key: cord-0713156-lii8wvaz authors: Turolla, Andrea; Rossettini, Giacomo; Viceconti, Antonello; Palese, Alvisa; Geri, Tommaso title: Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer? date: 2020-05-08 journal: Phys Ther DOI: 10.1093/ptj/pzaa093 sha: a46fd5c2279b0a0e2f4009fc1e79a061ada9d08d doc_id: 713156 cord_uid: lii8wvaz nan The World Confederation for Physical Therapy has recommended that its member organizations 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 promoted the publication of a position statement of the World Confederation for Physical Therapy on the use of telerehabilitation to improve accessibility to rehabilitation care, offering to the community of physical therapists the opportunity to reflect on this new method of care delivery. 4 Several systematic reviews and meta-analysis 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] [12] [13] [14] [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] [12] [13] [14] [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] [17] [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] [17] [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 properties for the different clinical outcomes (eg, pain, swelling, muscle strength, balance, gait, active and passive range of motion). [19] [20] Lower validity and reliability have been identified in the assessment of the shoulder and elbow joints, for the examination of the nerve functioning around the elbow, the scar assessment of the knee, and the evaluation of lumbar spine posture. [19] [20] Furthermore, the absence of reporting of standard error of measurement and coefficient of variation, and the involvement of assessors with different clinical expertise and training (eg, naïve, expert) may limit the generalization of findings. [19] [20] On the other hand, one strength of qualitative studies investigating both patients' and physical therapists' perspectives is the good acceptability of telerehabilitation in terms of overall user experience, adherence, and satisfaction, both in MSK disorders and after elective orthopedic surgical conditions. 17,20-21 Furthermore, preliminary economic analyses have revealed that telerehabilitation enhances the quality of MSK care, which in turn impacts the total cost savings for national health care systems. 20 Nevertheless, satisfaction and economic outcomes are often poorly reported and not standardized, thus limiting usefulness of data. 20 and patients. 22 At multiple levels ( Figure) , user-friendly design of interfaces opens opportunities to the community of physical therapists to individualize the delivery of MSK care by telerehabilitation in conjunction with face-to-face usual care. These opportunities are especially evident during the COVID-19 pandemic. Patients can gain benefits from telerehabilitation, such as (1) Third, equipment barriers such as the lack of rehabilitation instruments (eg, elastic bands, medical balls, weights) could limit the delivery of MSK care by reducing the range of therapeutic solutions. 23 Therefore, during the initial planning of the rehabilitation program, physical therapists might establish which tools are needed for engaging in therapeutic exercise so that they can be rented and delivered to the patient's home. Fourth, time for consultation and reimbursements for telerehabilitation services differ widely among countries, as compared with traditional face-to-face care. 23 As a whole, in many countries with an insurance-based private health care system, telerehabilitation has been included in the list of reimbursed services; conversely, in those countries with universal health care systems and for therapists in private practice, it might be feasible to create monthly subscription fees established according to the related diagnosisrelated groups. Finally, medicolegal aspects need to be considered while using the telerehabilitation. 27 Protection of health care data and patient privacy within the deontological principles and codes, as indicated in the declaration of the Ethical Principles of World Physical Therapy Association, for example, provides a telehealth guidelines page (http://www.apta.org/Telehealth/). Is telerehabilitation the answer for MSK physical therapy during COVID-19 pandemic? At multiple levels (Table) , telerehabilitation unveils itself as a promising and timely model of care to be adopted alternatively, or in combination with, face-to-face usual The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. (1) promote their engagement and their own decision-making strategies, to help the transition from being passive to becoming active protagonists of their physical therapy program; (2) stimulate their self-efficacy and self-confidence capability, by alleviating fears and uncertainty, correcting maladaptive beliefs and expectations through education and advices; (3) guarantee their optimal recovery, minimising potential complications through the delivery of physical assessment, exercises, and periodical follow-ups. Researchers should run further studies on telerehabilitation for patients with MSK pain, with the aim to: (1) evaluate efficacy in different phases (eg, acute, chronic) and conditions (eg, injury, post-surgery) of MSK pain, including (2) inform about impact on long-term outcomes, using large sample sizes to establish which patients are likely to take advantage from this modality; (3) consider socioeconomic implications for patients, health care professionals, and National Health care Systems worldwide, embracing cost-effectiveness analyses; Mass gathering events and reducing further global spread of COVID-19: a political and public health dilemma World Confederation for Physical Therapy. Information and resources about COVID-19 Italian physical therapists' response to the novel COVID-19 emergency Report sets out future of digital physical therapy practice Chartered Society of Physiotherapy. 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