The Malcom Randall VAMC TCTs acquired clinical staff competencies in transfers, balance, and gait testing to prevent injury to both themselves and the patients. Extra safety measures were used when testing balance, such as using the corner of the room and having stable pieces of furniture proximate to the patient, creating a “safety zone” (Table 2). The TCTs were trained to obtain orthostatic blood pressure measurements, test first toe proprioception, screen for lower extremity muscle strength, and screen for dynamic visual acuity (ie, ability to perceive objects accurately while actively moving the head). The TCTs learned to ambulate patients using assistive devices: standard cane, rollator walker and rolling walker.
During the CVT encounter, the PT with the TCTs assistance, performedthe following evaluations: Berg Balance Scale, Dynamic Gait Index, Timed Up and Go, Clinical Test of Sensory Interaction and Balance (CTSIB), and postural reflex testing. The Berg Balance Scale measures 14 balance-related tasks on a 5-point scale (0-4). The DynamicGait Index measures gait during usual steady-state walking, and walking during more challenging tasks. The Timed Up and Go uses the time that a person takes to rise from a chair, walk 3 meters, turn around, walk back to the chair, and sit down. The CTSIB measures how vision, vestibular and somatosensory function impacts balance against the forces of gravity.20-24At the visit’s conclusion, using input the TCT PT educated patients and caregivers on home exercises, maintaining balance, compliant surface training, functional lower extremity exercise strengthening, gait activities, and vestibular adaptation exercises.
Results
The Malcom Randall VAMC partnered with 5 remote clinic sites delivering about 4 to 5 CVT visits weekly with 1 to 2 CVT visits per remote clinic monthly. Some of these sites serve primarily rural veteran enrollees. During the pilot project phase between April 2014 and August 2014, the PT performed 25 CVT encounters with veterans, evaluating gait and balance disorders. Anecdotal informal feedback on the CVT experience was positive for both clinicians and veterans. Moreover, the PT often ordered durable medical equipment during these initial CVT encounters to rapidly employ fall prevention environmental modalities.
The average round-trip mileage saved per veteran per visit was about 120 miles (Table 3). Reducing the drive time is an important consideration for elderly veterans and their caregivers.
Discussion
The transition from face-to-face to CVT visit was seamless for the PT. Paramount to this success was the TCTs training and related competencies to expect common balance losses during testing. The experienced LPN was a good fit for the TCT role for this particular CVT clinic. Special emphasis in the TCT competency training sessions was given to body and hand positioning to prevent falls in all directions. Placing the hands both in front and behind the patient simultaneously in anticipation of a fall was critical. Walking alongside a patient during gait testing with similar hand placement was also important. Special attention was given during and after the turn when most balance-impaired patients are prone to fall. This provided a feeling of security to both the patient and the remote PT.
Conclusion
Veterans expressed satisfaction to the PTs and TCTs about the reduced travel time and transportation costs. This pilot showed that employing a specialized gait and balance clinic is feasible using CVT technologies with positive results.
Acknowledgments
The authors wish to acknowledge the NF/SGVHS telehealth coordinator, Mr. Indra-Jeet Seenauth, for his invaluable assistance with this pilot clinic and the various telehealth certified technicians for their dedicated support to this clinic and the veterans.
