. And so this all kind of starts from the early 1800s, kind of the mid 1800s, the telegraph and radio kind of came about. And then towards the early 20th century, you had the telephone and then kind of in the middle of the 20th century, you also had the television and all of those technologies have kind of paved the way to be able to have telemedicine as we know it today. And so the telegraph and Morse code, sorry. So the telegraph and Morse code invented in the early 1800s came to be used. And so they actually used it in civil war to get supplies that they needed for the medical tents. The telephone, of course, Alexander Graham Bell made that possible. And then there was actually some cardiology consults that would take place across long distances. They could send EKG waves. And so then from that standpoint, that kind of opened up, opened up kind of transcontinental as well as transnational communication. And then you have the television, which came about, brought about video recording. And that kind of really took aim in the mid 1900s. And so they have been doing virtual tele consultations for quite some time and comes to be telemedicine as we know it. And so I'm going to pass along the torch here to my colleague, Dr. Natasha Romanosky. And she is going to tell us a little bit more. Excellent. Thank you, Dr. Russell. Okay. So we're gonna jump right into the virtual spasticity exam. My disclosures are listed here. And the objectives for this portion of the talk, I want to go over the variables to your virtual setup for both the patient as well as yourself as the clinician. We will review the components of the virtual exam as well as the limitations. We will then review some outcome measures that I hope you will consider adapting for use in the virtual format, specifically for goal attainment when assessing spasticity. And then lastly, I hope that you will recognize some educational opportunities that may be unique to the virtual assessment. So moving right into the variables, I'm sure many of us on this call today have likely already experienced some component of the telehealth visit. For those of you who haven't, or just trying to kind of get a refresher of how to reorganize yourself, I encourage you to think about the camera setup for both yourself as well as the patient that you're evaluating. The location of the patient, both where are they physically, which can come into play with some of the reimbursement components, as well as the location of the patient, perhaps in their home, within different rooms, which may be useful for their functional assessment. Consider the patient's cognitive abilities prior to scheduling these visits. For example, they may require family or caregiver support to assist within their visit. Are there equipment needs that you may want to consider, such as wheelchairs to assess wheelchair mobility or other types of ADL assessments within the home? Considering your patient's physical functional needs. And then lastly, don't forget the interpreter or potential language needs, which may need to be adapted to the virtual format as well. So as your patient is preparing for the visit, we want to ensure technology assistance. At some point, technology will likely fail, and you want your patient to be able to recognize who do they contact. More often than not, they'll likely try to contact your office and be put on hold for several minutes. And so to be efficient, make sure that that information is passed along. You will likely also want to consider alerting your patient to how they can best prepare themselves physically for this visit. You may want to alert them to wear loose, comfortable clothing, to allow visualization of the area being examined. Oftentimes, when we see our patients in the clinic room, we may change them into a gown, for example. And so having the patient already ready with the area visualized ready will be helpful. Recommending a large enough area for any requested mobility. For example, you may want to assess task-specific areas. Maybe a goal for the patient is a bed transfer. And so having them arranged with their audio and video in that location may be helpful in advance. And then the consideration for any caregiver support. For the provider, again, recognizing technology options in the event the visit fails. Early on in the pandemic, we had the opportunity for audio-only visits, telephone visits, for example, but recognizing what options for video visits may be available if your visit fails. And then consider how any educational materials might be delivered. For the platforms that you're using, there may be a separate portal, for example, that can be very useful to either deliver materials to the patient. And we'll go over within a few moments here some different outcome measures that you may want to use in these visits, but also consider how your patients can communicate with you. Maybe they can send you photos, for example, through this portal, which may be helpful for your assessment. And then consider providing any pre-visit questionnaires that may be helpful. If there are questionnaires or tools that you may use in the clinic setting, consider providing those to your patient in advance, and then they can send them to you potentially through that portal. So now that you're prepared for the visit, I want to go through the components of the exam as we have listed here. For the most part, the components of the exam when done virtually are not that different than in person if we get a little creative. So starting with inspection, we know that when we're evaluating patients for spasticity, we are looking at resting posture, joint positioning, are there deformities developing, for example. We may be assessing for things like skin breakdown or physical discomfort. Those may be a little bit more challenging to assess in the virtual setting, which is where our