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TOPICAL REVIEW
Ahead of print publication  

Virtual consulting for remote physiotherapy advice in chronic rheumatic diseases during the COVID-19 pandemic


 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University, Adana, Turkey

Date of Submission18-Oct-2020
Date of Acceptance06-Dec-2020

Correspondence Address:
Ilke Coskun Benlidayi,
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University, Adana
Turkey
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_292_20

  Abstract 


The coronavirus disease-19 pandemic has caused a considerable deterioration in medical practices. This resulted in a rapid shift to telemedicine/telehealth as an alternative to conventional interventions and in-person visits. Telerheumatology practices have been increasing worldwide. Virtual consulting for remote physiotherapy advice in rheumatic diseases is also essential. The present topical review aimed to provide an insight to telehealth for musculoskeletal physiotherapy among patients with rheumatic diseases. Patient assessment, goal setting, teleeducation, and providing individual-based, goal-directed exercises are components of telerehabilitation. Telephone/video calls can be used to further progress the exercise program and to evaluate patient adherence. Future studies on the role of virtual consulting for physiotherapy advice in rheumatic diseases would be of value.

Keywords: Physical medicine and rehabilitation, physiotherapy, rheumatology, telehealth, telemedicine, telerehabilitation



How to cite this URL:
Benlidayi IC. Virtual consulting for remote physiotherapy advice in chronic rheumatic diseases during the COVID-19 pandemic. Indian J Rheumatol [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=313581




  Introduction Top


Rehabilitation is an essential component of management protocols for rheumatologic disorders. Rehabilitative approaches help to improve muscle strength, aerobic capacity, joint range of motion, functionality and, quality of life among patients with rheumatic disorders. Rehabilitation also aims to improve psychological and social functioning, not just the medical aspects of a certain disease.[1] On the other hand, physical modalities such as transcutaneous nerve stimulation are used with favorable results in noninflammatory rheumatic conditions and during the nonacute phase of inflammatory and/or autoimmune rheumatic diseases.[2] Thus, overall, physiotherapy has an important role in the well-being of patients with rheumatic conditions.

The coronavirus disease-19 (COVID-19) pandemic has led to a considerable deterioration in medical practices worldwide. The interruption is related to several factors including curfew restrictions, cancellation of nonurgent clinical practices, and overoccupation of hospitals and health-care workers. Due to these restrictions, the pandemic has forced a rapid shift to telemedicine as an alternative to conventional interventions, in-person visits, and follow-ups.[3]


  Digital Health Practices Top


The World Health Organization (WHO) recommends digital technologies to provide concrete opportunities in order to tackle health system challenges.[4] The WHO adopts a three-tier approach to digital health delivery: (i) supporting decision-makers and ensuring the maintainable, safe, and ethical use of digital sources, (ii) facilitating the capacity of practitioners in using technologies in order to provide health-care promptly and efficiently, and thus (iii) improving the population health/well-being by digital health approaches.[5] A recently published task force on digital physiotherapy practices describes the digital practice as a term that covers remotely provided health care services, support, and information by means of digital communication and devices.[6]


  Telerehabilitation Top


Telerehabilitation, as a clinical telehealth service, focuses patient assessment, diagnosis, and treatment. Telehealth may be considered as an umbrella term which represents the provision of health care at a distance using information and communication technology sources and is inclusive of all health-care professions. Several distinct terms are used in order to address the health-care profession involved (i.e., telerheumatology) or the type of interaction (i.e., telerehabilitation and teleconsultation). Moreover, the terminology can be interchangeable and may vary among countries according to several factors such as available technology.[7]

Telerehabilitation is provided by asynchronous electronic-visits, 2-way real-time visits with audio and/or video, virtual check-ins, remote assessments of recorded videos/images, telephone calls, and management services.[8] While implementing telehealth for musculoskeletal physiotherapy, individual patient factors (age, comorbidities, balance deficits, disabilities, etc.), patient's physical location, and clinician's experience/skills are important. Besides, the video-conferencing platform should be carefully selected in order to meet the needs of the telehealth initiative. In this regard, fit-for-purpose approach is recommended. The platform should also meet privacy/security regulations and ethical principles. The financial costs, usability, and interoperability of the platform should be considered. Additional built-in features (i.e., exercise library, schedule table, questionnaires, video-recording, and playback) can be used to support the telehealth experience.[7]


  Components of the Telerehabilitation Top


The assessment of the patient is an essential component of telemedicine for musculoskeletal physiotherapy. It is required not only for setting objective goals but also for the assessment of potential contraindications to physiotherapy [Figure 1]. Dijkstra et al. in their guide for sport and exercise remote consultations, recommend observation of the patient (i.e., gait, posture, and joint motion) and assessment of range of motion (active and if possible, passive with the assistance of a carer).[9] While performing and documenting a musculoskeletal examination through telemedicine, the physician can also instruct the patient palpate the painful area for the evaluation of tenderness and temperature.[9],[10] However, most components of musculoskeletal examination are impossible to evaluate remotely and partial evaluation might also be an issue of concern. Effective verbal/nonverbal telecommunication is essential for a satisfying assessment. In this regard, the physician or physiotherapist should ensure that the dialogue is coupled with an appropriate camera angle to establish a clear view of the patient.[11]
Figure 1: Basic components of virtual consultation

