Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to Action for Telerehabilitation

Abstract

The emergence of coronavirus disease 2019 (COVID-19) has presented a global health threat, and it poses challenges to how physiotherapists deliver health care. Physiotherapists have an ethical obligation not only to reduce the spread of COVID-19 but also to provide client-centred care and to improve or maintain function among those living in the community. Telerehabilitation provides an opportunity to maintain function, prevent future hospitalizations, and assist with discharge from hospitals while maintaining physical distancing recommendations. This editorial outlines the evidence for telerehabilitation, key considerations for its use, challenges to its use, and we issue a call to action.

The emergence of coronavirus disease 2019 (COVID-19) has presented a global health threat, posing challenges to health care delivery among physiotherapists. Outpatient physiotherapy clinics have closed, and in-patient therapists are working on the front lines to treat clients. In the acute care setting, referral to physiotherapy is recommended for clients at significant risk of developing functional limitations.¹ Physiotherapists can also help individuals living in the community who are susceptible to functional limitations, falls, and subsequent hospitalization. Clinicians have an ethical obligation to reduce the spread of COVID-19 but also to provide client-centred care and to improve or maintain function for those living in the community. Telerehabilitation provides an opportunity to maintain function, prevent future hospitalizations, and assist with discharge from hospitals while maintaining physical distancing recommendations. In this editorial, we outline the evidence for telerehabilitation, key considerations for its use, challenges to its use, and we issue a call to action.

Evidence for Telerehabilitation Interventions

The evidence for the effectiveness of telerehabilitation for musculoskeletal, neurological, and cardiorespiratory conditions is emerging.^2–7 Several recent meta-analyses have revealed that telerehabilitation is, at minimum, as effective as face-to-face therapy for improving (1) physical function and pain in individuals with arthritis and spinal conditions and after elective musculoskeletal surgeries;³ (2) exercise outcomes for people with chronic obstructive pulmonary disease;⁶ and (3) activities of daily living, balance, health-related quality of life, and depressive symptoms after stroke.⁴ In some instances, telerehabilitation has been more effective than traditional therapy: a meta-analysis determined that it reduced pain and improved function more effectively than usual care (ranging from education to standard rehabilitation) among individuals after total knee replacement.²

Key Considerations

Although telerehabilitation is a viable solution at a time when physical distancing is necessary to prevent viral transmission, modifications to standard practice procedures should be considered:

• Review your professional liability coverage for telerehabilitation; you must have coverage to provide it.

• You must be a registered member of the physiotherapy regulatory body in the jurisdiction in which you and the client reside.

• Check with the client’s insurance provider to determine whether it provides telerehabilitation coverage. Some insurance providers that do are Blue Cross, Manulife, Chamber of Commerce, Canada Life, and Sun Life.⁸

• Screen the client to ensure that telerehabilitation is appropriate for the client’s assessment and treatment needs.

• Consider whether the client will require physical or cognitive assistance from a family member during the session, and if so, arrange this ahead of time.

• Obtain consent from the client, which includes the typical information included in consent but also information about the security of the computer platform used.

• Use a secure platform such as Embodia,⁹ Doxy,¹⁰ or Jane.¹¹

• Before starting the session, identify yourself and your jurisdiction to the client and ask the client to identify her- or himself verbally.

• Use normal documentation (e.g., a SOAP note [subjective, objective, assessment, and plan]), including what services you have provided and the fact that you used telerehabilitation.

• Provide the client with an invoice that states that you used telerehabilitation. The Canadian Physiotherapy Association provides an invoice template.¹²

Challenges and a Call to Action

Until the COVID-19 pandemic struck, the uptake of telerehabilitation into physiotherapy practice had been slow. A recent systematic review identified the global barriers to telemedicine among providers and clients, including a lack of technical knowledge, resistance to change, cost, and a lack of reimbursement for services provided.¹³ Since the crisis began, many insurance companies across Canada have agreed to cover telerehabilitation services, and the Canadian Physiotherapy Association has offered webinars to help physiotherapists learn how to deliver them.¹⁴ As uptake increases incrementally, initial telerehabilitation caseloads will be small, and self-employed physiotherapists will face significantly reduced financial compensation. Thus, the Government of Canada must financially support physiotherapists as they provide telerehabilitation.

While the COVID-19 outbreak continues to spread throughout the world, telerehabilitation may be the new norm because people need care to maintain their function and quality of life. Fortunately, it appears that clients are ready and open to this form of treatment; a survey of 254 individuals with chronic respiratory diseases determined that 57% indicated that they were technologically competent, and 60% were willing to use telerehabilitation.¹⁵ Telerehabilitation offers physiotherapists opportunities to provide innovative, effective movement-, exercise-, and education-based treatments.

COVID-19 represents a serious threat to the health and well-being of all Canadians. Physiotherapists have the skills and creativity to provide care to keep people moving, functional, and out of hospitals while maintaining physical distancing. It is time to take our practice online.