Musculoskeletal telerehabilitation experience during the 70 days of COVID-19 lockdown in Italy

In this letter we shortly describe and discuss the characteristics and the acceptability, under the perspective of the physiotherapists, of a telerehabilitation service quickly organized to face the 70 days of the Italian lockdown following the COVID-19 outbreak.

The telerehabilitation service, named “At home with you,” was costlessly proposed to all the patients attending the seven clinics of a private sports rehabilitation network with the aim to maintain the contact with them after the unexpected start of the lockdown. Patients were asked to participate in the study signing an informed consent, in accordance with the 1964 Helsinki World Medical Association Declaration involving human participants.

According to medical prescription, every program carried out by every patient during the until then in-presence sessions was updated by 48 physiotherapists, i.e. 12 females, 36 males aged 36.0±8.3 yrs (range 25-53 yrs), with a working experience less than 5 years, 18 (37%), between 6 and 10 years, 8 (17%), more than 11 years, 22 (46%), and transformed in a written document containing information regarding the prescribed sessions/week, and all the exercises that should be done at home, included the number of series and repetitions, along with some images to a better understanding. Considering that physiotherapists were used to deliver leaflets for home-based rehabilitation, the time taken to prepare a single leaflet, containing a minimum of 5 to a maximum of 12 exercises, was no more than 20 minutes each.

The individual program was sent by e-mail during the first days of the lockdown together with none to 10 video tutorials showing the execution of exercises taken from a video-tutorials archive created within 5 days, containing 152 exercises, lasting 20 to 60 seconds each. Patients were instructed to perform exercises partly alone and partly under the remote supervision of the physiotherapist through phone and video calls (teleconferences). During video calls, the physiotherapist was charged of checking the correct execution of exercises, making changes if necessary or to progress exercise workloads, proposing and demonstrating the correct execution of new exercises and looking for solutions to do exercises in absence of specific equipment. Furthermore, through telephone calls and the most common form of electronic text messaging, the physiotherapist kept in close contact with the patient, checking the adherence to the program and health status, encouraging, carrying out the follow-up, taking care of any medical and physiotherapeutic doubts, managing eventual complications, and eventually referring to the physician.

Overall, this telerehabilitation service resulted in a home-based supervised rehabilitation, which included the delivery of personalized written programs, video tutorials, periodical phone and video calls (Table I), and other contacts between the physiotherapist and the patient, including short message service and multimedia message service. In summary, physiotherapists dedicated 89.0±44.2 hours to phone and video calls during the lockdown period.

Table I. —Telerehabilitation contacts recorded by physiotherapists with all the patients during the lockdown period.

Variables	N. (%)	Contacts/patient	Contacts/physiotherapist
Total (N.)	15,137 (100)	10.9±4.7	315.4±136.3
Video calls (N.)	3134 (21)	2.3±1.6	65.3±45.9
Phone calls (N.)	6257 (41)	4.5±1.6	130.4±71.5
E-mail and social media (N.)	5746 (38)	4.1±3.2	119.7±68.3
Video tutorial sent (N.)	2962	2.1±1.9	61.7±61.3

Mean±SD.

The 1392 patients involved in the service (Table II) attended 2.4±1.4 sessions/week of in-presence rehabilitation before the lockdown. During lockdown attendance was higher (2.9±1.2 sessions/week; P<0.001) probably because of the pandemic that forced patients to stay at home for long time and by the fact that the service was proposed costless and delivered by already known physiotherapists.

Table II. —Patients involved in the study (42% female; 58% male; aged 45.4±19.1 years) were affected by musculoskeletal disorders of knee (39%), back (19%), muscle and tendon (15%), ankle and foot (11%), upper limb and shoulder (8%), hip (5%), and other non-musculoskeletal disorders (2%).

