key: cord-0953338-geldd9y4
authors: Ivy, Cynthia C.; Doerrer, Sarah; Naughton, Nancy; Priganc, Victoria
title: The Impact of COVID-19 on Hand Therapy Practice
date: 2021-02-01
journal: J Hand Ther
DOI: 10.1016/j.jht.2021.01.007
sha: cd190d95bfe7616aaeed1cd06578820a496ee174
doc_id: 953338
cord_uid: geldd9y4

BACKGROUND: : Hand therapists and health care providers across the spectrum have been profoundly impacted by COVID-19. Greater insight and information regarding how practitioners have been affected by this unparalleled pandemic is important. Purpose: Survey research was performed to examine the impact of the COVID-19 pandemic on hand therapy practice. STUDY DESIGN: : Online survey research. Methods: Four constructs guided the development of the survey: psychosocial and financial impact; safety practice patterns; changes in current practice patterns; use of telehealth. The survey was distributed to members of the American Society of Hand Therapists from April 14, 2020 through May 4, 2020. Descriptive demographic data were obtained. Frequencies were examined using ChiSquare, correlations were examined using Spearman Correlation Coefficient, and means were compared via independent t-test. RESULTS: : A total of 719 members responded to the survey. 86% of therapists reported feeling more stress than they did prior to the COVID-19 pandemic. This level of stress was similar across ages, practice settings, financial stability or instability, and geographical settings. Older therapists (r(s) = .04) and those that practiced longer (r(s) = .009) felt more comfortable with in-person treatment. 98% of therapists reported a decrease in caseload. Post-operative cases (p= 0.0001) and patients ages 19-49 were more likely to receive in-person treatment (p=.002). 46% of therapists reported providing telehealth services. Non-traumatic, non-operative cases (p = .0001) and patients aged 65 or older were more likely to receive telehealth services (p=.0001). Younger therapists (r(s) = .03) and therapists working in outpatient therapist owned, outpatient corporate owned, and outpatient academic medical centers (X(2) (4, N=637)=15.9463, p=.003) were more likely to utilize telehealth. CONCLUSION: : Stress was felt globally among hand therapy clinicians regardless of financial security or insecurity, age, practice area, or geographical setting. Therapists saw a drastic decrease in caseloads. In-person caseloads shifted primarily to post-operative cases. STUDY DESIGN: : Web based survey

Stress was felt globally among hand therapy clinicians regardless of financial security or insecurity, age, practice area, or geographical setting. Therapists saw a drastic decrease in caseloads. In-person caseloads shifted primarily to post-operative cases.

Suggested Reviewers: miranda materi mmateri@yahoo.com she has participated in survey research Corey McGee mcge0062@umn.edu He has written a lot and is a professor at UM so would appreciate his feedback.

Caroline Jansen cwjansen@gmail.com She is on the board of the hand therapy foundation and speaks about research at ASHT frequently. I heard her speak last year and she appears very knowledgeable and wise.

Response to Reviewers: Dear reviewers, Thank you for the thoughtful and thorough feedback. All feedback has been addressed. For your convenience, changes in the manuscript and tables documents are in red font so they can be easily viewed. We appreciated the feedback.

Reviewer Feedback

Section A -As stated in "Reviewer Comments to Author" This is a timely manuscript with implications for the hand therapy community and beyond. I would like to applaud the authors for a thorough survey, which was completed in a prompt manner with a high response rate. I also find the mixed methods approach to the analysis to be enriching; it provides a more complete picture of how hand therapists are feeling about and adjusting to the pandemic. Additionally, the discussion section of the manuscript is well explained and rigorous.

I have a few general questions regarding the survey, methodology, and results that I will ask here. My specific recommendations (regarding the writing and presentation of the manuscript) can be found attached.

1. In terms of assessing "stress" in the survey (Q 42), how are you defining stress? Is this negative stress only? Is this psychological stress or other types of stress? Could there be sources of positive stress during the pandemic? We did not define the word "stress" in the survey. We were just looking to get a general, global sense of stress levels. In lines 319-321, we acknowledge that the increased stress appears consistent across practice areas, financial stability, current job status, age, and geographical areas. To address the inherent bias, we added a statement in our limitations section. Please see below: "When designing the survey, we did not define stress. It was our bias that increased stress levels would have a negative implication, but without offering qualifying information related to stress in the survey, the bias that increased stress is negative is an assumption on our part." Why was the follow-up question (Q 43) not presented to those who identified feeling less stress? In Q 44, you specifically asked how stress associated with the pandemic had affected therapists' ability to provide quality care. Is the assumption that the pandemic has been "stressful" for therapists creating any sources of bias in your results/analysis? Can you address the issues related to the way in which "stress" was phrased and asked in the survey (and related biases) in the manuscript? We had acknowledged in our limitations section that we experienced a problem with two questions and thus we were unable to analyze those questions. Please see the limitations section. "In addition, two questions (43 & 44) had a 0-response rate due incorrect coding 5. In the results section (line 125), you provide the number of respondents who were eligible to be included in the survey (719). Is the only difference between this number and the number who agreed to participate (877) due to the technical issue that was mentioned? Yes, that is correct In Table 1 , adding those who practice in the US with other locations does not equal 719. What accounts for the difference? Not everyone listed if they practiced in the US or other. The 'n' column in Table 1 indicates how many respondents answered each question. Did all 719 respondents fill out the entire survey? What was your completion rate? How did you account for those who stopped responding to the survey at various points in its administration? Can you please clarify in the manuscript if the 719 respondents completed 100% of the survey? If not, how did you analyze partially completed surveys? Not all 719 respondents completed 100% of the survey. We added additional language in lines 131-134 to help clarify this point. "Not all 719 respondents completed 100% of the survey. If a respondent did not answer a question, then that individual answer was not included in any analysis. The total number of respondents per survey question is represented in tables, graphs, and text."

