Physiotherapists during COVID-19: usual business, in unusual times

These are unusual times. The spread of COVID-19 (the illness caused by SARS-CoV-2 infection) is changing many aspects of our lives. As healthcare professionals, it is impacting us personally and professionally. This editorial will highlight important considerations and resources that are available to support us through these challenges.

Personally, we may be experiencing economic, social, physical and mental health impacts. These might include concerns re household job security and business viability (especially for private practitioners), through to cancelation of weddings and travel plans, and a loss of self-identity (eg, male colleagues are shaving their beards to ensure that mask fit is adequate for personal protection). These stressors may culminate in grief, anxiety and/or depression. More heart-wrenching aspects might include being unable to hug loved ones due to social distancing, or considering preferences for medical treatment in the event of critical illness for ourselves and those for whom we are responsible. We may experience anxiety about becoming infected and passing on the infection to others. We may also be anxious about the severity of the illness experienced. This may be particularly relevant if you or those close to you are at increased risk medically (eg, pregnancy, immunosuppression, older age)¹ and/or socially (eg, Aboriginal and Torres Strait Islanders, refugees, or those from culturally and linguistically diverse backgrounds, all of whom are typically underserved by the healthcare system). Caring responsibilities for children or the elderly introduce additional considerations and stress. Many avenues that we might ordinarily use to manage these stressors may no longer be available due to social distancing, governmental closures of non-essential services, and infection control requirements.

Professionally, we are also being challenged. We must contribute what we can to affected patients and identify where we provide the best value in the healthcare system.² We are rapidly moving to new models of care under pressure. This may involve re-skilling and redeploying staff to expanded intensive care units, and discharging patients from our care earlier than usual to maintain intensive care and hospital bed access and flow. In outpatient and private practice, treatment may be able to be provided via telehealth technology. We are also required to work within new confines of infection control, where we might have to reconsider standard approaches to assessment and management of equipment. These changes will influence how we interact with patients and their families to manage their clinical conditions or involve them in clinical research. Local and global perspectives, and federal and state recommendations, also influence the rapidly changing situation. With so many modifications to decide upon and implement with urgency, it is important that we do not reinvent the wheel where resources already exist to help us.

While we are working in unusual times, we would argue that there is an element of maintaining ‘business as usual’. There is a reassuring simplicity to this. Ultimately, as physiotherapists, we will still assess and treat patients, informed by the best available evidence. However, we will be doing this under a different set of conditions, in altered working environments, and/or with new teams. With the bandwidth of healthcare stretched to capacity, we must draw on existing resources and decades of research that is highly applicable to our practice. For example, in critical care, COVID-19 patients present with Acute Respiratory Distress Syndrome, for which the medical management, role of physiotherapy, rehabilitation interventions and outcome measures are well known.3, 4, 5, 6, 7, 8 We need not start from scratch preparing lists of what physiotherapists need to know to redeploy to the intensive care unit. Minimum standards of clinical practice for physiotherapists in critical care in Australia and New Zealand⁹ and in the United Kingdom¹⁰ have already been established, and should be used to guide training and upskilling.

Other acute service changes for physiotherapists may include seeing patients on the general wards who are medically more unwell than usual because they have been discharged early from the intensive care unit to free up beds. A clear role for physiotherapists is being the conduit between intensive care and the wards, whilst also limiting clinicians’ physical movement in the hospital to maintain infection control. The recommendations published in this issue suggest that physiotherapy interventions are likely limited in COVID-19 patients when in the intensive care unit,² so an important role will be advising and supporting colleagues on how best to exercise these compromised, hypoxaemic patients on the wards. For those patients who do survive intensive care, reducing ongoing disability will be an important role for physiotherapists.

Even though the situation (and therefore the advice) is changing rapidly, telehealth is going to be a viable option to maintain many services such as virtual fracture clinics for individual outpatients. The Australian Physiotherapy Association tweeted on 21 March 2020:

“the National Disability Insurance Scheme has advised that #telehealth can be used where appropriate and with the agreement from the participant. Providers should ensure they meet the NDIS Code of Conduct (https://www.ndiscommission.gov.au/providers/ndis-code-conduct) to ensure quality service provision”.¹¹

Physiotherapists should use resources like those linked in the above tweet before trying to figure out appropriate standards for themselves. Other national physiotherapy associations have also released recommendations about provision of physiotherapy via telehealth.^{12 , 13} Patients who might normally be managed in group settings must be managed more remotely. Again, research in tele-rehabilitation already exists for our profession.14, 15, 16, 17, 18 Physiotherapists who now need to switch to a telehealth delivery model of care should avail themselves of this ready-made research. It may also be particularly helpful for musculoskeletal physiotherapists to re-examine the evidence for hands-on treatment in some clinical scenarios. For example, telehealth models may provide an effective conduit for advice, education, and exercise instruction (eg, non-specific low back pain).

