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      Digital physical therapy in the COVID-19 pandemic

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          Abstract

          On March 11th/2020, the World Health Organization (WHO) declared Coronavirus Disease 2019 (COVID-19), a disease caused by the new coronavirus (severe acute respiratory syndrome coronavirus 2-SARS-COV-2), a pandemic. 1 In this global crisis, physical therapy all over the world, is being challenged to maintain its professional clinical activities in primary and secondary care in private clinics and public health systems.2, 3 Part of the challenge is to continue to provide necessary clinical care in a safe manner, for physical therapists, patients, and the community, by following the general recommendations of the WHO. 1 Social distancing and the interruption of physical therapy activities can have a tremendous negative impact on the health of thousands of patients. Digital physical therapy offers the possibility to continue providing some physical therapy services to patients, but regulations and implementation barriers are extremely heterogeneous around the world. The definition of digital physical therapy Before the COVID-19 crisis, in 2017 the World Confederation for Physical Therapy (WCPT) launched a collaboration to develop initiatives to the global practice and regulations of digital physical therapy practice through a Joint WCPT/INPTRA digital physical therapy Practice Task Force (Task Force). This report published in 2019 defined digital practice as “a term used to describe health care services, support, and information provided remotely via digital communication and devices”. The purpose of this initiative was “to facilitate effective delivery of physical therapy services by improving access to care and information and managing health care resources.” 4 However, for several physical therapists who have never had contact with this terminology, it is important to be aware that different terms are used in this field. There is still no global well-accepted term or definition for digital physical therapy among the literature industry, policymakers, and stakeholder groups. The variety of technologies that encompass this term may include tele-education, telemedicine, telemonitoring, teleassistance, mobile health, among others, and each field has its subset of technologies and specificities. The heterogeneity and barriers of digital physical therapy The worldwide COVID-19 pandemic forced the Brazilian health system to promptly adopt telehealth in different health care areas. The Federal Council of Physiotherapy and Occupational Therapy (COFFITO) allowed the use of telehealth, more specifically teleconsultation, teleconsulting and telemonitoring, for physical therapists (Resolution n° 516/March, 2020). 5 This change was promptly adopted to provide safe treatment delivery according to the WHO recommendations, however, no guidelines are available for physical therapists on how to use these technologies. Some countries currently use specifically designed and secure paid technologies to aid patient rehabilitation and monitoring. However, many physical therapists in Brazil and other similar countries are using free video conferencing software such as Google Hangouts, Zoom, and Skype although these tools were not designed to provide the necessary security in the sharing of health data. Other options include web-based platforms to create customized home-based exercise programs or augmented virtual reality platforms. The implementation of digital physical therapy should be done proactively rather than reactively to generate long term benefits to all parties involved. The COVID-19 crisis has been considered an opportunity for the advancement of telehealth in several countries. Australia, England, and the United States are facing several challenges, however, they included digital practice within the healthcare system a few years ago and recently their associations developed guidelines to assist professionals during the COVID-19 outbreak. The digital practice uptake was only possible because these countries already had the infrastructure needed to support these technologies. Countries like Brazil are just starting to discuss digital practice due to the recent regulation changes. There are several barriers related to digital practice implementation in a country that depend on different factors including infrastructure, legal and social issues, and economic aspects. The most important barriers are related to cost and reimbursement; legal liability, ethical issues such as confidentiality, outdated equipment, patient age and level of education; computer literacy, bandwidth range, and internet speed. 4 Opportunities and perspectives Digital physical therapy offers opportunities for users, service providers, and society, such as the expansion of access to health providers or specialists, encouragement of self-management, increase of flexibility for healthcare delivery, and decrease of sick-leave duration. Treatment efficacy and patient evaluation using digital practice were already investigated for some acute and chronic musculoskeletal conditions, cardiac conditions, neurological problems, post-surgical rehabilitation, pain management, pelvic floor conditions, and respiratory dysfunctions.6, 7, 8, 9, 10, 11, 12, 13, 14 The large-scale implementation of telehealth demands innovation in the technology market to improve capabilities and reduce cost to increase benefits. An important step for digital practice that will need support is data integration. As patients are remotely assessed or treated, professionals will need access to their relevant health data to provide the best care possible. That may be particularly challenging in a country where hospitals and clinics have different electronic health records systems or no electronic record system at all. Brazil as many other countries will need specific laws and guidelines on how to work with telehealth so that obligations and rights for all involved parties are clearly stipulated. Currently in Brazil, in the absence of specific guidelines and legislations, the safety of patients treated with telehealth is supported by resolutions of professional councils and laws about data protection on the internet such as law 13.709/2018 and its amendment 13.853/2019. 15 This law is known as the “General Law on Protection of Personal Data (LGPD)” and it reinforces concepts from the federal constitution in the online environment like free speech, privacy and honor protection, and access to personal information. The LGPD states that clients own their data meaning that individuals must know how their data are used and they can also require the deletion of all stored data from online service providers. The COVID-19 pandemic is stressing the capability of the health care systems across the globe, including the delivery of care for non-pandemic related health conditions. Digital practice will not be the solution for all the challenges that physical therapists will face; however, it is an exponentially growing field, widely adopted within the virus outbreak, and with the potential to reduce costs, increase quality, and overall accessibility of modern health care systems. The question now is whether physical therapists are prepared to implement digital practice to offer rehabilitation services during this undefined period of social distance due to the COVID-19. There is an unmet need to develop specific guidance on the many specific issues involving digital physical therapy practice. This task should involve each country's governmental authorities, physical therapy councils, and corresponding associations. Funding L.O. Dantas is a Ph.D. researcher from the São Paulo Research Foundation ( 10.13039/501100001807 FAPESP , Process number 2015/21422-6). Conflict of interest The author Barreto R.P.G is one of the owners of Vedius, a Brazilian company that has an online platform that enables health professionals to create and share home-exercise programs.

