Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer?

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has induced worldwide governments to adopt severe rules limiting individual freedom and imposing social distancing (eg, closing school, mandatory quarantine, restricting entertainments)1 in order to prevent the collapse of national health care systems. In addition to the goal of reducing the COVID-19 pandemic, this paradigm shift brings a different allocation of resources within diagnosis-related groups toward high-intensity levels of care (eg, intensive care units) needed for patients suffering of severe COVID-19. Although these measures are necessary in this pandemic, they constitute a barrier for health care professionals who are usually in close contact with patients needing low-intensity care, such as musculoskeletal (MSK) physical therapists. The World Health Organization has recommended to postpone treatments considered not urgent in order to ensure safety, still guaranteeing the essential rehabilitation services.2 As a consequence, almost all MSK physical therapists have suspended their not-urgent professional activities. Although this decision underscores the high social responsibility of physical therapists, it also may create a sense of bewilderment—both among patients, who may be living with pain and disability, and among professionals who find their practice limited and their income reduced.3 The described scenario has highlighted the importance of recommendations on the future of digital physical therapist practice developed by the World Confederation for Physical Therapy (WCPT) with the International Network of Physiotherapy Regulatory Authorities, offering to the community of physical therapists the opportunity to reflect on this new method of care delivery.4 At the national level, different member organizations (eg, Chartered Society of Physiotherapy, Italian Physiotherapy Association, Australian Physiotherapy Association, American Physical Therapy Association) have already introduced or expanded resources and advice to implement telerehabilitation.5–8 Physical therapists adopt a mixture of hands-on and hands-off skills to manage MSK pain related to acute and chronic disorders (eg, low back pain) and elective orthopedic postsurgical conditions (eg, joint arthroplasty). Manual therapy is a prime example of the hands-on skills, encompassing several approaches (eg, education, therapeutic exercises) aimed at increasing patients’ self-efficacy and restoring functional capabilities.9 Recently, several recommendations on the management of patients with MSK pain have increasingly highlighted the importance of hands-off approaches to improve the quality of care and, consequently, the quality of life.10 It seems that the time is ripe, therefore, to exploit the potential of telerehabilitation for patients with MSK pain. This Point of View debates the values and limits of telerehabilitation in patients with MSK pain, reflecting on the use of telerehabilitation during COVID-19 outbreak. The aims of this point of view are to (1) report clinical evidence on telerehabilitation, (2) describe its feasibility and acceptability, (3) explain opportunities and challenges for MSK physical therapists, and (4) suggest clinical implications, calling to action the community of physical therapists. Several systematic reviews and meta-analyses have assessed the efficacy of telerehabilitation following total arthroplasty (eg, shoulder, knee, hip) and upper limb interventions (eg, proximal humerus fractures, carpal tunnel release surgery, rotator cuff tear).11–15 Within this context, findings are promising as outcomes commonly considered in postsurgical physical therapy (eg, reduction in pain intensity and improvements in range of motion, muscle strength, functional activities, and disability) are similar or even superior in comparison with face-to-face usual care.11–15 Moreover, the effects of telerehabilitation, when associated with usual care or as a stand-alone intervention, has been investigated also in chronic nonmalignant MSK pain (eg, low back pain, lumbar stenosis, neck pain, osteoarthritis, fibromyalgia, arthritis).16–18 Thus, preliminary evidence has suggested adopting telerehabilitation in substitution of face-to-face interventions for reducing pain and improving physical function, daily life activities, and quality of life in patients affected by these disorders.16–18 Caution should be applied, however, to avoid overestimation of findings given the several methodological weaknesses in available studies, such as small sample size (n < 100), short follow-up (<12 months), missed evaluation of barriers/facilitators, and lack of blinding of participants, caregivers, and outcomes assessors.11,14,16 Systematic reviews have also reported that telerehabilitation-based consultation for MSK pain is feasible in terms of concurrent validity and intrarater and interrater reliability in the assessment of peripheral joints and the spine, with good to excellent psychometric pr