Telemedicine During COVID-19 and Beyond:
A Practical Guide and Best Practices
Multidisciplinary Approach for the Orthopedic
and Neurologic Pain Physical Examination
Authors: Yerra Sandeep 
Published: February 2021

Background: The COVID pandemic has impacted almost every aspect of human interaction,
causing global changes in financial, health care, and social environments for the foreseeable future.
More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have
been identified in the United States, testing the capacity and resilience of our hospitals and health
care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future
of our health care system and how we deliver routine care to patients. The adoption of social
distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus
and has been the only proven means of infection control thus far. Social distancing has prompted
hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial
despair to many outpatient centers. However, the need to treat patients for non-COVID problems
remains important despite this pandemic, as care must continue to be delivered to patients despite
their ability or desire to report to outpatient centers for their general care. Our national health
care system has realized this need and has incentivized providers to adopt distance-based care
in the form of telemedicine and video medicine visits. Many institutions have since incorporated
these into their practices without financial penalty because of Medicare’s 1135 waiver, which
currently reimburses telemedicine at the same rate as evaluation and management codes (E/M
Codes). Although the financial burden has been alleviated by this policy, the practitioner remains
accountable for providing proper assessment with this new modality of health care delivery. This is
a challenge for most physicians, so our team of national experts has created a reference guide for
musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience.
Objectives: To describe and illustrate musculoskeletal and neurologic examination techniques
that can be used effectively in telemedicine.
Study Design: Consensus-based multispecialty guidelines.
Setting: Tertiary care center.
Methods: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee
physical examinations were performed. A multidisciplinary team comprised of physical medicine
and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each
examination and provided consensus opinion to select the examinations most appropriate for
telemedicine evaluation. The team also provided consensus opinion on how to modify some
examinations to incorporate into a nonhealth care office setting.
Results: Sixty-nine examinations were selected by the consensus team. Household objects
were identified that modified standard and validated examinations, which could facilitate the
examinations.The consensus review team did not believe that the modified tests altered the validity
of the standardized tests.Limitations: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed.
Conclusions: The physical examination is an essential component for sound clinical judgment and patient care planning. The
physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic
examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.
Key words: COVID, pain, telemedicine, physical examination, spine, shoulder, elbow, hand, hip, knee