caregivers and our support individuals may be able to help us with inspection. Some of the limitations to inspection, as we know, are limitations within the camera space. So again, preparing your patient to have a large enough space available. You are, of course, limited with the ability to move on to the palpation phase of your exam. And so again, consider for some of those skin types of exams to send photos. Moving on to passive activity. This is perhaps one of the more challenging components of something that when performed in person, we can passively range our joints of our patients, for example. But when performing passive activity virtually, we can either train our caregivers to range an elbow, for example, or if this is a patient with a spastic hemiparetic limb, for example, train them to use their other limb to show us some range of motion. So these are areas that we can still translate into the virtual setting to still have a successful exam. Some of the limitations here are the, again, need for caregiver support. It may be painful. And we may misperceive a contracture. So our patients or our caregivers may be fearful, for example, of moving a joint through more range of motion than what they may be comfortable with. And this is certainly a limitation. We know that the risk of fractures is a real concern. And so when these are done unsafely, that can be a concern as well. So we do have some limitations here. Perhaps one of our most useful measurements with the virtual exam is active activity. So active activity is any sort of movement, functional assessment, ADLs, that is done by the patient. As physiatrists, this is near and dear to our heart, right? To be functional, to assist our patient with these functional goals. And this is the prime time to be able to assess our patients within their home. Some great examples that I've been able to assess patients with is similar to the photo you see here, being able to really assist a patient in their goals, for example, with a transfer at a certain place in their home, for example, in and out of bed. Other examples are self-feeding, for example, that you can visualize in the kitchen. And so really, this is a time to really get creative with you and your patients, and really be goal-oriented and task-specific with your spasticity goals. And the more that you can arrange to have your patient already set up in this location prior to the visit, the more successful it's likely to be. Some limitations of active activity, however, remain similar to the limitations we've discussed already. Cognitive challenges. Patient may attend unsafe tasks. Patients may require more assistance. You may be evaluating a patient for DME, so they may not have the appropriate DME. And so safety certainly is a factor when you are monitoring your patients. The spasticity measures that we commonly use in the clinic settings, such as the modified Ashworth, the TARDU, these are scales that are likely to be very difficult. Of course, in the virtual setting, there's complexity in training. It's not going to be as consistent with how you might perform this in the clinical setting, but that's okay. Again, I would argue in the virtual setting, actually being able to really see what the patient's doing functionally is probably your most useful tool here. Quality of life measures. These are measures that we use in the clinic setting that we should continue in our virtual setting. So really having that conversation, how is the spasticity affecting your pain, continence, fatigue, therapy, any of those types of things. Being able to really talk about social limitations or vocational limitations is very important. I think one limitation that really may occur within the virtual platform here is that potential loss of empathy or trust. In certain populations or generations, individuals may feel disconnected due to the lack of physical touch that often occurs when you're assessing a patient in the clinic settings. So be mindful of that. But I would also say on the flip side, there are generations and individuals who are incredibly comfortable in the virtual setting and may share more with you than they would in the office setting because now they're in their own homes, they feel comfortable, they can really share their concerns and their fears. And so I encourage you to be open to that and trying to recognize kind of where on the spectrum your patient may be in their comfort level of talking to you about these things. As you're moving through your virtual assessment, of course, we should always be considering, what is our goal? What is our goal of treatment? Is our goal a functional goal with ADLs or gait? Is it a range of motion goal? Is it with caregiver burden or pain control? And so I wanna go through some examples of some different measurement tools that you can consider using. So some very, very simple tools. Well, let me go back to the slide. Some very simple tools are listed here. So starting at the top, the percent of function scale, this is a very subjective, but easy score that your patients can assess a certain task with. And so this is a zero to a hundred percent score of function. It is the estimation of the amount of function a patient has at this point in time. Again, very subjective, but gives your patient some ownership and being able to determine if the treatments that you are offering are making meaningful progress towards their goal attainment. And so you could use an example of a clenched fist and a patient who has a goal to be able to open that hand, be able to hold a cup, take a drink, and then be able to release that hand. And so if they are starting with a clenched fist, maybe that zero percent function with the full goal being a hundred percent. So again, that just gives you kind of somewhere to see where you are in your progress. This is very similar, of course, to our global