In general, please review the use of commas and hyphens throughout the manuscript. There are several sentences and terms where commas and hyphens are needed,

Line 41: Use acronym "PPE" and not "PPE's" -this change was made Line 50: Are you referring to both aerosol and droplet forms? Please clarify because they are different forms of transmission.-this sentence was reworded. Please see lines 50-51.

Line 50: Is "changes" the correct word in this context? -this sentence was reworded. Please see lines 50-51.

Line 87: Add "questions" after "multiple choice" --this change was made

Line 273: Add "and were" before "troubled" -this change was made

Lines 302 to 304: Is there a reference for this? -during this time, we were relying on websites and news reports. We included two of the website references we were accessing during this time Title: If in fact only US therapists data was included and analyzed, I would recommend this information to be added to the manuscript's title, due to the international aspect of the JHT (something as "The Impact of COVID-19 on United States Hand Therapy Practice: a survey study").

We did include the international data, so we are opting to keep the title the same.

Reviewer #2:

This is a timely manuscript with implications for the hand therapy community and beyond. I would like to applaud the authors for a thorough survey, which was completed in a prompt manner with a high response rate. I also find the mixed methods approach to the analysis to be enriching; it provides a more complete picture of how hand therapists are feeling about and adjusting to the pandemic. Additionally, the discussion section of the manuscript is well explained and rigorous.

I have a few general questions regarding the survey, methodology, and results that I will ask here. My specific recommendations (regarding the writing and presentation of the manuscript) can be found attached.

1. In terms of assessing "stress" in the survey (Q 42), how are you defining stress? Is this negative stress only? Is this psychological stress or other types of stress? Could there be sources of positive stress during the pandemic?

We did not define the word "stress" in the survey. We were just looking to get a general, global sense of stress levels. In lines 319-321, we acknowledge that the increased stress appears consistent across practice areas, financial stability, current job status, age, and geographical areas. To address the inherent bias, we added a statement in our limitations section. Please see below:

"When designing the survey, we did not define stress. It was our bias that increased stress levels would have a negative implication, but without offering qualifying information related to stress in the survey, the bias that increased stress is negative is an assumption on our part."

Why was the follow-up question (Q 43) not presented to those who identified feeling less stress? In Q 44, you specifically asked how stress associated with the pandemic had affected therapists' ability to provide quality care. Is the assumption that the pandemic has been "stressful" for therapists creating any sources of bias in your results/analysis?

Can you address the issues related to the way in which "stress" was phrased and asked in the survey (and related biases) in the manuscript?

We had acknowledged in our limitations section that we experienced a problem with two questions and thus we were unable to analyze those questions. Please see the limitations section.

"In addition, two questions (43 & 44) had a 0-response rate due incorrect coding rendering these questions void from inclusion in the analysis or results of the study."

2. In the methods section, you state that open-ended questions were read and grouped based on similar meaning. How did you do this? Was this done by the authors (i.e. by hand) or was a software (e.g. NVivo) used to accomplish this? Was there a qualitative paradigm/lens endorsed by the authors during this analysis?

Can you please provide a description of your qualitative paradigm/lens and method of analysis in the manuscript?

Please refer to wording changes in lines 113-114. We also added a statement acknowledging that our study was not a true qualitative study. Please see below.

"Because this study was not a full qualitative study and we did not conduct interviews to fully explore ideas, we were unable to identify codes and themes. Rather, we were only able to categorize statements and utilize those statements to provide additional insight into the quantitative results. No qualitative software program was used."

3. In the methods section (lines 116 to 119), you describe how COVID-19 "hot spots" in the US were identified. I assume you did not identify hot spots for the non-US respondents. Can you mention why you did not do this this for the non-US respondents (i.e. too few for analysis, etc.)?

Can you please include one statement addressing this in the manuscript?

Please refer to the following statement in the limitations section (lines 463-465).

"Finally, although we received responses from therapists in other countries, we did not receive enough responses to perform any analysis on that data. Thus we were not able to elaborate on this data."

