key: cord-0987258-ntnfu5ns authors: Tack, Christopher Topol; Grodon, Jack; Shorthouse, Faye; Spahr, Nicolas title: “Physio Anywhere”: digitally-enhanced outpatient care as a legacy of coronavirus 2020 date: 2020-07-18 journal: Physiotherapy DOI: 10.1016/j.physio.2020.07.004 sha: 4114dff468fc639b932782cd0be0f17f62d147fd doc_id: 987258 cord_uid: ntnfu5ns nan COVID-19 infections. Outpatient services, including physiotherapy, quickly transitioned to remote working practices to comply with emergency measures to protect the safety of staff and the public [1] . Remote working via telemedicine (telephone or video-assisted consultation) displaces the need for face-to-face contact whilst providing care within patients' own homes [2] . To facilitate rapid deployment of video consultations, NHS England and NHS Improvement funded access to the Attend Anywhere platform for NHS providers, in line with that available in Scotland. Clinical guidance on remote care during the emergency period was rapidly published both by NHS England [3] and the Chartered Society of Physiotherapy [4] . Despite the relative infancy of remote working in physiotherapy, there is an emerging body of evidence that supports its incorporation in clinical practice as both an assessment and rehabilitation tool. Non face-to-face consultations conducted via remote contact have utility to provide a platform for effective clinical assessments. Remote assessment for musculoskeletal disorders shows good concurrent validity and excellent reliability in most areas [5] . Clinicians working by phone are able to modify their communication to counteract loss of visual bodily cues which would usually aid assessment [6] . This may include greater reliance of verbal description, and Shaw et al. [7] advise the pre-planning of themes to guide conversation. There is evidence of moderate to high agreement between remote and face-to-face examination in patients with low back pain [8] [9] and ankle disorders [10] . Inter and J o u r n a l P r e -p r o o f intra-rater reliability are high and moderate, respectively, for knee assessment [11] . Telehealth and in-person assessments, in an advanced-practice physiotherapy screening clinic, demonstrate a high level of agreement in relation to clinical management decisions and diagnosis in patients with chronic musculoskeletal conditions [12] . Further, video consultation is deemed acceptable to most patients [13] . Treatment interventions can also be delivered successfully via remote working. Patients with chronic knee pain report satisfaction with the patient-therapist relationship, the use of technology and the provision of exercises provided remotely [14] . High levels of patient satisfaction, adherence to rehabilitation protocols and clinically significant improvements in outcome measures were also demonstrated in individuals undergoing remote pulmonary rehabilitation [15] and cardiac rehabilitation [16] . Non-adherence with face-to-face physiotherapy care can be as high as 70% [17] , and is particularly poor for unsupervised home-based exercise [18] [19] . Further, there is little evidence that interventions to facilitate better adherence are effective [20] . In the current situation, with patients not able to come to attend exercise classes and have their condition monitored, adherence and compliance is likely to decline even further. However, telemedicine, aided by an ever-increasing number of digital health tools, can significantly increase patients' confidence in undertaking exercise and improve compliance and adherence to exercise-based rehabilitation programmes, compared to usual physiotherapy care [21] [22] . Digital health tools provide images and videos J o u r n a l P r e -p r o o f of exercises, patient advice and education and include reminders for patients to carry out prescribed exercise programs given by their physiotherapist in a 'virtual' exercise class, which can be remotely delivered and adherence monitored. Tools which combine education with appropriately timed reminders and exercise prompts can use "nudges" to positively transform behaviour and modify heuristics [23] . Moderate-high quality evidence supports the use of nudges to improve self-management outcomes, including physical activity adherence [24] . Digital tools and telemedicine can allow physiotherapists to remotely monitor and supervise a patient's rehabilitation, whilst at the same time promoting patient self-management and empowerment. Admittedly, the majority of the research in this area remains based upon small trials, however does provide a basis of evidence to support adoption of technology in practice. The step change in outpatient care provision as an emergency response provides an opportunity to redesign services within a new framework of innovative working practices that can extend beyond the immediate crisis. Quality improvement initiatives in response to rapid deployment of virtual services due to COVID-19 have already begun in the area of allied health [25] . Changes to services adopted in response to an emergency situation, although wellintentioned, may not necessarily turn out to be changes for the better. Providers will need to demonstrate they have a mandate from patients for provision of the new services and the patient experience must be fully explored. Similarly, the experience of physiotherapy staff working in these clinics needs to be examined. Knowledge of the challenges and difficulties encountered by physiotherapy staff will guide the delivery of specifically tailored training and education to ensure that staff feel fully supported and confident to meet the challenges that lie ahead in the new remote working environment. The shape, structure and processes of remote working practices in the future will be determined by the careful assessment of current services that have been delivered in response to the ongoing emergency situation. Providers must aim to co-design the new remote care pathways with, and for the benefit of, all stakeholders. Remote working practices can be an appropriate, well received and, efficient method of J o u r n a l P r e -p r o o f providing physiotherapy care. Without careful evaluation, however, providers run the risk of redesigning pathways, only to discover that the future isn't as bright and successful as was first envisaged. There are no conflicts of interest to be reported in association with this piece of work. When is a face to face consultation necessary during the covid-19 pandemic NHSX's offer to support secondary care Specialty guides for patient management during the coronavirus pandemic: Clinical guide for the management of remote consultations and remote working in secondary care during the coronavirus pandemic COVID-19: guide for rapid implementation of remote consultations. Practical advice for physiotherapists and support workers on how to implement remote consultations rapidly and efficiently Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review Doctor, can you see my squats? 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Clinical rehabilitation An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial Does a Web-Based Exercise Programming System Improve Home Exercise Adherence for People With Musculoskeletal Conditions?: A Randomized Controlled Trial. American journal of physical medicine & rehabilitation Debate: To nudge or not to nudge The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review. Health Policy Rapid implementation of virtual clinics due to COVID-19: report and early evaluation of a quality improvement initiativeBMJ We thank the specialist team at Guy's and St Thomas' NHS Foundation Trust