pain scale, our visual analog scale, which is the zero to 10 or zero to a hundred that you can rate pain on. Again, these are tools that can be useful to be able to measure outcomes. The Penn spasm frequency scale is a self-reported measurement of the frequency of spasms. As an example, this might be a good scale to use for an individual who has a lot of leg spasms that are waking them up at night. And so this gives the patient some autonomy to be able to say, this is how often they are, this is the frequency. Is it mild? Is it occurring once per hour, more than once per hour, more than 10 times per hour, and then to assign some severity to it. So again, allows your patient to really be a part of identifying what the problem is, but also what the goal is. Two other tools that I find very useful. The first is the disability assessment scale. This is a perceived description of a patient's disability. You could use the same example where I mentioned a clenched fist with the goal of opening the hand, holding a cup, taking a drink, releasing the hand. May start with a three of a severe disability. This activity is very limited. And as you're working through your recommendations, hopefully moving that rating, for example, down to a two where it requires increased effort or maybe some assistance, but the patient is able to start performing that task. And then the goal attainment scale, this is probably one of my more favorite scales recently, which is the patient-specific goals with an associated action plan. And so this is where we use our SMART goals, our specific, measurable, attainable, very time-specific goals. Where this is really helpful is again, when you're evaluating a patient virtually, and they're trying to explain what their goal is, and you want to be able to show progress. We're probably all very familiar when patients come in and say, XYZ is not working, or it worked a little bit, but not quite enough. And as subjective as that may be, it can be really helpful to add that objective measurement to it. And so with the goal attainment scale or the GIS, you could use an example of having a clenched fist and wanting to be able to tolerate a resting orthotic, for example, for four hours. If you see the patient in a follow-up visit, and that is your very specific SMART goal, and you achieved four hours, that's great. You get a zero. If they come back and say, it's much better. I was able to wear it for eight hours. Maybe that's a plus one or a plus two. So again, it just gives some measurement to what your goal is. And these tools are incredibly useful, especially in the virtual setting when maybe you can't put your hands on the patient to assess. Next, I would encourage you as we move through these virtual times to consider creating your own template with some of these tools. Things like, again, like the MAS scale, you may use less often, but you may want to incorporate some of these outcome measures into your template. And then lastly, some educational considerations. As physiatrists, education of our goals is incredibly important to the services that we provide for our patient. And telehealth is a phenomenal time to be able to continue that education. One benefit of many of these virtual platforms is being able to add a guest to our visits simply by adding their email address. This is really great for individuals who have family members, perhaps out of the home or in different states who may still want to kind of know what's going on, know what the plan is, be able to encourage their loved one with the treatment plan. So this is a great opportunity to really provide more education all at once with everyone on the screen. It's also a great time to continue your rehab specific education. We are very frequently performing and showing our patients how they can perform safe exercises or stretches at home. This is an opportunity to really be able to determine can that patient safely do that particular activity at home. And so we can watch them in real time while accommodating for their home environment with those specific therapeutic tasks. And then lastly, safety education. We have the privilege of truly virtually stepping into our patient's home and seeing what's happening. And so this may be a really great time to be able to, for example, identify a rug on the floor that is a fall or tripping hazard and educate our patients on that. So it's a really great time to be able to add that safety piece with a real photo of the patient's environment, which is something that we don't get in the clinic setting. So as we've quickly moved through some physical exam and measurement tools that I hope you will consider for telehealth, you may be thinking, well when do I want to add a telehealth visit, especially for my patients with spasticity? And I encourage you to think perhaps more frequently than you might have considered in the past. For example, initial evaluation. This is something I know many individuals maybe are a little bit hesitant for and prefer to see a patient in the clinic for the first visit. But I am here to empower you that maybe you can actually do an initial evaluation via telehealth. You can still evaluate history, you can modify your exam, you can determine patient-specific goals through your virtual platform. You can also begin to outline potential treatment interventions and provide substantial amounts of education in your initial evaluation. Post-injection follow-up is another great time to be able to evaluate your patients at the time of initial consultation and at the time of injection. If you have a very specific goal with one of those tools that we talked about prior, your post-injection follow-up when done virtually should run very smoothly because you can talk through that specific SMART goal that you had, you can talk through the outcome measure that you had discussed, and you can quantify