4. In the results section (line 123), you mention two separate mailings being sent to ASHT members. Were these the same members or different members? What is the difference between the two mailing lists?

Can you please include a statement in the manuscript to answer this question?

Please refer to the following statement on lines 124-126.

"The emails were sent to active ASHT members; however, members were only allowed to take the survey once despite receiving two emails alerting them to the survey.

In the results section (line 125), you provide the number of respondents who were eligible to be included in the survey (719). Is the only difference between this number and the number who agreed to participate (877) due to the technical issue that was mentioned? Yes, that is correct

In Table 1 , adding those who practice in the US with other locations does not equal 719. What accounts for the difference? Not everyone listed if they practiced in the US or other. The 'n' column in Table 1 indicates how many respondents answered each question.

Did all 719 respondents fill out the entire survey? What was your completion rate? How did you account for those who stopped responding to the survey at various points in its administration?

Can you please clarify in the manuscript if the 719 respondents completed 100% of the survey? If not, how did you analyze partially completed surveys?

Not all 719 respondents completed 100% of the survey. We added additional language in lines 131-134 to help clarify this point.

"Not all 719 respondents completed 100% of the survey. If a respondent did not answer a question, then that individual answer was not included in any analysis. The total number of respondents per survey question is represented in tables, graphs, and text."

In general, please review the use of commas and hyphens throughout the manuscript. There are several sentences and terms where commas and hyphens are needed, respectively.

In addition to the mentioned addition of commas below, commas, hyphens or other small grammatical changes were added in red on the following lines: Line 50:

Is "changes" the correct word in this context? -this sentence was reworded. Please see lines 50-51.

Line 87:Add "questions" after "multiple choice" --this change was made

Line 273:

Add "and were" before "troubled" -this change was made

Lines 302 to 304:

Is there a reference for this? -during this time, we were relying on websites and news reports. We included two of the website references we were accessing during this time Line 340:

Remove "global" before "pandemic" because a pandemic implies global reach -this change was made Line 344:

Missing a period -this change was made Line 345:

Change "kids" to "children" -this change was made Line 349:

Change "3-week" to "three-week" -this change was made

Line 372:

Write out the full term for "CDC" because it is the first (and only use in the manuscript) -this change was made Line 392:

Change "COVID-10" to "COVID-19" -this change was made Line 397:

Clarify/change the wording for "resistance to change and technically challenge staff" is unclear in the list of items provided in that sentence -commas were added to help clarify Line 416:

Write out the full term for "CPT" -this change was made Line 440:

Remove "global" -this change was made

Line 450: Change "2" to "two" -this change was made

Line 469:

Change "and childcare closed" to "and closure of childcare" -this change was made

Thank you for the opportunity to resubmit this manuscript.

Sincerely, Cindy C. Ivy, Corresponding author

Nancy Naughton

Dear reviewers, Thank you for the thoughtful and thorough feedback. All feedback has been addressed. For your convenience, changes in the manuscript and tables documents are in red font so they can be easily viewed. We appreciated the feedback.

Section A -As stated in "Reviewer Comments to Author"

This is a timely manuscript with implications for the hand therapy community and beyond. I would like to applaud the authors for a thorough survey, which was completed in a prompt manner with a high response rate. I also find the mixed methods approach to the analysis to be enriching; it provides a more complete picture of how hand therapists are feeling about and adjusting to the pandemic. Additionally, the discussion section of the manuscript is well explained and rigorous.

I have a few general questions regarding the survey, methodology, and results that I will ask here. My specific recommendations (regarding the writing and presentation of the manuscript) can be found attached.

1. In terms of assessing "stress" in the survey (Q 42), how are you defining stress? Is this negative stress only? Is this psychological stress or other types of stress? Could there be sources of positive stress during the pandemic? We did not define the word "stress" in the survey. We were just looking to get a general, global sense of stress levels. In lines 319-321, we acknowledge that the increased stress appears consistent across practice areas, financial stability, current job status, age, and geographical areas. To address the inherent bias, we added a statement in our limitations section. Please see below: "When designing the survey, we did not define stress. It was our bias that increased stress levels would have a negative implication, but without offering qualifying information related to stress in the survey, the bias that increased stress is negative is an assumption on our part." Why was the follow-up question (Q 43) not presented to those who identified feeling less stress? In Q 44, you specifically asked how stress associated with the pandemic had affected therapists' ability to provide quality care. Is the assumption that the pandemic has been "stressful" for therapists creating any sources of bias in your results/analysis? Can you address the issues related to the way in which "stress" was phrased and asked in the survey (and related biases) in the manuscript? sponse to Reviewers (without Author Details)

We had acknowledged in our limitations section that we experienced a problem with two questions and thus we were unable to analyze those questions. Please see the limitations section.

"In addition, two questions (43 & 44) had a 0-response rate due incorrect coding rendering these questions void from inclusion in the analysis or results of the study."

