Telemedicine for the Musculoskeletal Physical Exam: A Pocket Guide

Description:
Telemedicine has ballooned in popularity and necessity in the COVID-19 world, and it has proved its worth. Even in the post-pandemic world, telemedicine will be here to stay, as it offers both patient and provider many advantages. However, physicians are often ill-equipped and lack sufficient training in how to conduct a physical examination remotely.
Practical and timely, this book presents the current best practices for performing musculoskeletal examination remotely via telemedicine. It takes an anatomical approach, covering all joints and disorders commonly seen in the clinic, including preparation and general principles, the upper and lower extremities and the axial skeleton. For each region, the challenges and limitations of telemedicine are systematically highlighted and discussed, with techniques clearly described and illustrated. Concluding chapters present telemedicine procedures for both the functional assessment of a patient and evaluation and management of respiratory muscle dysfunction.
Orthopedic and sports medicine practitioners, as well as general physicians, nurse practitioners, and physician assistants who treat patients with musculoskeletal disorders, will find this book highly engaging and enlightening.

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Acknowledgments

To my coeditors and to my authors—this isn’t for you, but by you. Thank you. Dr. Herrera, you have been a friend, a mentor, and a guiding presence throughout my entire career, and I am honored to have completed this project with you. Thank you to my outstanding residents German and Craig who kept this machine going and were my right-hand men. Thank you to my husband Bishoy who has had to deal with my highs and lows throughout the process and made sure the lows were outnumbered. Your patience exceeds any and all expectations—you’re the real MVP.

Mariam Zakhary

It has been a pleasure to collaborate on this book. I want to first thank my coeditors and all of the amazing authors who worked so hard to make this book a reality. In particular to my good friend and colleague, Dr. Herrera, it’s great to finish yet another terrific project with you. Thank you to my colleagues at Princeton Spine & Joint Center for continuing to push, nurture, and challenge me. And thank you to my family, Ana, Mila, Lara, Luka, Twinkle, and Lili, for putting up with me when I disappeared into the study to write.

Grant Cooper

I would like to thank my amazing family, Sandra, Alex, Mikhayla, and Andrew, for all of their continued love and support through this journey. Thank you to all of our fantastic authors and other editors who came together to make this book a success.