your outcome from that injection. Similarly, you can do the same thing with medication follow-ups. This is a great time to be able to discuss efficacy, any adverse effects, as well as functional outcomes. Post-pumped titrations. Of course, unfortunately, we can't yet virtually adjust some of our intrathecal pumps, but if we make an adjustment and we need to evaluate the patient post-adjustment and talk about efficacy and any adverse effects, this is a wonderful time to do so. Then anytime socioeconomic barriers exist, which may limit your in-person visit, our population of patients often has transportation barriers, limited caregiver support, or excessive travel distance, and so I encourage you to consider the virtual platform when evaluating these patients for spasticity. Lastly, patient preference. I encourage you to be reminded that patients have the right to high-quality care in a timely fashion, and if we can provide them that through the telehealth platform, we really are serving our patients well. I hope you will consider any of these options for your patients with spasticity. In summary, I encourage you to optimize preparation for your virtual visit, including any information that you may want the patient to have prior to your visit. During the visit, in addition to your inspection and visual exam findings, please evaluate for both passive versus active function and other quality of life measures. Consider the use of specific measurement tools so that you can quantify your outcomes, and then utilize this virtual platform for your rehabilitation-specific education. Please include caregivers whenever possible, and lastly, consider broadening the opportunities for your patients in their virtual visits, especially when barriers to in-person visits exist. Thank you. That is the end of my portion, so I am going to pass it along to Dr. Monica Verdusco-Gutierrez for the next session. All right. Are we seeing the right thing? We're supposed to be seeing my slide? We're seeing the one with the presenter view. Yes. I did not share like I wanted to. Hold on. Okay. We practiced this before. And then. Dr. Romanosky, there were a couple of questions that popped up in the chat while Dr. Gutierrez is getting her presentation. One was from Brian. What concerns are there regarding injuries or falls that may occur when assessing patients via telehealth? I'm not sure if you'd want to answer that, or Dr. Gutierrez. Oh, sure. Actually, it looks like her slides popped up, but they're still in presenter mode. Yeah. I'll answer that. I see that now, Brian. So, yes, I would agree. There are definitely concerns regarding injury and falls specifically. I think the more that you can prepare your patient in advance with what the expectations of the visit are and preparing the patient if they do have caregivers or someone to be with them, especially for the first visit, I think is one of your best safety measures there. Okay. Are y'all seeing it the right way? It's still in presenter mode. No, it was better the last way. I know, but then I couldn't see my notes. And then another question that came from Audrey was suggestion for difficulty for caregivers holding the smartphone while at the same time helping pediatric patients to demo things in the physical exam. Yeah, that's a tough one. I've definitely encountered that where we're trying to tell patients, go up, go down. I can see their foot or their knee are not quite trying to support your patients. For many individuals, it's very stressful, although convenient to be able to do a virtual visit. If there are, again, options to prop a phone up, I think when you first set up the camera, setting up the, again, the expectations at the beginning and making sure that you have the full view is important. I find that people are oftentimes, much like ourselves, really up close because they want to be able to see you and they want to be close to their device. But I think before you even begin the visit, they don't really need to see you maybe as much sometimes when you're showing them what to do, but really encourage your patient to be much further back, about six feet back, so that they can prop the phone up and not have to worry about holding it and showing it up close. It takes a little creativity because then we can't maybe see you, but we can see you. It takes a little creativity because then we can't maybe see something close, but that's one example. Yes, no. Okay, forget it. We'll work and I just won't have notes, but so just kind of be a continuation of Dr. Romanosky. And so this is myself. I am a obviously academic podiatrist, just like many of you. I'm at UT Health San Antonio, my main practice center is around spasticity, brain injury, stroke, and now post COVID. And I see a lot of patients spasticity, dystonias, migraines on the bottom is my disclosure. The other thing is that I have two types of outpatient practices. The first type of practice is that I do have a practice that is a more of a clinic that's our university clinic that has patients that have a lot more funded patients. And then I have a clinic at university health that is kind of our hospital safety net clinic and for patients who have more underinsured patients. So that being said, this has had to be adopted for patients with both types of needs. Ones who may have a lot of access and ones who may not have a lot of access. And so we had to quickly adopt this technology as you know. And so I'm gonna give you a little bit of setting and what do you have to do when you have patients who may not have the same resources or access to telemedicine and how do you work with that? So the first, I'm gonna go through some case examples of spasticity and why and where and what settings I like to see patients. So first, I just, I think that telemedicine gives us the opportunity to not only look at modified Asher scale, but