2. In the methods section, you state that open-ended questions were read and grouped based on similar meaning. How did you do this? Was this done by the authors (i.e. by hand) or was a software (e.g. NVivo) used to accomplish this? Was there a qualitative paradigm/lens endorsed by the authors during this analysis? Can you please provide a description of your qualitative paradigm/lens and method of analysis in the manuscript? Please refer to wording changes in lines 113-114. We also added a statement acknowledging that our study was not a true qualitative study. Please see below.

"Because this study was not a full qualitative study and we did not conduct interviews to fully explore ideas, we were unable to identify codes and themes. Rather, we were only able to categorize statements and utilize those statements to provide additional insight into the quantitative results. No qualitative software program was used."

3. In the methods section (lines 116 to 119), you describe how COVID-19 "hot spots" in the US were identified. I assume you did not identify hot spots for the non-US respondents. Can you mention why you did not do this this for the non-US respondents (i.e. too few for analysis, etc.)? Can you please include one statement addressing this in the manuscript? Please refer to the following statement in the limitations section (lines 463-465). "Finally, although we received responses from therapists in other countries, we did not receive enough responses to perform any analysis on that data. Thus we were not able to elaborate on this data."

4. In the results section (line 123), you mention two separate mailings being sent to ASHT members. Were these the same members or different members? What is the difference between the two mailing lists? Can you please include a statement in the manuscript to answer this question? Please refer to the following statement on lines 124-126. "The emails were sent to active ASHT members; however, members were only allowed to take the survey once despite receiving two emails alerting them to the survey. 

Line 5: Study Design Mention that the survey was an online survey (consider mentioning the platform). -this change was made -please refer to the abstract Line 6: Don't capitalize "psychosocial" -this change was made -please refer to the abstract Line 7: Add "and" in front of "use of telehealth" -we kept this the same to remain within the Line 17: Add "of therapists" in front of "reported" for clarity -this change was made -please refer to the abstract

Line 41: Use acronym "PPE" and not "PPE's" -this change was made Line 50: Are you referring to both aerosol and droplet forms? Please clarify because they are different forms of transmission.-this sentence was reworded. Please see lines 50-51.

Line 50: Is "changes" the correct word in this context? -this sentence was reworded. Please see lines 50-51.

Line 87: Add "questions" after "multiple choice" --this change was made

Line 273: Add "and were" before "troubled" -this change was made

Lines 302 to 304: Is there a reference for this? -during this time, we were relying on websites and news reports. We included two of the website references we were accessing during this time Line 340: Remove "global" before "pandemic" because a pandemic implies global reach -this change was made Line 344: Missing a period -this change was made Line 345: Change "kids" to "children" -this change was made Line 349: Change "3-week" to "three-week" -this change was made

Line 372: Write out the full term for "CDC" because it is the first (and only use in the manuscript)this change was made Line 392: Change "COVID-10" to "COVID-19" -this change was made Line 397: Clarify/change the wording for "resistance to change and technically challenge staff" is unclear in the list of items provided in that sentene -commas were added to help clarify

Line 416: Write out the full term for "CPT" -this change was made Line 440: Remove "global" -this change was made

Line 450: Change "2" to "two" -this change was made

Line 469: Change "and childcare closed" to "and closure of childcare" -this change was made Highlights  86% of therapists reported feeling more stress than they did prior to the COVID-19  Older therapists and those that practiced longer felt more comfortable with in-person treatment.  98% of therapists reported a decrease in caseload.  Post-operative cases and patients ages 19-49 were more likely to receive in-person treatment.  46% reported providing telehealth services.  Telehealth was used more in non-traumatic, non-operative cases and older patients  Younger therapists were more likely to utilize telehealth. The survey was distributed to members of the American Society of Hand Therapists from April 14, 2020 through May 4, 2020. Descriptive demographic data were obtained. Frequencies were examined using ChiSquare, correlations were examined using Spearman Correlation Coefficient, and means were compared via independent t-test. Results: A total of 719 members responded to the survey. 86% of therapists reported feeling more stress than they did prior to the COVID-19 pandemic and this level of stress was similar across ages, practice settings, financial stability or instability, and geographical settings. Older therapists (rs = .04) and those that practiced longer (rs = .009) felt more comfortable with in-person treatment. 98% of therapists reported a decrease in caseload. Post-operative cases (p= 0.0001) and patients ages 19-49 were more likely to receive inperson treatment (p=.002). 46% of therapists reported providing telehealth services. Nontraumatic, non-operative cases (p = .0001) and patients aged 65 or older were more likely to receive telehealth services (p=.0001). Younger therapists (rs = .03) and therapists working in outpatient therapist owned, outpatient corporate owned, and outpatient academic medical centers (X 2 (4, N=637)=15.9463, p=.003) were more likely to utilize telehealth. Conclusion: Stress was felt globally among hand therapy clinicians regardless of financial security or insecurity, age, practice area, or stract   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62  63  64 geographical setting. Therapists saw a drastic decrease in caseloads. In-person caseloads shifted primarily to post-operative cases.