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          Most cited references 4

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          Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer

          Background Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. Objective The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Methods We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots. Results We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma. Conclusions While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.
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            Internet-based treatment of stress urinary incontinence: a randomised controlled study with focus on pelvic floor muscle training

            What’s known on the subject? and What does the study add? Stress urinary incontinence (SUI) affects 10–35% of women, and it is sometimes very distressful. Pelvic floor exercises are the first line of treatment, but access barriers or embarrassment may prevent women from seeking help. There is a need for new, simple, and effective ways to deliver treatment. Management of SUI without face-to-face contact is possible, and Internet-based treatment is a new, promising treatment alternative. Objective To compare two treatment programmes for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post. Patients and Methods Randomised, controlled trial conducted in Sweden 2009–2011. Computer-generated block-randomisation, allocation by independent administrator. No ‘blinding’. The study included 250 community-dwelling women aged 18–70 years, with SUI ≥1 time/week. Consecutive online recruitment. The women had 3 months of either; (i) An Internet-based treatment programme (124 women), including e-mail support and cognitive behavioural therapy assignments or (ii) A treatment programme sent by post (126). Both programmes focused mainly on pelvic floor muscle training. Primary outcomes: symptom-score (International Consultation on Incontinence Questionnaire Short Form, ICIQ-UI SF) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life, ICIQ-LUTSQoL). Secondary outcomes: (i) Patient Global Impression of Improvement, (ii) Incontinence aids, (iii) Patient satisfaction, (iv) Health-specific QoL (EQ5D-Visual Analogue Scale), and (v) Incontinence episode frequency. Follow-up after 4 months via self-assessed postal questionnaires. Results In all, 12% (30 women) were lost to follow-up. Intention-to-treat analysis showed highly significant improvements (P 0.8) with both interventions, but there were no significant differences between groups in primary outcomes. The mean (sd) changes in symptom-score were: Internet 3.4 (3.4), Postal 2.9 (3.1) (P = 0.27). The mean (sd) changes in condition-specific QoL were: Internet 4.8 (6.1), Postal 4.6 (6.7) (P = 0.52). Compared with the postal-group, more participants in the Internet-group perceived they were much or very much improved (40.9% (43/105) vs 26.5% (30/113), P = 0.01), reported reduced usage of incontinence aids (59.5% (47/79) vs 41.4% (34/82), P = 0.02) and were satisfied with the treatment programme (84.8% (89/105) vs 62.9% (71/113), P 50%. Conclusions Concerning primary outcomes, treatment effects were similar between groups whereas for secondary outcomes the Internet-based treatment was more effective. Internet-based treatment for SUI is a new, promising treatment alternative.
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              SARS CoV-2 (COVID-19): lessons to be learned by Brazilian Physical Therapists