looking beyond that and looking at function. I think it's just wonderful that we can finally see what is it our patients doing? What is it they're doing at their home? And the visit doesn't always have to be at the home. I really love it when the visits at therapy or if they have home health, if the therapist's with them. And so then I can really see what's going on much, much better than I would just evaluating them myself. And so just let me see if I can show this video. So I want to see patients moving. So someone has to obviously hold the camera for her to do that. And you can see the motor overflow that she has. And in this patient, I also am asking them to act. And so there you can see some of the clonus and you can even hear some of the clonus that is in the elbow flexors. So, you know, that's something that they even noticed. And then this patient, someone that's in therapy and I'm able to do a telemed visit while they're in therapy to be able to do a better assessment that I wouldn't even probably be able to do in my own clinic since now I don't have a therapist in clinic to walk this patient. Then I can see what they're actively doing and, you know, be able to see what their ambulation's like. She has very low vision. That's why there's many people that are around her for safety. And I can look at what's happening in her posture, in her muscles. So those are some of the benefits is that it just doesn't have to be in the home, but it can obviously be, but it also could be when they're doing their therapy. So a lot of some of the stuff that you were seeing with the videos were associated reactions, which can be normal. And sometimes we ourselves, when we're deep in concentration, you might bite your tongue or do something and that's a normal associated reaction, but then there's pathological associated reactions. So those are sometimes things that you can see when you're looking at telemedicine and seeing patients and asking them to do certain activities. And so this is from a paper that shows this patient that when he's asked to activate his left side, then the hemiparetic spastic side kicks in as part of his associated global, well, kind of not global synkinesis, but at least associated reaction with his flexor synergy in the right upper extremity. So it's also something that you can test without having to do an hands-on modified Ashworth scale assessment. And there you could see, I could get his family member, just say, ask him, put pressure against and have him lift his strong left hand. And then you can see what happens on the other side on the right to help determine how you're going to treat this patient's spasticity. And that's my normal associated movement and deep. This is like at the end of a half marathon trying to finish. And I have several pictures at different races where my tongue's sticking out because it's part of a normal motor overflow. So this is another video and this is me seeing the patient in clinic. And this is something that it's, I can do something like this in clinic. So it's a patient with an incomplete spinal cord entry. And so I'll do my own passive range of motion and then active range of motion on this patient. And then if you want to put in the chat box, if you have any idea, like of these here, what would you tend to inject? And this was, it would be me doing a, you know, that's me doing a real live evaluation in person, which I may not be able, like obviously on telemedicine, I wouldn't be able to do that. So nothing, quads, hamstrings, other. It's like no one's put anything in the chat, what they think, what they would inject. Okay. Yes. Someone's doing it. Thank you. Hamstrings. Do you need to see the video again? Yeah. You can see when I'm doing the passive range motion, it's hard to get it straight. Okay. So then my point of this video is that the gait analysis is what's worth a thousand words. So that's something that also, if you went to our spasticity session that we had the other evening, we did part of it was a journal update review, and that is that when they assess spasticity via either modified TARDU and spasticity angles and MAS scores in patients sitting and standing, it was a lot higher when the patient was standing. And so that's the importance of evaluating your patient in different positions. So this is now doing a gait analysis, which is something that you can do if the patient's in the home and you're doing on telemedicine, it's something that I would very much encourage that you to do. So this is a patient when she walks, which actually you would not want to do her hamstrings at all based on seeing her walk where she has a lot more adductor tone, some plantar flexor tone, and even including knee extensor tone as well. So actually probably do more adductors, a little bit of quads and a little bit of plantar flexors as well for this patient. So again, the importance of getting them up and seeing them walk, and that is something that you can do on telemedicine. And the other thing is that if someone has, you know, listening, of course, to their goals and some patient's goals, and this is a patient who had a severe traumatic brain injury and her goals are to self-feed. And so what a better way than for her to get a plate of food out on her telemedicine visit and be able to see what happens so that when she comes in person, that I'm able to determine what her muscles are that are going to need to be injected. And again, especially in this time of COVID, we can't have people come into the clinic bringing a plate of food, trying to eat their food, taking their mask off. We don't, you know, are not allowing that. So this is a better way to align with someone's goal and doing it on telemedicine. So let's see, she has also a taxia and tremor, too, but. Just can't quite get it there. Try one more time. Your mouth part? Yeah. No, no, no. Leave your fork that