Covid-19, stress, outpatient healthcare workers, personal protective equipment, telehealth, hand therapy   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60  61  62 Frequencies were examined using ChiSquare, correlations were examined using Spearman 10 Correlation Coefficient, and means were compared via independent t-test. Results: A total of 719 11 members responded to the survey. 86% of therapists reported feeling more stress than they did 12 prior to the COVID-19 pandemic. This level of stress was similar across ages, practice settings, 13 financial stability or instability, and geographical settings. Older therapists (rs = .04) and those that 14 practiced longer (rs = .009) felt more comfortable with in-person treatment. 98% of therapists 15 reported a decrease in caseload. Post-operative cases (p= 0.0001) and patients ages 19-49 were 16 more likely to receive in-person treatment (p=.002). 46% of therapists reported providing telehealth 17 services. Non-traumatic, non-operative cases (p = .0001) and patients aged 65 or older were more 18 likely to receive telehealth services (p=.0001). Younger therapists (rs = .03) and therapists working in 19 outpatient therapist owned, outpatient corporate owned, and outpatient academic medical centers 20 (X 2 (4, N=637)=15.9463, p=.003) were more likely to utilize telehealth. As hand therapists continue to navigate their way and understand their role in this tumultuous 45 time, newer concepts such as telehealth and the importance of PPE continue to emerge. Although there 46 is limited information and evidence currently available, research is emerging. In a recent rapid review 47 and recommendations article, 6 the use of face masks for allied health workers was discussed. Based on 48 evidence from the influenza virus the authors infer that while surgical masks are not a reliable protector 49 against a patient with COVID-19, the mask is useful to prevent personnel from an accidental aerosol 50 incident from an asymptomatic carrier. Further, the authors explain that reducing the amount of viral 51 load acquired, facemasks are protective as they likely reduce the severity of the illness. 6 52

Telehealth is another service that has entered the arena of hand therapy. Previously telehealth 53 had an extremely limited role and was primarily associated with rural or underserved areas. Prior to 54 COVID-19 Medicare, Medicaid and most private insurance companies did not recognize rehabilitation 55 codes or occupational therapy (OT) or physical therapy (PT) providers, therefore making this an 56 unfamiliar area of practice for most hand therapists. Since the start of the pandemic some progress has 57 been made in this area. However, a lack of clarity remains regarding appropriate coding, documentation 58 guidelines, inconsistent reimbursement, and an unclear future for OT and PT as telehealth providers. 59

The psychological and emotional impact COVID -19 has had on hand therapists is unclear. 60 However, considering the unusual and dramatic changes this virus has had on the typical work pattern 61 of hand therapists it seems likely that the overreaching stressors from this pandemic will inevitably 62 strike the hand therapy community. One recent publication reported that although health care workers 63 often accept increased risk of infection as part of their chosen profession, they exhibit concern about 64 family transmission, especially involving family members who are elderly, immunocompromised, or have chronic medical conditions. 7 Similarly an article addressing anxiety in health care workers during 66 COVID-19 8 identified several sources of anxiety, which included: access to proper PPE, exposure to the 67 virus and taking it home to family, not having rapid testing if exposed, and fear of propagating the 68 infection at work. 8 69

Another concern is the financial impact that occurs as each state defines an "essential worker" communications within each category. Because this study was not a full qualitative study and we did 116 not conduct interviews to fully explore ideas, we were unable to identify codes and themes. Rather, we 117

were only able to categorize statements and utilize those statements to provide additional insight into 118 the quantitative results. No qualitative software program was used. 119

To analyze state data, COVID-19 prevalence data were gathered on May 11, 2020 from two 120 websites. 14-15 The states (including the District of Columbia) with the lowest and highest COVID-19 cases 121 per 100K were identified. Data from both websites was the same, and thus this data were used to 122 examine the COVID-19 'hot spots' and non 'hot spots' during the timeframe of the survey. 123 124

Demographic data 126 Two separate e-mailings were sent to ASHT members (n=2,919; n=2,953). The emails were sent 127 to active ASHT members; however, members were only allowed to take the survey once despite 128 receiving two emails alerting them to the survey. A total of 877 members agreed to participate in the 129 survey. However, due to a technical error in the initial hours of distribution, which was corrected 130 quickly, only 719 responses were considered complete and eligible to be included in the survey. Not all 131 719 respondents completed 100% of the survey. If a respondent did not answer a question, then that 132 individual answer was not included in any analysis. The total number of respondents per survey 133 question is represented in tables, graphs, and text. Demographic data are represented in Table 1 . 134

The average age of participants was 49.62 years (range 24-79). Therapists were licensed as 135 either an OT or PT for an average of 24.61 years (range 0-52). A total of 646/680 therapists (95%) 136 considered hand therapy an essential service. All states were represented with the exception of 137

Arkansas and Rhode Island. The District of Columbia and Puerto Rico, along with Canada, Australia, New 138

Zealand, Bhutan, and Mexico were also represented. See Table 2 for state data. 139

