This article is meant to share our experience with developing, designing and working through the logistical issues of a telemedicine consultation. Our goal is to help practitioners learn a different way to help their patients during these challenging and ever-changing times of COVID-19.
Telemedicine Considerations
Patient Consent Forms: Contact your state acupuncture board for more information on guidelines and regulations regarding telemedicine consultations.
Preparing the Space and Distancing the Camera: Ask the patient to prepare the space, preferably with a blank wall in the background (this is best for video quality). From our experience, to get a full-body view on a tablet or laptop, the patient should be positioned about 7-8 feet away from the camera. Of course, this will change depending on the height of the patient and the equipment they are using.
Make the best of the space provided. The goal is for the practitioner to have a clear view of the patient as well as to watch them perform static and functional assessments.
If possible, ask the patient to place a 3 ft. strip of duct tape perpendicular to the wall (at a 90 degree angle). This will help to keep the patient in the same location when the practitioner is examining both left and right sides from a lateral view.
Getting the Best Camera Angle: This can be difficult and depends on which device the patient is using. We found that a tablet was very useful because of its ability to have a profile (vertical) image.
Laptops and tablets both had good horizontal capability. Most patients don't have a tripod for balancing the tablet, so they may need to be inventive with stacking books, a picture frame, etc., in order to balance the tablet. Both devices had to be moved to different levels in height to get the best angles.
The floor, different chair heights, a stepping stool, dining room table and even a bed are suggestions to use to obtain a good camera angle, which is very important for proper visualization and instruction.
Lighting: Try to have the patient perform the assessment exams and exercises against a blank wall with lighting behind the camera, such as a window with natural light. If natural light is not available, lamps and lighting behind the camera is often best.
Patient Assessment
Chief Complaint: A 41-year-old female complains of persistent low back pain that is worse with activity such as walking long distances. It is worse in the morning upon waking, better with heat, and is an acute episode of a chronic low back issue.
Patient History: TCM Differential Diagnosis:
Description of Pain: Make sure you ask the patient to rate their pain on a scale of 1-10 during their first virtual visit.
Where is the pain? Can the patient identify the location with their fingers? The patient describes her pain in different regions. With extension-type movements (standing lumbar extension and stork standing test), the pain is on the midline (indicating possible facet joint irritation) and also on the right in the soft-tissue regions (which indicates possible involvement of the lateral fibers of the iliocostalis, the lateral raphe and/or the quadratus lumborum).
As a practitioner, you could be anticipating an elevated ilium and possible anterior tilt with this information (again, refer to Patient Assessment below).
If the pain is in a fixed region, consider injuries such as yaoyan syndrome, lumbar facet joint pathology, sacroiliac joint and soft-tissue strain, etc. The patient indicates fixed regions of pain a few times after performing particular functional exams.
Is the pain radiating? Does the patient describe a traveling sensation verbally or with their hand? In this case study, the patient traces from the upper lumbar / lower thoracic region toward the SI joint, deep gluteals and also toward the greater trochanter. With this body language, consider the possibility of thoracolumbar junction syndrome (TLJS) and possibly a radicular pain pattern.
Because a manual assessment for this condition is not a current option, a virtual examination is needed. The lumbopelvic rhythm test, positive in this case, can be helpful in this situation. To rule out the possibility of the patient's pain being radicular (S1 dermatome in this case), have the patient perform a simple nerve tension test, the straight leg raise test (SLR). This examination is normally performed by the practitioner and is passive for the patient. For this telemedicine examination, the patient can actively perform the SLR on the affected side with hip flexion and with the knee extended.
Second, have the patient perform the SLR using a large towel placed around the ankle. You will need to verbally guide the patient step-by-step with this examination.
Static Postural Assessment
Posterior view:
Lateral View: Left and Right
Posture and Zang Pathology Patterns: Exam for the five different body postures [see image] and inquire with TCM questioning to help support the corresponding zang postural pattern. The patient has an anterior hip shift with the rest of the body in alignment. This particular posture is indicative of kidney qi deficiency, and qi and blood deficiency.
You should expect a pale, possibly swollen tongue body. The tongue coat is often thin. This particular posture (a frontal-plane deviation) requires therapeutic exercise prescription, but it is also imperative to address the kidney qi and the overall quality of qi and blood so the postural changes hold and the low back pain subsides.
Pelvic and trunk rotation: Examine the left and right innominate bones, hip joint and shoulders (acromion at LI 15). The patient has the right hip joint farther forward than the left hip joint, which indicates a left pelvic rotation. At this point, you may suspect a right trunk rotation as a compensation. The torsion between the trunk and pelvis is very common in low back pain cases. You should be considering using points such as GB 41– SJ 5, SP 3 – ST 40. (Refer to the Patient Treatment section in part 2 for more information.)
Editor's Note: Part 2 of this article appears as a digital exclusive in the June issue. It completes the patient assessment with functional testing, and then details the diagnosis, treatment plan and treatment protocols. Parts 1 and 2 are excerpted from a more comprehensive blog post that also features corrective exercises, as well a video presentation of the entire case study.
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