              The current severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) pandemic, also known as Coronavirus Disease 2019 (COVID-19), puts us at the forefront of scenarios with serious consequences for health systems in Brazil and in the world. 1 Current viral interstitial pneumonia has resulted in severe hypoxemic respiratory failure, which has resulted in overcrowding in intensive care units (ICUs), shortage of equipment and personnel, and significant mortality, especially in populations at risk who have chronic health conditions. 2 In most countries, the volume of patients has exceeded critical care capacities, with a shortage of personal protection equipment, multi-professional teams, and mechanical ventilators dominating the discussions in local hospitals and in the media.3, 4 While COVID-19 brought several challenges to the overall health care system, it also specifically highlighted the need for physical therapists to be properly trained and prepared to respond to such pandemic. First, it demonstrated the importance for every professional being updated, trained, and qualified in all technical skills related to infection control strategies such as wearing adequate professional clothing, effective hand washing, and use of personal protective equipment. Second, the importance of primary care in a good health care system. Patients with at least one comorbidity have higher odds of being hospitalized and being in ICUs. Also, individuals with chronic health conditions are more likely to develop a more severe form of the disease requiring ICU admission, mechanical ventilation, and more resources. Hypertension, cardiovascular diseases, hypercholesterolemia, and diabetes are the most common comorbidities in patients who died from COVID-19. 5 Consequently, the mortality rate (6.4%) of confirmed cases of COVID-19 in Brazil, within 52 days from the beginning of COVID-19 in every country, is around twice that of other countries, like Germany and Canada (3.0% and 4.1%, respectively), where the primary health care system is more effective in providing primary care.6, 7, 8 Thus, countries that have greater control over chronic health conditions may consequently have a lower mortality rate, with a population in better health being an important benefit in pandemic situations like the one we are witnessing with COVID-19. Third, the importance of the Cardiorespiratory and Intensivists (CRI) Physical Therapists in the Brazilian health system. CRI Physical Therapy is an established profession worldwide; however, the number of professionals in Brazil is much higher, and dozens of thousands work in hospitals. Interestingly, the ventilatory support and the improvement in musculoskeletal dysfunctions in ICUs are assisted by two professionals (Physical Therapists and Respiratory Therapists) in most countries; however, the CRI Physical Therapists are responsible for both in Brazil. The cumulative function reinforces the importance of the CRI Physical Therapists in the ICUs, as part of the multiprofessional team, minimizing the consequences of hospitalization and facilitating the recovery of patients. Ventilatory support in patients with COVID-19 includes several approaches: assistance in orotracheal intubation, support and management in mechanical ventilation, removal of airway secretion, changing patient's decubitus to improve gas exchange, and weaning patients from mechanical ventilation. 9 Additionally, these patients can present with consequences due to intensive care syndrome, including prolonged intubation, continuous sedation, and use of neuromuscular blocking agents that result in muscle weakness. 10 All these consequences from prolonged stay in the ICU are associated with an increase in morbidity and mortality. 11 Therefore, it is essential to start early rehabilitation in the ICU to promote rapid functional recovery. Some of these patients will present low exercise capacity, low physical activity level, increased sedentary behavior, dyspnea on exertion, and poorer quality of life after hospital discharge. CRI Physical Therapists will also be requested to help with the post hospital discharge rehabilitation program. Fourth and finally, this pandemic reinforces the importance for physical therapists to remain scientifically updated. The COVID-19 pandemic resulted in a significant increase in the number of studies reporting the impact of the disease 9 ; despite that, the pulmonary repercussion of the disease remains poorly known. 12 The difficulty in understanding how to offer optimal ventilatory support was the primary barrier for the CRI Physical Therapists. The previous professional experience was to administer ventilatory support for pneumonia based on the pathophysiology of Acute Respiratory Distress Syndrome (ARDS), where the severity of hypoxemia is associated with lung compliance. However, in COVID-19, CRI Physical Therapists faced, at least, two distinct phenotypes. Some patients present severe hypoxemia with respiratory system compliance remaining near normal, where hypoxemia seems to occur due to the loss of the hypoxic pulmonary vasoconstriction and impaired regulation of pulmonary blood flow. In another group of patients, severe hypoxemia is associated with lower compliance values, a condition similar to severe ARDS. 12 The difference between COVID-19 and ARDS required CRI Physical Therapists to be updated almost daily to understand how to give the proper ventilatory support. In conclusion, COVID-19 imposed a huge impact on the health care system in all countries, and everyone had to respond promptly in a very short time. Brazilian hospitals entire buildings and wards have been converted in semi-intensive and ICUs, and multidisciplinary teams, including CRI Physical Therapists, Physicians, and Nurses, have to receive special training for COVID-19. The Brazilian health system presents a special environment because it can count on the presence of CRI Physical Therapists as part of the ICUs multidisciplinary team. However, this is a unique moment in human history, and the countries that have adequately invested in research, the entire health care system, and hospital infrastructure are those that will suffer less in this war. Funding Conselho Nacional de Pesquisa (CNPq). Conflicts of interest The authors declare no conflicts of interest.
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                Author and article information

                Contributors
                Journal
                Braz J Phys Ther
                Braz J Phys Ther
                Brazilian Journal of Physical Therapy
                Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda.
                1413-3555
                1809-9246
                1 May 2020
                1 May 2020
                Affiliations
                [a ]Physical Therapy Department, Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil
                [b ]Private Practice, Porto Alegre, Brazil
                [c ]Department of Health Sciences, Ribeirao Preto Medical School, Universidade de São Paulo (USP), Ribeirao Preto, SP, Brazil
                Author notes
                [* ]Corresponding author at: Department of Health Sciences, Ribeirao Preto Medical School, Universidade de São Paulo, Avenida Bandeirantes, 3900, Vila Monte Alegre, CEP: 14049-900, Ribeirão Preto, SP, Brazil. cristine@ 123456fmrp.usp.br
                Article
                S1413-3555(20)30402-0
                10.1016/j.bjpt.2020.04.006
                7252186
                32387004
                © 2020 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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