Quantitative analysis 140 The four constructs that guided development of the survey also guided analysis of the data. 141

A total of 86% of therapists reported feeling more stress than they did prior to the COVID-19 143 pandemic (n=549/642). Additionally, many therapists reported a financial impact during this time. See 144 Figure 1 . 145

All levels of stress were compared to age, practice setting, and practice versus non-practice 146 owners. See figures 2-4. None of these variables were found to be statistically significant. However, 147 when just the higher levels of stress ('a little more stress,' 'much more stress') were factored out for 148 those that owned a practice and those that did not, there was a statistically significant relationship 149 between non-practice owners and higher levels of stress (Figure 4 ). See Table 3 for all correlation  150 coefficients. 151

There were a limited number of responses in the 'no change,' 'much less stress,' and 'a little 152 less stress' categories. Therefore, only the higher stress level categories ) were analyzed. The analyzed 153 categories included those that reported financial impact due to a change in job status (hours cut by > or < than 50%, furloughed, or laid off) and those that expected or did not expect a financial impact. In both 155 cases, none of these variables were found to be statistically significant ( Figure 5) . Comfort level treating patients in-person was also assessed and findings indicated that older 170 therapists (rs = .04 ) and those that practiced longer (rs = .009) felt more comfortable with in-person 171 treatment. Refer to Table 3 . 172

Practice changes 173 A total of 98% (671/684) of therapists reported caseloads decreasing during the pandemic. 174

There was also a decrease reported in hours per week of direct clinical care and changes to employment 175 status as captured during the survey timeframe of April 14, 2020 -May 4, 2020. See Figures 9 and 10 . 176

Post-operative cases were more likely to receive in-person treatment (t(738) = 6.84, p= 0.0001) and non-traumatic, non-operative cases were more likely to receive telehealth services (t(730) = 7.94, p = .0001). 178

Patients ages 19-49 were more likely to receive in-person treatment (t(745) = 3.1694, p=.002) and 179 patients aged 65 or older were more likely to receive telehealth services t(743) = 6.12, p=.0001). Refer 180 to Figure 11 . 181

Telehealth 182

Only 28 therapists reported using telehealth prior to the COVID-19 pandemic. During the 183 COVID-19 pandemic, 305 reported providing telehealth services in the past two-weeks whereas 354 did 184 not. More therapists reported receiving some telehealth training versus not (yes = 171; no = 123). 185

Younger therapists were more likely to use telehealth than older therapists (rs = .03) (Refer to Table 3) . 186

Therapists working in outpatient therapist owned clinics, outpatient corporate owned clinics, and 187 outpatient academic medical centers were more likely to utilize telehealth and was confirmed 188 statistically. See Figure 12 . The keywords that emerged from this category were associated with loss and decrease, most 206 frequently linked to revenue, although there was also an association to the idea of losing staff. One 207 member expressed, "I have a 70% loss of revenue overall" while another participant stated, "Loss of 208 income, planning for when and how my practice will reopen" and another member added, "Going broke, 209 hoping to get the PPP loan so I can keep my staff." Financial concerns were prevalent among both 210 private practice owners as well as non-practice owners. 211

Balancing sudden changes at home 212 The keywords that emerged from this category were centered around working from home and 213 balancing multiple roles of homeschooling, several people working in the household, and childcare. 214

Participants expressed concern over needing to continue to work in the clinic, but also having children at 215 home that needed home schooling and care. Responses included this becoming a financial concern as 216 they needed to take time off to tend to family members suddenly home, but did not have enough 217 vacation time to get paid. Key words that surfaced in this category were-do not know/unknown, concern, and future. patients continue therapy-"Patients may choose to switch over to a HEP sooner than recommended to 263 limit exposure." Therapists also identified the strict disinfecting regimen as critical for preventing the 264 spread of the virus while also recognizing the extra time required to complete this task-"Despite seeing 265 fewer patients due to more 1:1, I won't have any extra time due to the amount of cleaning and sanitizing 266 I will need to do." Several therapists mentioned the idea of plexiglass dividers becoming typical in the 267 clinic and that Fluidotherapy™ may become "a thing of the past". Therapists expressed concern about 268 contracting COVID-19 as well as the fear of exposing family members. One therapist who was 269 furloughed said "I am very stressed as I have family and friends who are very sick with Covid, including 270 therapists who did contract it from patients in facilities that were not using proper precautions so I am 271

very nervous of when I return." "I worry about bringing something home to them or getting sick myself." and PPE practices is: "I believe we will need to continue strict precautions including face shield and mask. 274

We work in such close contact with patients that unless this COVID-19 is irradiated I believe precautions 275 will be long standing for patient and staff protection." 276 277