way. And so in this patient, it showed me that she actually had a lot of co-contraction in her triceps. So when she was trying to flex her elbow to bring her food towards her, her triceps was co-contracting and not letting her bend her elbow enough. And then the other thing, she had difficulty, she was pronating too much, not able to get into supination to feed herself, and then also not able to bring her shoulder, abduct her shoulder. So then I knew when to, what I saw in person, if these are her goals, and I may inject muscles like her pectoralis, her elbow extensors and her pronators as well. So again, much would align very differently than, you know, when I'm doing an examination in person and if she wants to feed. So again, when you're doing evaluations, I recommend that they be functional and you can still make it very functional via tele-spasticity and ask them about, you know, how spasticity is impacting their lives. And just because it may look very severe does not mean that it's significant to them. And just because it may not look very severe, like the lady with the hand, but it was very significant for her to be treated for her dystonia. And then setting the goals that Dr. Romanosky kind of went through some of those goals that you can use. You want to observe them and that's great on telemedicine, since we can't as much put our hands on them and look at positionings, looking at them transfer, how are they positioning their wheelchair, if they can walk, watch them walk, eating, dressing, watching their, having their family do their home exercise program with them, or let me see how you stretch them. How they're positioned in bed and using the face-to-face video for that. And then, you know, it's harder to be objective. I can't make a 10-meter walk test in someone's house, so I can't, though I have it in clinic. So when they come into clinic, I may do something that is more objective when they're in clinic, like a 10-meter walk test and time them every time that they come in for their injections, or again, the disability assessment scale that you can do. This is another patient, and you can see on the bottom, I'm logged in there, and he was able to, he has right spastic hemiparesis, and he was a musician, and so he wants to get back to playing his guitar, and he gets injections in his upper limb. And so part of his goals is when we do telemedicine visits, that he can bring his guitar out and show me, you know, what's the position. And one thing that I had noticed was that he was not able to actually bring his shoulder forward to be able to strum enough. And then the other issue is once his elbow flexion spasticity gets too tight, then it's hard for him to strum because he doesn't have, because of the spasticity in his elbow flexor. So that's part of the reason why they kind of created this strap to help it keep a little bit down. But it also told me that I needed to inject some muscles around his shoulder. Specifically, I ended up doing his rhomboids so that way he could, I guess, retract his or move his shoulder blade out and bring his shoulder forward. And then, of course, focus on his elbow flexors with, again, his goal being guitar playing. And then in this patient, again, you can, if they live in a nice neighborhood, they can take a nice phone and camera outside. You can be able to, you know, see them walk and, you know, I can look and say, okay, I see what's going on and look at his elbow flexion. And he has a step through, step two gait pattern, and he's not landing on his heel, but rather kind of midfoot to forefoot strike. And so it's just a lot that I can see with telemedicine and encourage people to do so. It also helps you make decisions on surgery for some patients. And so this is a patient who had had a series of many injections over time and a back lip and pump and other things. And, you know, there's a question about how is her ankle doing and is there a need for her to have some type of surgical correction for that? And so this is something, again, where we can see someone on telemedicine, and then also they can send videos or pictures or whatever it might be, and be able to see that as well. So, you know, I can make the evaluation, this is her at home, and then I get a video that shows her working in a treadmill at therapy. And I see, okay, they have these huge braces on her that are wedged on both sides to make up for her contraction that she likely has. So at this point, it was like, okay, yeah, let's make the decision to do your tendon lengthening. And, you know, she did decide on surgery. She had it. Again, it made it easier for her just to make visits in between instead of having to come in with a cast and such. And then she went back into therapy and ended up doing exceptionally well with definitely just a really light carbon fiber brace that could fit in any kind of shoe. She didn't need wedges on both sides. And so, you know, a lot of things that were done for her that didn't have to be done face to face. So I have a little bit of going now. Those were why I want you to see patients on telemedicine and what you can get out of it and some case examples. And then I'm going to pivot to a few, I probably have about three papers related to specifically looking at telemedicine barriers and challenges and including for persons with disabilities that we notice really with COVID-19. Then I have another couple that are looking at especially people who have disabilities who have intersectional identities. On top of their disability, they may belong to a marginalized community such as having poor insurance, being Black, Hispanic, Native American, or living in a rural area where they may not have as much access to care generally. And the reason kind of to start all this was, you know, people were rapidly adopted telemedicine at the beginning of the pandemic. It does improve access to