What about patients who are participating in our clinical trials? Many hospitals will have issued directives about how to appropriately manage research activity including contingency planning, communication, management of participants, notification of protocol breaches, suspension of research, and communicating with ethical review committees. The Australian Clinical Trials Alliance has also provided valuable resources that address issues such as: suspending/restarting a trial, remote monitoring, replacing in-person visits with phone calls, and reducing the number of participant monitoring visits.¹⁹ A critical point for physiotherapy researchers to note is this: if a trial is amended to accommodate new restrictions and organisational directives, the registered trial protocol should be immediately updated on the registry to explain what is being changed and why. Otherwise, the opportunity to publish in high-impact journals may be limited, given the submitted trial must be completely consistent with the registered protocol. Also consider liaising early with funding bodies about any anticipated delays or change in research plans. Physiotherapy research higher degree students should keep up to date with university directives, and ensure regular communcation with their supervisors to develop and modify research plans.

The clinical situation is rapidly changing, and we need to be agile. The recommendations published in this issue pull a lot of useful information together in one place for acute care physiotherapists.² However in an ever-changing environment it is relatively static, which the authors intend to address with a future update(s). Other alternatives in this dynamic clinical situation include a living systematic review as a way to “seamlessly connect evidence and practice”,^{20 , 21} or a clinical practice guideline following the methodology as set out by the National Health and Medical Research Council.²² Another rapid and clinically useful approach would be to adopt a model of crowdsourcing to identify the challenges, and then harness both clinical and research expertise to address them.^{23 , 24}

World events such as wars and the polio epidemic have fundamentally changed the way healthcare is delivered. Clinicians practise in ways previously considered impossible; road blocks to rapidly implementing new models of care are removed. The opportunity to evaluate these changes on important patient outcomes should not be missed. Comparative effectiveness trials are underway and the electronic medical record, not available to previous generations, provides opportunities to evaluate the impact of these natural experiments.

While they are a key part of business as usual, teamwork and collaboration are now more important than ever – within our own profession and interprofessionally. We need to organise and openly collaborate in order to draw on the very best expertise and ensure the right people are appropriately engaged. This may mean working with people we do not usually work with, but it may be vital to our collective success as healthcare professionals. Recommendations for interprofessional teamwork are presented in Box 1 .

Box 1. Recommendations for interprofessional teamwork.

• •Introduce yourself by your first name to build rapport fast and break down hierarchy.
• •Encourage people to speak up, question and voice concerns.
• •Make sure everyone knows your expertise and comfort level, by telling them what you can help with.
• •Verbalise your thought process: what you are doing now and next?
• •Ask for help when you need it.
• •Close the communication loop by asking for and confirming receipt of message/information/instructions.
• •Look after and be civil to each other; everybody is feeling the pressure.
• •Help others if you think they are reluctant to ask; trust your instincts and seek forgiveness later.
• •Share the leader role; the most senior person is often the most skilled and needs to act.
• •Debrief as soon as you find space and are able to.

Modified from.²⁷

Effective and compassionate communication is going to be critical. For example, physiotherapists may be required to facilitate early discharges from hospital, which may be challenging for less experienced clinicians. Again, there are existing resources that can help us based on scientific and clinical expertise.²³ Maximising our workforce will also include consideration of musculoskeletal physiotherapists (including private practitioners) as part of the broader team, and from a whole health system perspective. Empathetic discussions must also take place between musculoskeletal physiotherapists and hospital physiotherapy departments, to recognise the specific expertise of these physiotherapists and where they could make best use of their skills in contributing to patient care, if redeployed to hospitals. Operating as a large team, we must intentionally establish structures for maintaining morale, joy and comradery at work as best we can. Consider designating the role of maintaining socialisation and morale to specific people.

All this is stressful. Many avenues that we might ordinarily use to manage stress (group exercise, social gatherings, viewing theatre performances, receiving a massage or spectating at sporting events) may no longer be available. Therefore, we should avail ourselves of resources to help us manage stress. This might include meditation, maintaining a healthy diet and exercising in alternative ways. Useful resources for supporting our mental health and wellbeing can be found online. For example, the MindSpot website provides advice specific to coronavirus²⁵ and the Centre for Clinical Innovation website provides more generic self-help advice.²⁶

We would also like to remind the frontline staff – clinicians who typically have to perform in constrained environments and regularly identify new ways to work leanly – you have got this. Reach out to those around you and stay connected in these times of physical disconnectedness.

So while these are unusual times, we hope you will find some comfort that we may be able to preserve ‘business as usual’, as we weather the current storm together and then recover as a community.