Key words revealed in this subcategory were specific to the topic-telehealth, telerehab, and e-279 visits. There was some dichotomy in the responses regarding telehealth. Many participants expressed 280 skepticism and were troubled that virtual visits would replace traditional therapy, as acknowledged by 281 this response: "I am concerned that tele-health will be justified by insurance companies and attempt to 282 take the place of in person visits, which I believe is not comparable." Others embraced the idea of e-283 visits and telehealth as described in this response: "Hoping the use of e-visits and telehealth use for this 284 pandemic will be used as an advocacy strategy to again advocate for the therapies to be included on a 285 permanent basis," while another indicated "We need to establish better resources and training for 286 Key words emerging with this subcategory included-manual therapy, touch, face to face, and 293 hands-on. The members expressed concern over face to face hands on care being greatly reduced after 294 stay at home and other restrictions or COVID-19 are lifted, and that this change may affect quality of 295 care and professional enjoyment as a hand therapist. This category overlaps with the telehealth 296 category as several members linked the two stating that with the inevitable advent of increased 297 telehealth by hand therapists, the face to face, hands on care in the clinic will decrease. The concern for 298 human touch being an integral part of success in therapy is expressed in the following quotes taken 299 from the survey: "I'm afraid that manual therapy will be under emphasized and the face to face contact 300 may not be appreciated," and "I feel that one of the most important parts of hand therapy is the touch 301 and relationship that is achieved in the clinic," with even stronger statements of "Very difficult to provide 302 or allow for tactile input to the patients' hands, which is crucial in neuromuscular and sensorimotor re-303 education", and " manual hands on therapy is our bread and butter." One therapist expressed that 304 "manual treatment is one of the biggest interventions that sets us apart." Another said, "The services we 305 offer are best performed in proximity to the patient through hands on care and when will this return?" 306 307

The survey results captured the significant changes that occurred in the hand therapy profession 309 from April 14, 2020 to May 4, 2020. During this timeframe, the majority of states had implemented 310 stay-at-home orders, school closures, and restricted business operations. 14-15 Additionally, many 311 countries around the world were implementing strategies to address the pandemic. We refer to this 312 timeframe as the height of the spring 2020 COVID-19 pandemic. Our survey revealed that during this 313 timeframe, therapists experienced increased stress, feelings of uncertainty, and significant practice 314 pattern changes. 315

The Department of Homeland Security deemed both occupational and physical therapy services 316 essential during the COVID-19 response and described these jobs as essential for continued national 317 critical infrastructure viability. 16 Research supports that for many upper extremity musculoskeletal 318 conditions, interventions within the scope of therapy increase function and decrease pain. 17-19 319

However, how these essential services are delivered in the future may be different as a result of the 320 COVID-19 pandemic. During our survey timeframe, individuals who had surgery received significantly 321 more in person treatment then telehealth. While the majority of the respondents deem hand therapy 322 as essential (95%), some therapists acknowledged in the open-ended questions that not all hand 323 therapy services are essential. It is important during a pandemic to recognize that many of our services 324 are essential; however, the lessons learned during the spring 2020 COVID-19 pandemic may help the 325 hand therapy profession to better delineate essential services, and identify those services that need to 326 be delivered in-person versus ones that can be effectively delivered via telehealth. 327

Increased levels of stress were reported by most of the participants, and this increased stress 328 level appeared consistent across practice areas, financial stability, current job status, age, and 329 geographical areas despite the fact that during April 14, 2020 -May 4, 2020, some states were 330 experiencing a significant crisis and major restrictions (Eg. NY and NJ), while other states experienced 331 few cases and very little restrictions (Eg. MT and AK). Most clinicians experienced a significant decrease 332 in direct client hours and many had a reduction in overall work hours. Even therapists that were not 333 impacted financially and did not expect to be impacted financially experienced the same levels of stress. One of the more drastic practice changes observed in this study was the sudden move to 377 telehealth rehabilitation. Telehealth in rehabilitation had been slowly gaining traction as a viable 378 method of conducting orthopedic assessments 29,30 and receiving needed therapy services. 31-33 379 However, the COVID-19 pandemic resulted in a drastic, unexpected, and unplanned swing to telehealth, 380 as a result of sudden state restrictions and the Centers for Disease Control and Prevention's 381 recommendation to explore alternatives to face-to-face visits with a specific recommendation of 382 "promoting the increased use of telehealth" 34 . In our survey, only 28 therapists reported using 383 telehealth prior to the COVID-19 pandemic. During the height of the spring 2020 COVID-19 pandemic, 384 that number rose to 305. Other practice settings also reported a sudden increase in telehealth visits 385 during the COVID-19 pandemic. 35 Those more likely to receive telehealth services were non-traumatic, 386 non-operative clients and clients aged 65 or older. 387