care and reduces barriers. But still persons with disabilities are really a vulnerable population during this pandemic. And I'm going to go into a little bit more of a talk about for the last five minutes just what the reasons are that we did this. So we know there's a lot of benefits to telemedicine. You kind of probably heard that it's better for people who may not have all the financial resources. They don't have to drive in far. They don't have to pay for parking. They don't have their family member or caregiver doesn't have to take the day off or they don't have to pay for extra caregivers. They're not exposed to COVID-19. So that's all really great reasons. And then on telemedicine, it's really easy. So what medicines are you on? Oh yeah, let me grab those because they have them right there at their home. Again, and then all the things I just showed you about being able to see them in their real surroundings. So there are still barriers and challenges for people with disability. And some of these ideas come from that paper that Dr. Anaswami and myself and Lex Friedman wrote. So these are some of the barriers I'm going to quickly go through. And the first is infrastructure and access. So right now, broadband is accessible to everyone. It just depends where you live, how many towers there are, what city are you in. There's some areas where they're really making this a focus on getting broadband to other areas and making it accessible and affordable. I know New York is really leading the, you know, taking a lead on this. And here in San Antonio, we just had someone, a friend of mine who is actually trying to lead in getting this really accessible to our county and our part of Southern Texas. And a lot of patients who have disabilities often don't live in, you know, these areas. And they may be in a rural area where there is not great broadband. And that's something that I see a lot of times doing these telemedicine visits is, you know, it's cutting off. It may not be very good. And we don't have legal requirements for these to be there, you know, that they need to have this. And there's no financial incentive to make it to happen in these rural areas either. So those are things that, you know, and at a country level need to be changed. And then also novel bio peripherals. One thing I can see someone on telemedicine, I can't take their temperature. I can't do their blood pressure unless they have those things at home. So is there some way that we can start measuring that? Or can there be, you know, something that the patient wears that measures their heart rate or, you know, an Apple watch that sends information to us? There's operational system challenges. So what are the costs associated with these platforms? And are the resources improving, you know, the quality of experiences? And then hopefully as, you know, we're trying to improve this, are they going to make us pay more? Are they going to make the patient pay more? I know now, you know, if someone has some proximity, for example, from a physician standpoint, you can do it up to a certain period, like a 45 minute talk or visit. But after that, then they cut you off because then you have to be paid to be able to do that. And then we have to also figure out how we're integrating telehealth and academic medicine, which you heard a little bit about the education component from Dr. Romanosky. There's also logistical challenges because I may be able to see them and know them. But what if I need to do labs or diagnostic tests or injections? I can't yet do it through this way. But then they're still going to have to go to a place to get that done. There's regulatory barriers. So, you know, at the beginning, regulatory barriers were eased. And actually, they're now more and more regulatory barriers, and we need something permanent. We need something legalized and standardized in telehealth. So, you know, at the beginning, we could do phone calls. We could do face-to-face synchronous visits. And now the only one that will pay for phone calls is Medicare only. No other payers are doing it. So, you have to be able to see a person. And if you're trying to do a face-to-face visit, and they're set up on telemedicine, and then they can't ever figure out how to connect the video part, then you are going to lose out on being able to bill for that patient. So, we need to make sure that we figure out regulations for that. Again, on telemedicine, there can be communication barriers, especially if a patient's deaf, blind, or has cognitive deficits, as many patients with brain injury may have. And then also, we notice that, you know, for patients to sign on to the MyChart or Epic, that's what we have where we are. You know, they're like, we'll send you the information. And if the information's in English, but they speak Spanish, then that's going to be a problem for them to be able to sign on to something that they can't read, or they have cognitive deficits and can't figure out how to sign on and read and get their records. Legislative barriers. So, interesting, of course, ADA, we love the ADA, but it was passed before we had the internet. So, there's no provisions in there for virtual spaces. It's all about physical spaces. And so, we need to look at regulations and legislations to ensure that the ADA also encompasses virtual and telemedicine spaces as well. And then there's just other, you know, unique barriers still. Like someone had asked a question about, how do you do video? And what if someone doesn't have good manual dexterity, or they don't have someone that's there? And what if they, you need to have different virtual interfaces for someone who's maybe on the autism spectrum, who may have difficulty with having certain light on, or with sounds, and there may be, you know, different barriers for different people. And so, there have been a lot of healthcare