Joseph Herrera

Acknowledgments
Contents
Contributors
1: Remote Patient Monitoring
Remote Patient Monitoring (RPM): Working Definition and Central Concepts
The Value of RPM in Telemedicine
RPM and MSK: Introduction
Remote Patient Monitoring for the Musculoskeletal Patient
Inspection
Pain
Range of Motion
Palpation
Strength
Sensation
Function and Mobility
Technology Utilized in RPM
When to Triage for Telemedicine or Video Visit
Barriers of RPM
Billing and Coding Legislation
References
2: Video Visit Preparation and Patient Education
General Description
Prior to the Visit
Optimizing Visual and Auditory Quality
Choosing an Ideal Space
Clothing
Helpful Objects
During the Visit
After the Visit
Preparing Your Patient for the Video Visit/Patient Education
Outline
References
3: The General Telemedicine Exam
Chief Complaint/Patient History
Physical Exam
Initial Setup (Suggestions on how to visually optimize)
Inspection/Observation
General
Pulmonary
Cardiovascular
Gastrointestinal
Genitourinary
Palpation
Pulmonary
Cardiovascular
Gastrointestinal
Genitourinary System
Differential Diagnosis
Marfan Syndrome
Dermatomyositis/Polymyositis
Systemic Lupus Erythematosus
Spondyloarthropathies
Rheumatic Fever
Management/Treatment
Marfan Syndrome
Dermatomyositis/Polymyositis
Systemic Lupus Erythematosus
Spondyloarthropathies
Rheumatic Fever
Complications/Red Flags
References
4: The Telemedicine Cervical Spine Exam
Chief Complaint/Patient History
Physical Exam
Inspection
Palpation
Range of Motion
Neurological Examination
Muscle Strength Testing
Sensation
Reflexes
Special Tests
Spurling’s Neck Compression Test
L’hermitte’s Test
Shoulder Abduction Test
Examination of Related Areas
Considerations for Certain Populations
Children
Rheumatoid Arthritis
Down Syndrome
Differential Diagnosis
Management/Treatment
Complications/Red Flags
Follow-Up
References
5: The Telemedicine Thoracic Spine Exam
Chief Complaint/Patient History
Physical Exam
Initial Setup to Optimize the Physical Exam
Inspection
Palpation
Active Range of Motion
Neurological Examination
Differential Diagnosis
Mechanical Causes of Thoracic Spine Pathology
Nonmechanical Causes of Thoracic Spine Pathology
Visceral Causes of Thoracic Spine Pathology
Special Considerations
Management/Treatment
Mechanical
Non-mechanical and Visceral Causes
Complications/Red Flags
Follow-Up
References
6: The Telemedicine Lumbar Spine Exam
History
Physical Exam
Inspection
Palpation
Active Range of Motion
Gait
Muscle Strength
Psoas
Quadriceps
Tibialis Anterior
Extensor Hallucis Longus
Gastrocnemius-Soleus
Gluteus Medius
Reflex Testing
Sensation Testing
Special Testing
Seated Straight Leg Raise
Slump Test
Seated/Supine FABER
Kemp’s Test
Standing Stork Test
Prone Stork Test
Reverse Straight Leg Raise
Ely’s Test
Supine Straight Leg Raise
Supine FAIR
Modified Gaenslen’s Test
Thomas Test
Examination of Related Areas
Special Considerations
Follow-Up
References
7: The Telemedicine Shoulder Exam
History
Physical Examination [2, 3] Initial Setup
Inspection
Palpation
Range of Motion (ROM)
Apley Scratch Test
Flexion
Extension
Abduction
Adduction
External Rotation
Internal Rotation
Special Considerations for ROM
Muscle Strength
Special Tests [3] Supraspinatus
Empty Can Test
Drop-Arm Test
Serratus Anterior
Standing Push-Up Test
Shoulder Impingement
Hawkins Test
Acromioclavicular Joint
Scarf Test
Biceps Tendinopathy
Speed’s Test
Yergason’s Test
Labral Tear (SLAP Lesions)
O’Brien’s Test
Cervical Nerve Root Disorder
Spurling’s Test
Differential Diagnosis
Management/Treatment
Complications/Red Flags
Follow-Up
References
8: The Telemedicine Elbow Exam
Chief Complaint/Patient History
Physical Exam
Initial Setup
Inspection/Observation
Palpation
Active Range of Motion
Neurological Examination
Muscle Strength
Reflex Testing
Sensation
Special Tests
Provocative Lateral and Medial Epicondylitis Testing
Examination of Related Areas
Considerations for Certain Populations
Acute Elbow Injuries in Children
Chronic Elbow Injuries in Children
Osteochondritis Dissecans
Differential Diagnosis
Anterior Elbow Pain
Bicep’s Tendinopathy
Medical Elbow Pain
Medial Epicondylitis (Golfer’s Elbow)
Ulnar Collateral Ligament Injury
Physical Exam
Cubital Tunnel Syndrome
Physical Exam
Lateral Elbow Pain
Lateral Epicondylitis (Tennis Elbow)
Radial Tunnel Syndrome
Posterior Interosseous Nerve Syndrome
Posterior Elbow Pain
Olecranon Bursitis
Posterior Impingement
Physical Exam
Triceps Tendinopathy