In the present survey, there was a significant relationship between age and therapists' 388 utilization of telehealth. From a clinical perspective, this relationship between age and telehealth is 389 worth exploring. A recent study aimed at assessing readiness of use of medical apps from physicians in 390 Australia found that younger physicians used more medical apps at work and yielded higher readiness 391 for telehealth scores than physicians over age 44. 36 In our study, we also found that younger therapists 392 were more likely to use telehealth. There is speculation that older clinicians may feel less comfortable 393 utilizing telehealth; however, this is only speculation as our survey did not examine variables that 394 influence the utilization of telehealth. In a literature review Dziechciaz and Fillip 37(p847) presented the 395 aging processes of humans and changes in bio-psycho-social areas. In their study they found that "with 396 age, there are increasing difficulties in adapting to new situations." Perceived apprehension in this age 397 group could be related to the need to learn several new technologies and during the case of the COVID-398 19 pandemic, learning these technologies at a rapid pace of change. 399

Perceived apprehension in this age group could also be the result of paradigms engrained 400 regarding service delivery through years of providing therapy in person. In an account of a thoracic 401 surgery practice transitioning to almost exclusive telehealth outpatient practice during the COVID-19 402 outbreak, they describe one of their challenges as "some providers may not have adequate experience 403 in this modality and there may be a learning curve associated with engaging patients through the 404 telehealth platform." 38(p7) 405 Training and experience have been shown to increase positive attitudes toward telehealth in 406 providers 39,40 while lack of training, resistance to change, technically challenged staff, and age, among 407 other themes, were identified in a systematic review as barriers. 41 Implementing telehealth at short 408 notice was a response to COVID-19 stay at home orders and concern over spreading the disease rather 409 than a service that was provided customarily in most clinics. In an article discussing the use of telehealth 410 in global emergencies, the authors stress the need to implement telehealth proactively in order to be 411 better prepared for pandemics and other emergencies. 42 These authors also suggest that formal 412 telehealth strategies are needed and that it would be important to include telehealth in medical 413 curricula. These findings and suggestions are echoed in an article describing the use of telemedicine in 414 an orthopedic practice that performs primarily total joint arthroplasties. 43 In our study, only 171 415 therapists reported receiving some telehealth training. However, it is important to note that the switch 416 to telehealth during the COVID-19 pandemic was sudden and adequate training was likely not plausible. 417

Variables that predict clients liking or preferring telehealth include lack of medical insurance, female 418 gender, an understanding of telehealth, and convenience. 44 Recognizing these variables and providing 419 education and training to all clinicians along with having guidelines in place proactively may reduce 420 stress around use of telehealth in times of emergency and may help with a paradigm shift to an 421 accepted delivery model of telehealth. 422

In addition to appropriate training to provide telehealth services, appropriate remuneration for 423 services is also necessary. 42 Staphylococcus aureus (MRSA), and could therefore feel more prepared from past encounters and 441 acquired knowledge. Studies have also found that older adults in general worry less than younger 442 adults 47,48 and worry less than younger adults following other natural disasters and terrorist attacks. 49.50 443 Therefore, because the older cohort of therapists may be less worried about in-person delivery than the 444 younger therapists, it may explain a perceived preference for in-person treatment versus telehealth. 445

Uncertainty for the future was a consistent undertone in many of the free text statements. 446

Relative to this emotion, in a recent psychology review uncertainty was described as the precision with 447 which a prediction can be made based on the available information. 51 The survey was not without technical flaws. Shortly after the electronic distribution of the 460 survey it was reported that two questions that permitted a "check all that apply" response did not allow 461 the participants to do so. Therefore, the survey was paused for 12 minutes to allow for remediation of 462 this issue and necessitated the discarding of 158 responses. In addition, two questions (43 & 44) had a 0-response rate due to incorrect coding rendering these questions void from inclusion in the analysis or 464 results of the study. 465

Response bias is a potential consideration in this study due to the conditions or factors that may When designing the survey, we did not define stress. It was our bias that increased stress levels 473 would have a negative implication, but without offering qualifying information related to stress in the 474 survey, the bias that increased stress is negative is an assumption on our part. 475

Finally, although we received responses from therapists in other countries, we did not receive 476 enough responses to perform any analysis on that data. Thus, we were not able to elaborate on this 477 data. 

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ASHT Scope of Practice

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Health Care Professionals During the COVID-19 Pandemic

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COVID-19 Pandemic: A Systematic Review of Availability, Usage, and Rationing

The emotional impact of Coronavirus 2019-nCoV 539 (new Coronavirus disease)

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COVID-19) cases as of May ??

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Are Austrian practitioners ready to use medical apps? Results of a 612 validation study

Biological psychological and social determinants of old age: Bio-psycho-615 social aspects of human aging

Transitioning a Surgery Practice to Telehealth During COVID-618

Model in Telemedicine: A Change in Participation

Changes in provider attitudes toward telemedicine

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Telehealth for global emergencies: Implications for 628 coronavirus disease 2019 (COVID-19)

Academic Total Joint Arthroplasty Practice: Needs and Opportunities Highlighted by the

COVID-19 Pandemic

Patients' Satisfaction 635 with and Preference for Telehealth Visits

Health Care Workers in Singapore

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H (2020) COVID-19 Worries and Behavior Changes in Older and Younger 644

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We would like to acknowledge Brocha Stern for her assistance in developing the survey used in this 504 study. 505 506 507

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