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Teleeducation is another important factor in increasing understanding and developing confidence for home management during musculoskeletal telerehabilitation. A thorough explanation of the disease/pain mechanisms and information about the management plan are essential. The session may include counseling in terms of behavioral/lifestyle modification (i.e., weight reduction and healthy diet), self-management protocols, functional activity training, and the use of orthotics/walking aids.[11] Self-management options such as superficial cold and heat applications should be tailored when necessary. Patients with acute arthritis/synovitis should be advised to apply cold (i.e., cold packs) and to avoid heat application. On the other hand, those with chronic painful conditions such as fibromyalgia and osteoarthritis would benefit from superficial heat application (i.e., hot packs).

Patients with chronic rheumatic diseases should also be taught to perform appropriate self-mobilization techniques and active exercise sequences to help manage symptoms. In this regard, video sessions should include the explanation of correct exercise positions and the description of the exercises being tailored.[11] While adopting a home-based exercise regimen, it is of importance to structure the components of exercise appropriately. The type, frequency, time, and intensity of each exercise regimen should be set in an individual basis by taking each patient's needs, health status, and comorbidities into consideration.[12] For instance, patients with knee osteoarthritis would benefit from a home-based exercise program involving range of motion exercises, stretching, muscle strengthening, and aerobic training (i.e., cycling).[13] Patients may use free weights (i.e., dumbbells) or exercise bands for muscle strengthening when appropriate. Shariat et al. proposed a novel approach to manage low back pain through the self-application of several myofascial release, stretching, and strengthening techniques.[14] This home-based self-therapeutic approach targeted the key musculature (quadratus lumborum, iliacus, psoas major/minor, and gluteal muscles) involved in low back pain.[14] It is of value to assist verbal explanation with written materials which would have a clear font without technical jargon.[11] Telephone coaching can be used to monitor adherence, ensure safety, and to progress the exercise when necessary.[12] Exergaming, in which body/extremity movements are tracked and converted into virtual movements through several video games may also be used for unsupervised physical activity at home.

In some instances, cardiac and/or pulmonary rehabilitation may be necessary for patients with rheumatic diseases. Cardiovascular rehabilitation is generally provided in specialized centers under direct supervision. During the pandemic, the implementation of home-based cardiac rehabilitation options has served as a precious resource for delivering cardiac rehabilitation to patients who were already in a cardiac rehabilitation program.[12] Babu et al. proposed technology-driven cardiac rehabilitation as an alternative model of delivery.[15] This cost-effective model uses technology for assessment (telephone/video calls, online surveys, etc.), interventions (telephone/video calls, internet-based, emails, etc.), monitoring (wearable sensors, mobile applications, emailing, calls, etc.), and follow-up (calls, emails, online questionnaires, etc.).[15] In a virtual home-based cardiac rehabilitation model, trackers can be used to quantify physical activity and to monitor safety. It would be of great benefit to assess parameters such as blood pressure, heart rate, electrocardiogram, and energy expenditure by wearable sensors and if the interface could be able to record those and send to the related physician.[12] On the other hand, face-to-face visits would be required when a cardiopulmonary exercise test/a field test is being held, particularly in patients who are naïve to the rehabilitation program.[12],[15] Studies examining cardiac/pulmonary telerehabilitation in patients with rheumatic diseases are required to come up with clear conclusions on this point.

Limitations

There are a number of studies evaluating the experience of teleconsultation for rheumatology during the COVID-19 pandemic.[16],[17] There are also reports on the rapid expansion of physiatric telemedicine.[18] Nevertheless, there are limited data on the use of telerehabilitation/virtual musculoskeletal physiotherapy in patients with rheumatic diseases in the time of the COVID-19 pandemic. Telerehabilitation-based consultation for musculoskeletal pain appears as a feasible and promising model of care.[19] On the other hand, the integration of digital tools in physical medicine and rehabilitation might have some handicaps, as well. Several diagnostic procedures, radiological investigations, and interventional approaches still require patients with rheumatic disorders to go in-person to a medical center.[3],[7] Issues of privacy data and difficulty in engaging the elderly and/or patients with no computer literacy are other challenges.[12] There are also several barriers holding back the widespread use of telerehabilitation.[3] Lack of ability to perform a comprehensive physical examination was reported as a limitation of telemedicine in the era of physiatry.[18] In relation to the absence of infrastructure, stable and powerful internet is not accessible in resource-limited rural and low-income communities. On the other hand, operational and systems challenges such as software/hardware costs also limit health-care delivery. Lack of custom features to enable telecommunication for patients with disabilities (cognitive, visual, etc.) is another issue of concern.[3]


  Conclusion Top


Physiotherapy is a widely used treatment option and an integral part of management protocols in rheumatic diseases. The experience and knowledge regarding the telerehabilitation models in rheumatology practices are growing. Future studies would be of benefit to further examine the effectiveness and safety of telerehabilitation/virtual consulting for remote physiotherapy advice in rheumatic diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
de Thurah A, Bremander A, Primdahl J. High-quality RMD rehabilitation and telehealth: Evidence and clinical practice. Best Pract Res Clin Rheumatol 2020;34:101513.  Back to cited text no. 1
    