Patients	N. (%)
At the start of lockdown	1351 (97.0)
Entered during lockdown	41 (3.0)
Total	1392 (100.0)
Discharged during lockdown	48 (3.4)
Did not finish (symptomatic SARS-CoV-2 infection)	12 (0.9)
Did not finish (other)	7 (0.5)
Total (discharged + did not finish)	67 (4.9)
At the end of lockdown	1325 (95.2)
Continue in-presence rehab at three weeks after lockdown	738 (53.0)

Only 0.9% of the patients did not finish the program because of symptomatic infection and no physiotherapists got infected. Thus, during COVID-19 pandemic telerehabilitation plays a crucial role minimizing the risks to healthcare workers, lowering the risk of transmission to other patients and healthcare staff.¹

Teleconferencing was utilized by 49% of the patients, that resulted younger than those not involved in teleconferences (40.7±18.2 vs. 50.1±18.9 years; P<0.001). WhatsApp, Skype, and Zoom were utilized, depending on the age and expertise of both patients and healthcare professionals, and on tools and equipment availability.

In our service, asynchronous supervision was planned together with synchronous supervision, leaving the patient alone in carrying out some sessions of the program. The lack of companionship while performing rehabilitation exercises was reported as cause of dissatisfaction;² thus, group telerehabilitation should be implemented.³ It is interesting to note that some physiotherapists organized teleconferences with two to four patients simultaneously connected to each other. They attended the same gym sessions with the same physiotherapist before the lockdown, thus it was easy to involve them in multiple people teleconferences. Furthermore, patients were invited to record with their phone cameras some exercises to be checked by the physiotherapist. From this, some patients spontaneously recorded serious and funny videos and pictures of exercises to be shared in their web sites and social media, creating a network of unexpected contacts, helping socialization during the lockdown, irrespective of privacy.

Three weeks after the end of the lockdown only 53% of the patients restarted in usual in-presence rehabilitation sessions. This lower percentage was probably due to some effects of the pandemic, such as fear to became infected, quarantine due to close contacts with infected people or to infection, and difficulty in moving.

From an on-line survey on personal perception of telerehabilitation regarding frequency and agreement, filled 8 months after the end of lockdown, it emerged that all the 48 physiotherapists think that they were able to agree with their patients the goals of the telerehabilitation program, having no technical difficulties in contacting patients and utilizing video systems. They think that most patients had no technical difficulties using the means of communication to interact with them. In fact, patients attending a private rehabilitation center, funding themselves, have a medium to high income, as well as level of education. They probably have technological tools that are well suited to telerehabilitation, with Wi-Fi connections and high-speed internet.

Although most of the physiotherapist think to be competent in their job, for 48% of them it was not so easy to organize their telerehabilitation work. Obviously, it was a new work that no one had ever done before. Thus, at the beginning of “At home with you” 10% felt very/completely prepared, while at the end they became 50%, confirming that here is a learning curve to using telerehabilitation.⁴

Finally, considering clinical outcomes, pain improved from 2.1±2.1 to 1.3±1.5 of VAS scale (P<0.001) and mean rehabilitation phase improved from 2.7±1.7 to 3.1±1.9 (P<0.001) of the prevailing phase of a five-phases progression model of rehabilitation.⁵ Most of the physiotherapists agree/strongly agree that they are satisfied of their work, and almost all that their patients have been satisfied with their work, indicating the power of telehealth, even when practiced in emergency situations.

From all the above, it can be concluded that a telerehabilitation service quickly organized after the unexpected lockdown due to the COVID-19 pandemic was effective in maintaining the contacts with musculoskeletal patients providing continuity of care for 70 days. It ensured high levels of adherence, clinical improvements, and good perceived satisfaction by physiotherapists. However, based on the retrospective design, the present study cannot be used to support the efficacy of telerehabilitation intervention.

Telerehabilitation was easy to organize in the short time imposed by the emergency-situation thanks to the personal availability of telematic communication tools. The attitude of expert physiotherapists was crucial in adapting to a new professional situation never faced before. Anyway, telehealth engaged both patients and physiotherapists by finding ways to communicate with their own tools, not only in a professional way, but also for fun.

Further studies are necessary to understand how to implement telerehabilitation to match the ever-increasing demand for telehealth, not only in emergency-situation.