disparities that we've obviously seen during the pandemic that can be made a lot worse, or a lot better through telemedicine. It just depends on how we empower our patients. And we know sometimes disabled Americans and also persons who may not come from, or who do come from marginalized communities may not have the same access to this. And that's something that we kind of see between our two clinics as well. And so, that is my section. And that'll give us time for questions now. So, Dr Gutierrez, it looks like Dr. Shank had post about living in rural West Mountain States, where they're caring for individuals that travel five to six hours for their appointments and use virtual telehealth often however frequently run into issues with patients not being able to have service where they live, go to sit in their car and drive to areas of service, etc. Who in your office or how are you setting up with therapists in the office? They've tried to do that, but it takes a lot of coordination and obtaining emails for us because of the virtuals through Microsoft Teams. So, like I said, I have two different clinics and sometimes there's two different processes, but one of them is, you know, my clinic that I have at UT Health, they, this is all figured out beforehand. And so that if we were supposed to meet at 2 p.m. for our visit, then before that, my MA and the office staff are working with person starting the day before, you know, a lot of it is pre-work than it is the moment of, I don't want them to get on it too and start trying to figure it out with the patient. I want them to, by the time it's two, I'm ding dong, hi, it's me, Dr. Gutierrez. And so that means some of the office staff are doing the work beforehand and figuring out and helping them troubleshoot it. You know, making sure that they can sign on, that they've gotten a MyChart account, that they've practiced it with them so that when I come on, it's done. I will tell you at our other clinic, we may not be as well staffed to do that. And so that's where I have to use different, you know, okay, if that didn't work, then I'm going to use Doxy.me or I'm going to use Doximity or sometimes I'll just use FaceTime or something else just as, you know, to get the patient to be face-to-face. But you want, it's time that you put in before. I would echo that too. We have staff who will do, you know, med reconciliation and things like that, usually even sometimes a day in advance. I think the challenge that many of us are probably running into is that our staff are very busy and now we're adding a new task for them. And so I think back to some of the points about, you know, legislation and different responsibilities of the healthcare system. This is something that we need to advocate for, especially for individuals with disabilities because this likely is going to be a new role that maybe, you know, a new staff member may take on to help prep some of these visits for us. And we need to advocate for that. Okay. And another question for how did you encourage your administrative teams to recognize the needs of these patients? You know, given the shortages in staffing and any special recommendations? I'm the boss, so they try to make things work well for me. It doesn't work for everyone. I think the other time is when I do telemedicine, I'm pretty much, this is a half day that's dedicated to telemedicine. So, you know, I'm not trying to run back and forth or see a patient and do telemedicine. Though, you know, sometimes in my other clinic, I do have it set up that way. So, if they know beforehand, okay, this is a telemedicine day, how are we setting it up? This is important. You know, the nurse themselves doesn't have to be running, you know, in person. They have to be taking blood pressure and doing, you know, that kind of stuff. Well, they're not doing that. So, they can take that little, you know, your MA can take the extra effort to help them sign on the same time that they would be taking, you know, review of systems, blood pressure in person. So, I think you can just maybe frame it that way. If you make it a telemedicine day and say, well, you're not seeing people and moving them to the room and mixing my meds and doing whatever else you're doing. So, let's just focus on getting them on. And I would add to that, although it does take still some more staffing as we prepare to advance more telemedicine, is I do the same thing every Wednesday morning is dedicated telehealth. And because I'm in a larger group, that means one of my partners can be in clinic. And so, we can actually see more patients. We can be more productive. We can build more visits because of that space, I can be in an office and those clinic rooms can still be used. And so, I think trying to encourage the utility in that may be useful as well. Well, thank you everyone for your attention. And thank you, Dr. Verduzco Gutierrez and Dr. Romanosky. And any final words or questions? I don't know. I think that patients like this, it's convenient. The other thing is that sometimes what will happen is if we have in-person clinic and then someone's like, oh, they can't show. And so, it actually saves me from having no shows. I said, let's convert it for a telemedicine. They can't make it today because that always happens with persons with disabilities. They have car trouble or their caregiver can't get off. Let's switch it to telemedicine. So, it actually can be very still profitable for your organization. Okay. And another comment that it's really great for face-to-face for equipment too. Yes, definitely. I think there was a comment. Yeah, I've had good success in face-to-face visits as long as there is video components. Absolutely. All right. Thank you, everybody. Thank you, everyone.

telemedicine

virtual assessments

spasticity

telehealth technology

virtual setup

home environment

barriers

challenges

advocacy