The Move to Zoom

Albert Cohen using soup cans as weights
Albert Cohen, 92, uses canned goods instead of weights as part of his Zoom-based physical therapy appointments with Lori Ginoza.

USC physical therapists turn to telehealth options to maintain ongoing treatment for patients sheltering in place during the coronavirus crisis.

BY JAMIE WETHERBE MA ’04
June 8, 2020

FOR THE PAST EIGHT YEARS, Brit Davis has seen Kimiko “Kimi” Yamada DPT ’06 for physical therapy on a regular basis.

“I’ve had multiple surgeries that Kimi’s helped me heal from,” Davis says. “I see her as a partner in my recovery.”

In 2012, Davis was diagnosed with two separate cancers at the same time — a tumor in her left breast and a melanoma tumor under her right arm.

“I had my left breast removed because of cancer and my right breast removed prophylactically,” explains Davis, who tested positive for the BRCA1 gene mutation that increases susceptibility to breast cancer.

The cancer and its treatment caused Davis chronic lymphedema in both arms. Part of her ongoing physical therapy, called complete decongestive therapy, includes lymphatic drainage and other therapies. 

In December, Davis underwent her most extensive procedure yet: A 14-hour surgery to harvest and transplant lymph nodes from both arms as well as reconstruction of both breasts.

“I didn’t have breasts for 7 years,” she says. “It was quite a big surgery.”

Davis resumed PT in February, and soon after, the coronavirus halted treatment.  

Even though USC takes precautions to keep its clinics safe, with Davis being immunocompromised and at a higher risk, Yamada opted to turn to telehealth. 

“When we realized this could go on for months, I didn’t want [Brit] to go through a long period of time without any care,” says Yamada, associate professor of clinical physical therapy. 

After a successful first telehealth session, the pair wished they had started sooner. 

“Originally, we just wanted to bide time,” Yamada says. “But we accomplished so much; it was a surprise for both of us.”

Yamada has since reached out to other patients to schedule telehealth sessions. 

“We can be effective in this modality,” she explains. “I do think this will be a game-changer for healthcare.”

 

After lymphedema treatment, Brit Davis’s weekly treatments include techniques to improve range of movement and to stretch scar tissue.

The Move to Zoom

Like many meetings in our current situation, physical therapy sessions start by turning on the computer and opening Zoom. 

Yamada and other providers at USC use a HIPAA patient-protected version of the video-conferencing platform. Additionally, Yamada restricted her own recording, screen-sharing and other features to keep patient information private.

“Our DPT program at USC uses a hybrid format with a lot of content taught online over Zoom,” Yamada says. “That experience helped me prepare for this type of patient care.” 

Davis’ 50-minute, weekly treatments include techniques to improve range of movement and to stretch scar tissue.

“Kimi holds me accountable, and I’m indebted to her for staying invested in me. Thanks to her and my whole time at USC, the word ‘chronic’ doesn’t feel as overwhelming.”

—Brit Davis

“It’s a lot of exercise description and prescription,” Yamada says. “About 70 percent of what I do comes from talking.”

A more challenging aspect of Davis’ care includes reducing lymphatic fluid. During in-person treatments, this involved measuring and manual mobilization. 

Yamada had to come up with creative solutions, including recording a how-to video for Davis to perform her own lymphatic drainage.

“The video is an exceptional tool; I know exactly what to do,” Davis says. “I might not get the same results, but I certainly see a benefit.”

While Yamada can’t feel the edema or document Davis’ progress in the same way, Davis says there hasn’t been much of a trade-off in transitioning to telehealth. 

“Based on the overall experience, those pieces are minor,” Davis says. “I come away from the exchange feeling it was a very productive session, and I’m making progress.”

Perhaps even more important is the continued sense of connection Davis receives. “Kimi holds me accountable, and I’m indebted to her for staying invested in me,” Davis says. “Thanks to her and my whole team at USC, the word ‘chronic’ doesn’t feel as overwhelming.” 

Challenges and Comforts of Home

When the pandemic hit, it was critical for Albert Cohen, 92, to keep up with physical therapy. 

“If I’m going to continue to be able to walk at all, I have to have this workout,” says Cohen, who has Parkinson’s disease. 

Additionally, Cohen is recovering from two separate falls that caused a broken leg and shoulder. His weekly, 30-minute sessions with Lori Ginoza DPT ’06 focus on boosting balance, posture and strength. 

“Since we started telehealth, he’s one of the highlights of my week,” says Ginoza, assistant professor of clinical physical therapy. “He’s always so positive and kind.”

Still, their online sessions have posed unique challenges. 

“I’m forced to really work on my verbal communication, since I can’t do demonstrations in the same way,” she says. “As a clinician, I’ve been pushed to problem-solve with patients in creative ways to accommodate both their home environments as well as the equipment they have available.”

For instance, instead of weights, Cohen uses cans of soup. “They work really well,” Ginoza says. “We started with tomato, and he’s progressed to cans of chili — Al says those are a little heavier.”

Online sessions often incorporate different areas of Cohen’s home, from the kitchen counter to his favorite chairs.

“[Telehealth’s] certainly opened doors for us in ways that are really helpful. So we hope it’s here to stay.”

—Lori Ginoza DPT ’06,
Assistant Professor of Clinical Physical Therapy

 

“We might try to move to his front porch if the Internet feed allows,” Ginoza says. “I know he likes being on his porch, and there’s a chair that’s become challenging.”

Understanding a patient’s living environment more intimately has helped Ginoza provide better care.

“In the clinic, we would try to mock a chair a patient might be having trouble with at home, but it’s not the same as seeing it like this,” she says.

 For both balance and tech support, it’s critical that Cohen’s family or caregivers are involved in his telehealth treatments. “It’s a big help to be living with people who are computer savvy,” Cohen says. “I couldn’t do this by myself.”

There are other limitations with telehealth treatments, including properly stretching Cohen’s body and the intensity of exercises.

“Right now, I’m pushing patients to a minimal- to moderate-challenge level,” Ginoza explains. “Whereas in clinic, it’s a moderate- to high-intensity level because I’m there. With Parkinson’s, we know challenging the body, balance, muscles and brain are important to help manage the disease. I’m not able to do that as well with telehealth.”

The Future of Telehealth 

Like many aspects of our healthcare system in the time of coronavirus, issues of telehealth coverage, consent and access are continually evolving.

The pandemic has prompted more insurance companies to cover telehealth, although some, including Medicare, have stated this will be temporary.

Access to technology can limit the number of patients providers can reach, although the pandemic has motivated more people to get online. “My grandma is 97, and with a little help, she’s on Zoom,” Yamada says. “It became a necessity.”

While most patients experience more benefits from in-clinic treatment, perhaps telehealth could be used as part of a hybrid model or as a training resource. 

“Perhaps patients, especially those who live far away, come in once a month, and we incorporate telehealth,” Ginoza says. “Or we offer family or caregivers training remotely so they can assist with treatment at home.”

The Zoom model might allow for faculty, PT students or other providers to attend treatment sessions remotely for more of a team approach to care. 

“It’s certainly opened doors for us in ways that are really helpful,” Ginoza says. “So we hope it’s here to stay.”