Elbow Instability
Management/Treatment
Unique and Extra Considerations
Medial Epicondylitis
Lateral Epicondylitis
Complications/Red Flags
Follow-Up
References
9: The Telemedicine Hand and Wrist Exam
Chief Complaint/Patient History
Physical Exam
Initial Setup
Inspection/Observation
Palpation
Motor Exam
Range of Motion
Neurovascular Examination
Differential Diagnosis
Scaphoid Fracture
Lacerations
Skier’s/Gamekeeper’s Thumb
Jersey Finger
Mallet Finger
De Quervain’s Tenosynovitis
Flexor Tenosynovitis
Carpal Tunnel Syndrome
Special Considerations
Management/Treatment
Complications/Red Flags: Potential Limb Threatening Conditions Requiring Emergent Intervention
Follow-Up
References
10: The Telemedicine Hip Exam
Chief Complaint/Patient History
Physical Exam
Setup
Inspection
Gait
Range of Motion
Hip Flexion
Hip Abduction
Hip Adduction
Internal Rotation
External Rotation
Palpation
Muscle Testing
Sensation
Special Tests
Modified Log Roll
FABER (Flexion, ABduction, External Rotation of the Hip)
Modified Stinchfield
Sit-Up or Resisted Sit-Up
Seated Slump Test/Straight Leg Raise
Resisted Hip Adduction
Single Leg Hop Test
Differential Diagnosis
Special Considerations
Management/Treatment
Complications/Red Flags
References
11: The Telemedicine Knee Exam
History
Physical Exam
Two Person Physical Exam
Inspection and Gait
Range of Motion Testing
Palpation
Strength Testing
Sensation Testing
Reflex Testing
Provocative Testing [1] Supine Provocative Testing
Patellar Apprehension
Patellar Compression Test (Clarke Sign)
Anterior and Posterior Drawer
McMurray
Prone Provocative Testing
Apley Grind Test
Seated Provocative Testing
Varus Stress Test
Valgus Stress Test
Standing Provocative Testing
Two-Legged Squat
Duck Walk (Childress Test)
One-Legged Squat
Thessaly Test
One Person Examination
Inspection and Gait
Range of Motion Testing
Palpation
Sensation Testing
Reflex Testing
Strength Testing
Provocative Testing
Seated Provocative Testing [2] Standing Provocative Testing
Duck Walk (Childress Test)
Thessaly Test
Differential Diagnoses
Considerations for Specific Populations
Special Considerations
Management and Treatment
Complications and Red Flags
Follow-Up
References
12: The Telemedicine Foot and Ankle Exam
Chief Complaint and History of Present Illness
Pain
Swelling
The Virtual Exam of the Foot and Ankle
Initial Setup
Inspection
Palpation
Range of Motion
Neurologic and Vascular Examination
Strength Testing
Reflex Testing
Special Tests
Seated Special Tests
Thompson Test
Evaluates Achilles Tendon Rupture
Anterior Drawer Test
Evaluates Anterior Talofibular Ligament Laxity
Talar Tilt
Evaluates Talar Instability
Metatarsal Squeeze
Evaluates Morton’s or Interdigital Neuroma
Kleiger’s Test
Evaluates for Medial Ankle Sprain
Standing or Walking Special Tests
Coleman Block Test
Gait Assessment
Tiptoe Walk
Heel Walk
Evaluates L4–5 Nerve Function
Hop Test
Evaluates Power and Strength Usually Before Return to Sports Post-injury
Special Populations
Differential Diagnosis
Management and Treatment
Red Flags
Complications
Infection
Neoplasm
Vascular Compromise
Fracture and Dislocation
Follow-Up
References
13: Telemedicine Evaluation and Management of Respiratory Muscle Dysfunction
Preparation for the Telemedicine Visit
General Considerations
Patient Interview
Physical Exam
Inspection/Observation
Specialized Testing
Indications for Treatment and Prescriptions
Follow-Up
Conclusion/Summary
References
14: The Telemedicine Functional Assessment
Chief Complaint: Functional Testing
Physical Exam
Web-Based Goniometers
Functional Assessments
Functional Assessment of the Upper Limb
Shoulder
Assessing Functional Strength of the Shoulder
Elbow
Push-Up Test
Stand-Up Test
Functional Assessment of the Lower Limb
Hip
Maximum Depth Squat
Single Leg Squat [25–30] Single Leg Squat Variations [28] Self-Paced Walk Test [31, 32] 13 Meter Walk Test [19, 33] Timed Up and Go Test [36–39] Knee
One-Legged Hop Test for Distance [43] Timed One-Legged Hop Test [44–46] Maximal Controlled Leap Test [47] Three Hop Test [44–46, 48] Ankle
Standing Balance [49–51] Side Hop Test [52] Functional Assessment of the Spine
Cervical Spine
Supine
Prone
Side Lying
Cervical Myelopathy
Simple Walking Test
Foot Tapping Test
(Ten Second) Step in Place Test [59] Lumbar Spine
Repeat Sit to Stand Test [36, 64] Repeat Trunk Flexion Test [36, 41, 65, 66] 50 Foot Walk Test [36, 67] 5-Minute Walk Test [36, 67] Loaded Reach Test [36, 41, 63, 68] References
Index