2.
Coskun Benlidayi I. The effectiveness and safety of electrotherapy in the management of fibromyalgia. Rheumatol Int 2020;40:1571-80.  Back to cited text no. 2
    
3.
Annaswamy TM, Verduzco-Gutierrez M, Frieden L. Telemedicine barriers and challenges for persons with disabilities: COVID-19 and beyond. Disabil Health J 2020;13:100973.  Back to cited text no. 3
    
4.
WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. Available from: https://apps.who.int/iris/bitstream/handle/10665/311941/9789241550505-eng.pdf?ua=1. [Last accessed on 2020 Oct 16].  Back to cited text no. 4
    
5.
WHO-Digital Health. Available from: https://www.who.int/health-topics/digital-health#tab=tab_2. [Last accessed on 2020 Oct 16].  Back to cited text no. 5
    
6.
World Confederation for Physical Therapy (WCPT), International Network of Physiotherapy Regulatory Authorities. Report of the WCPT/INPTRA Digital Physical Therapy Practice Task Force. WCPT & INPTRA; 2020. Available from: https://world.physio/sites/default/files/2020-06/WCPT-INPTRA-Digital-Physical-Therapy-Practice-Task-force-March2020.pdf. [Last accessed on 2020 Oct 13].  Back to cited text no. 6
    
7.
Cottrell MA, Russell TG. Telehealth for musculoskeletal physiotherapy. Musculoskelet Sci Pract 2020;48:102193.  Back to cited text no. 7
    
8.
Prvu Bettger J, Resnik LJ. Telerehabilitation in the Age of COVID-19: An opportunity for learning health system research. Phys Ther 2020;100:1913-6.  Back to cited text no. 8
    
9.
Dijkstra HP, Ergen E, Holtzhausen L, Beasley I, Alonso JM, Geertsema L, et al. Remote assessment in sport and exercise medicine (SEM): A narrative review and teleSEM solutions for and beyond the COVID-19 pandemic. Br J Sports Med 2020;54:1162-7.  Back to cited text no. 9
    
10.
Verduzco-Gutierrez M, Bean AC, Tenforde AS, Tapia RN, Silver JK. How to Conduct an Outpatient Telemedicine Rehabilitation or Prehabilitation Visit. PM R 2020;12:714-20.  Back to cited text no. 10
    
11.
Pugliese M, Wolff A. The value of communication, education, and self-management in providing guideline-based care: Lessons learned from musculoskeletal telerehabilitation during the COVID-19 Crisis. HSS J 2020;3:1-4.  Back to cited text no. 11
    
12.
Besnier F, Gayda M, Nigam A, Juneau M, Bherer L. Cardiac rehabilitation during quarantine in covid-19 pandemic: Challenges for center-based programs. Arch Phys Med Rehabil 2020;101:1835-8.  Back to cited text no. 12
    
13.
Karasavvidis T, Hirschmann MT, Kort NP, Terzidis I, Totlis T. Home-based management of knee osteoarthritis during COVID-19 pandemic: Literature review and evidence-based recommendations. J Exp Orthop 2020;7:52.  Back to cited text no. 13
    
14.
Shariat A, Anastasio AT, Soheili S, Rostad M. Home-based fundamental approach to alleviate low back pain using myofascial release, stretching, and spinal musculature strengthening during the COVID-19 pandemic. Work 2020;67:11-9.  Back to cited text no. 14
    
15.
Babu AS, Arena R, Ozemek C, Lavie CJ. COVID-19: A time for alternate models in cardiac rehabilitation to take centre stage. Can J Cardiol 2020;36:792-4.  Back to cited text no. 15
    
16.
Shenoy P, Ahmed S, Paul A, Skaria TG, Joby J, Alias B. Switching to teleconsultation for rheumatology in the wake of the COVID-19 pandemic: Feasibility and patient response in India. Clin Rheumatol 2020;39:2757-62.  Back to cited text no. 16
    
17.
Costa L, Tasso M, Scotti N, Mostacciuolo E, Girolimetto N, Foglia F, et al. Telerheumatology in COVID-19 era: a study from a psoriatic arthritis cohort. Ann Rheum Dis. 2020 Jun 11:annrheumdis-2020-217806. doi: 10.1136/annrheumdis-2020-217806. Epub ahead of print.  Back to cited text no. 17
    
18.
Tenforde AS, Iaccarino MA, Borgstrom H, Hefner JE, Silver J, Ahmed M, et al. Telemedicine during COVID-19 for outpatient sports and musculoskeletal medicine physicians. PM R 2020;12:926-32.  Back to cited text no. 18
    
19.
Turolla A, Rossettini G, Viceconti A, Palese A, Geri T. Musculoskeletal physical therapy during the COVID-19 pandemic: Is telerehabilitation the answer? Phys Ther 2020;100:1260-4.  Back to cited text no. 19
    


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