On 16th March 2020, the UK government announced a reduction in all non-essential travel
and a partial lockdown 7 days later, in response to the primary wave of COVID-19 infections.
Outpatient services, including physiotherapy, quickly transitioned to remote working
practices to comply with emergency measures to protect the safety of staff and the
public [1].
Remote working
Remote working via telemedicine (telephone or video-assisted consultation) displaces
the need for face-to-face contact whilst providing care within patients’ own homes
[2]. To facilitate rapid deployment of video consultations NHS England and NHS Improvement
funded access to the Attend Anywhere platform for NHS providers, in line with that
available in Scotland. Clinical guidance on remote care during the emergency period
was rapidly published both by NHS England [3] and the Chartered Society of Physiotherapy
[4]. Despite the relative infancy of remote working in physiotherapy, there is an
emerging body of evidence that supports its incorporation in clinical practice as
both an assessment and rehabilitation tool.
Remote Assessment
Non face-to-face consultations conducted via remote contact have utility to provide
a platform for effective clinical assessments. Remote assessment for musculoskeletal
disorders shows good concurrent validity and excellent reliability in most areas [5].
Clinicians working by phone are able to modify their communication to counteract loss
of visual bodily cues which would usually aid assessment [6]. This may include greater
reliance of verbal description, and Shaw et al. [7] advise the pre-planning of themes
to guide conversation.
There is evidence of moderate to high agreement between remote and face-to-face examination
in patients with low back pain [8], [9] and ankle disorders [10]. Inter and intra-rater
reliability are high and moderate, respectively, for knee assessment [11]. Telehealth
and in-person assessments, in an advanced-practice physiotherapy screening clinic,
demonstrate a high level of agreement in relation to clinical management decisions
and diagnosis in patients with chronic musculoskeletal conditions [12]. Further, video
consultation is deemed acceptable to most patients [13].
Remote Monitoring and Rehabilitation
Treatment interventions can also be delivered successfully via remote working. Patients
with chronic knee pain report satisfaction with the patient-therapist relationship,
the use of technology and the provision of exercises provided remotely [14]. High
levels of patient satisfaction, adherence to rehabilitation protocols and clinically
significant improvements in outcome measures were also demonstrated in individuals
undergoing remote pulmonary rehabilitation [15] and cardiac rehabilitation [16].
Non-adherence with face-to-face physiotherapy care can be as high as 70% [17], and
is particularly poor for unsupervised home-based exercise [18], [19]. Further, there
is little evidence that interventions to facilitate better adherence are effective
[20]. In the current situation, with patients not able to come to attend exercise
classes and have their condition monitored, adherence and compliance is likely to
decline even further.
However, telemedicine, aided by an ever-increasing number of digital health tools,
can significantly increase patients’ confidence in undertaking exercise and improve
compliance and adherence to exercise-based rehabilitation programmes, compared to
usual physiotherapy care [21], [22]. Digital health tools provide images and videos
of exercises, patient advice and education and include reminders for patients to carry
out prescribed exercise programs given by their physiotherapist in a ‘virtual’ exercise
class, which can be remotely delivered and adherence monitored. Tools which combine
education with appropriately timed reminders and exercise prompts can use “nudges”
to positively transform behaviour and modify heuristics [23]. Moderate-high quality
evidence supports the use of nudges to improve self-management outcomes, including
physical activity adherence [24]. Digital tools and telemedicine can allow physiotherapists
to remotely monitor and supervise a patient’s rehabilitation, whilst at the same time
promoting patient self-management and empowerment. Admittedly, the majority of the
research in this area remains based upon small trials, however does provide a basis
of evidence to support adoption of technology in practice.
The Post-Covid Era
The step change in outpatient care provision as an emergency response provides an
opportunity to redesign services within a new framework of innovative working practices
that can extend beyond the immediate crisis. Quality improvement initiatives in response
to rapid deployment of virtual services due to COVID-19 have already begun in the
area of allied health [25].
Novel working practices have the potential to enhance patient choice and clinical
efficacy. However, alongside the readiness to embrace innovation, there must be detailed
and careful evaluation of new remote working practices in order to ensure patient
safety, clinical efficacy and long term sustainability. Evaluation of new technology
in healthcare must be relative to the context of the service change [26]. Changes
to services adopted in response to an emergency situation, although well-intentioned,
may not necessarily turn out to be changes for the better.
Evaluation of remote consultations in general practice follows a model of evaluating
patient safety, patient and staff satisfaction, clinical efficacy and validity [27],
[28].
We suggest that evaluation of physiotherapy services adopted in response to the COVID-19
crisis follow a similar framework. The initial phase of evaluation should include
the administrative, technological and logistical feasibility of remote working clinics.
The acceptability of remote working and levels of satisfaction for patients must also
be assessed, in particular the willingness of patients to embrace remote working in
the long term, after the C-19 crisis has passed. The evaluation model should be applied
in two stages; both during the rapid deployment, and subsequently in the development
of new innovative pathways for the longer term.
Providers will need to demonstrate they have a mandate from patients for provision
of the new services and the patient experience must be fully explored. Similarly,
the experience of physiotherapy staff working in these clinics needs to be examined.
Knowledge of the challenges and difficulties encountered by physiotherapy staff will
guide the delivery of specifically tailored training and education to ensure that
staff feel fully supported and confident to meet the challenges that lie ahead in
the new remote working environment.
The shape, structure and processes of remote working practices in the future will
be determined by the careful assessment of current services that have been delivered
in response to the ongoing emergency situation. Providers must aim to co-design the
new remote care pathways with, and for the benefit of, all stakeholders. Remote working
practices can be an appropriate, well received and, efficient method of providing
physiotherapy care. Without careful evaluation, however, providers run the risk of
redesigning pathways, only to discover that the future isn’t as bright and successful
as was first envisaged.
Conflict of Interest
There are no conflicts of interest to be reported in association with this piece of
work.