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Out-patient physiotherapy service delivery post COVID-19: opportunity for a re-set and a new normal?

2021; Elsevier BV; Volume: 111; Linguagem: Inglês

10.1016/j.physio.2021.02.001

1873-1465

Gillian Rawlinson, Louise Connell,

Healthcare professionals’ stress and burnout

Since the COVID-19 pandemic was declared by the World Health Organization (WHO) in March 2020, there has been seismic shift in healthcare delivery including physiotherapy [1Chartered Society of Physiotherapy Remote physiotherapy delivery options. The Chartered Society of Physiotherapy, 2020Google Scholar, 2Keesara S. Jonas A. Schulman K. Covid-19 and health care's digital revolution.New Engl J Med. 2020; 382: e82Crossref PubMed Scopus (659) Google Scholar]. The COVID-19 pandemic has brought challenges but also opportunities. There have been calls for the profession to maximise opportunities to transform and adapt itself to better meet the needs of populations. This not only relates to tackling the impact of COVID-19 and infectious diseases [3Landry M.D. Geddes L. Park Moseman A. Lefler J.P. Raman S.R. van Wijchen J. Early reflection on the global impact of COVID19, and implications for physiotherapy.Physiotherapy. 2020; 107: A1-A3Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 4Lee A.J.Y. Chung C.L.H. Young B.E. Ling L.M. Ho B.C.H. Puah S.H. et al.Clinical course and physiotherapy intervention in 9 patients with COVID-19.Physiotherapy. 2020; 109: 1-3Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Abdullahi A. Covid-19 pandemic experience: can it serve as a clarion call to establish or revamp a specialty known as 'infectious diseases physiotherapy'?.Physiotherapy. 2020; 108: 1Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar], but also the increasing burden of non-communicable diseases and long-term conditions (LTC) [6Dean E. Jones A. Homer Peng-Ming Y. Rik G. Margot S. Translating COVID-19 evidence to maximize physical therapists' impact and public health response.Phys Ther. 2020; 100: 1458-1464Crossref PubMed Scopus (19) Google Scholar, 7James S.L. Abate D. Abate K.H. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1789-1858Abstract Full Text Full Text PDF PubMed Scopus (8578) Google Scholar]. Traditionally many out-patient services were based on post-war models of service delivery where patients are seen face to face, usually individually, for an initial longer appointment and followed by shorter appointments over the subsequent weeks. This model was designed in a predigital era when physical hands on and electrotherapeutic interventions prevailed. The first appointment to follow up appointment ratio in musculoskeletal (MSK) out-patients has reduced over time and in 2012 was just an average of 3.14 follow ups per patient [8Chartered Society of Physiotherapy Physiotherapy outpatient services survey 2012. London.2013Google Scholar]. This reduction appears to have been driven by capacity and demand responses, as well as an increased emphasis on self-management and less guidance for 'hands on' therapies [9Lin I. Wiles L. Waller R. Goucke R. Nagree Y. Gibberd M. et al.What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review.Br J Sports Med. 2020; 54: 79-86Crossref PubMed Scopus (490) Google Scholar]. Less overall time is spent with individuals. The need to deliver quality, person centred care arguably increases the demand on concentration, and emotional investment from physiotherapists (as well as expert clinical knowledge) [10Hall M.S. Podlog L. Newton M. Galli N. Fritz J. Butner J. et al.Patient and practitioner perspectives of psychological need support in physical therapy.Physiother Theory Pract. 2020; https://doi.org/10.1080/09593985.2020.1780654Crossref Scopus (3) Google Scholar]. With rising prevalence of long term conditions there has also been an increased focus on supporting patients to self-care through shared decision making (SDM) and personalised care (PC) approaches [11de Silva D. Helping people help themselves: a review of the evidence considering whether it is worthwhile to support self-management. The Health Foundation, London2011Google Scholar, 12Hutting N. Johnston V. Staal J.B. Heerkens Y.F. Promoting the use of self-management strategies for people with persistent musculoskeletal disorders: the role of physical therapists.J Orthopaed Sports Phys Ther. 2019; 49: 212-215Crossref PubMed Scopus (65) Google Scholar, 13Babatunde F. MacDermid J. MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.BMC Health Serv Res. 2017; 17: 375Crossref PubMed Scopus (135) Google Scholar]. Supporting self-management not only includes the provision of information but also enabling motivation and self-efficacy to help people achieve greater control and take appropriate action to manage their condition [11de Silva D. Helping people help themselves: a review of the evidence considering whether it is worthwhile to support self-management. The Health Foundation, London2011Google Scholar]. Physiotherapy self-management usually requires adherence to some form of behaviour change such as undertaking a home exercise programme or lifestyle adaptations [14Novak I. Effective home programme intervention for adults: a systematic review.Clin Rehabil. 2011; 25: 1066-1085Crossref PubMed Scopus (34) Google Scholar, 15Söderlund A. von Heideken Wågert P. Adherence to and the maintenance of self-management behaviour in older people with musculoskeletal pain – a scoping review and theoretical models.J Clin Med. 2021; 15: 303Crossref Scopus (12) Google Scholar]. Adherence to physiotherapy self-management programmes is suboptimal [16Peek K. Sanson-Fisher R. Mackenzie L. Carey M. Patient adherence to physiotherapist prescribed self-management strategies: a critical review.Int J Ther Rehabil. 2015; 22: 535-543Crossref Scopus (12) Google Scholar]. Literature supports the notion that adherence is a multi-dimensional construct, with a range of barriers and facilitators being identified [17Peek K. Sanson-Fisher R. Mackenzie L. Carey M. Interventions to aid patient adherence to physiotherapist prescribed self-management strategies: a systematic review.Physiotherapy. 2015; 102: 127-135Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar, 18Jack K. McLean S.M. Moffett J.K. Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review.Man Ther. 2010; 15: 220-228Abstract Full Text Full Text PDF PubMed Scopus (550) Google Scholar, 19Essery R. Geraghty A.W. Kirby S. et al.Predictors of adherence to home-based physical therapies: a systematic review.Disabil Rehabil. 2017; 39: 519-534Crossref PubMed Scopus (189) Google Scholar, 20Moore A.J. Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study.J Physiother. 2020; 66: 45-53Crossref PubMed Scopus (57) Google Scholar, 21Peek K. Carey M. Mackenzie L. Sanson-Fisher R. Characteristics associated with high levels of patient-reported adherence to self-management strategies prescribed by physiotherapists.Int J Ther Rehabil. 2020; 27: 1-15Crossref Scopus (8) Google Scholar]. No single interventions have been identified as the panacea for increasing adherence to self-management programmes in physiotherapy [6Dean E. Jones A. Homer Peng-Ming Y. Rik G. Margot S. Translating COVID-19 evidence to maximize physical therapists' impact and public health response.Phys Ther. 2020; 100: 1458-1464Crossref PubMed Scopus (19) Google Scholar, 22McLean S.M. Burton M. Bradley L. et al.Interventions for enhancing adherence with physiotherapy: a systematic review.Man Ther. 2010; 15: 514-521Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 23Room J. Hannink E. Dawes H. Barker K. What interventions are used to improve exercise adherence in older people and what behavioural techniques are they based on? A systematic review.BMJ Open. 2017; 7Crossref PubMed Scopus (84) Google Scholar]. Pre-COVID-19 we undertook an observational study (in press) based on the behaviour change wheel [24Michie S. van Stralen M.M. West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions.Implement Sci. 2011; 6: 42Crossref PubMed Scopus (6445) Google Scholar], to explore self-management programmes in MSK outpatient physiotherapy. Video recordings of face-to-face consultations and interviews with patients highlighted that physiotherapists focussed on ensuring patients had the practical capability to undertake the programmes but did not address opportunity or motivational components of adherence. Contextual factors including the physiotherapists' environment and service delivery structure for appointments affected the provision of programmes and patients' adherence which is in keeping with other studies [10Hall M.S. Podlog L. Newton M. Galli N. Fritz J. Butner J. et al.Patient and practitioner perspectives of psychological need support in physical therapy.Physiother Theory Pract. 2020; https://doi.org/10.1080/09593985.2020.1780654Crossref Scopus (3) Google Scholar, 20Moore A.J. Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study.J Physiother. 2020; 66: 45-53Crossref PubMed Scopus (57) Google Scholar, 25Meade L.B. Bearne L.M. Godfrey E.L. It's important to buy in to the new lifestyle": barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain.Disabil Rehab. 2019; 26: 1-11Google Scholar]. Patients' also reported valuing the therapeutic relationship and expressed a desire for social support and group exercises. None of the patients in our study were offered group exercises despite evidence supporting their cost effectiveness [6Dean E. Jones A. Homer Peng-Ming Y. Rik G. Margot S. Translating COVID-19 evidence to maximize physical therapists' impact and public health response.Phys Ther. 2020; 100: 1458-1464Crossref PubMed Scopus (19) Google Scholar, 26O'Keeffe M. Hayes A. McCreesh K. et al.Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions?. A systematic review and meta-analysis.Br J Sports Med. 2017; 51: 126-132Crossref PubMed Scopus (46) Google Scholar]. COVID-19 has increased the use of digital telehealth [27Pugliese 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: 1-4Google Scholar, 28Turolla 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: 1260-1264Crossref PubMed Scopus (186) Google Scholar, 29Bokolo A.J. Application of telemedicine and eHealth technology for clinical services in response to COVID-19 pandemic.Health Technol. 2021; https://doi.org/10.1007/s12553-020-00516-4Crossref Scopus (115) Google Scholar] which has accelerated digital ambitions [30Greenhalgh T. Shaw S. Wherton J. Vijayaraghavan S. Morris J. Bhattacharya S. et al.Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study.J Med Internet Res. 2018; 20Crossref Scopus (212) Google Scholar]. However, we must be careful not to just replace the existing appointments with remote consultations but instead consider how we use resources including time, the physical environment and digital technologies to optimise the delivery of evidence based, personalised care [31Tack C, Grodon J, Shorthouse F, Spahr N. "Physio anywhere": digitally-enhanced outpatient care as a legacy of coronavirus. Physiotherapy; 2020 [in press].Google Scholar]. Pugliese (2020) highlights how telehealth has enabled physiotherapists to re-focus on the interpersonal interactions and communication with patients. Post COVID-19 we have the opportunity to consider how we use face-to-face contacts and blend these with technologies including video or telephone communications, short messaging services (SMS) and online resources [32Bennell K.L. Campbell P.K. Egerton T. Metcalf B. et al.Telephone coaching to enhance a home-based physical activity program for knee osteoarthritis: a randomized clinical trial.Arthritis Care Res. 2017; 69: 84-94Crossref PubMed Scopus (83) Google Scholar, 33Bunting J.W. Withers T.M. Heneghan N.R. Greaves C.J. Digital interventions for promoting exercise adherence in chronic musculoskeletal pain: a systematic review and meta-analysis.Physiotherapy. 2020; (https://doi.org/10.1016/j)Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. This blended approach could be personalised, as we know this is not addressed by a one-size-fits-all approach [24Michie S. van Stralen M.M. West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions.Implement Sci. 2011; 6: 42Crossref PubMed Scopus (6445) Google Scholar]. Supporting long-term self-care, behaviour change and physical activity participation is complex [15Söderlund A. von Heideken Wågert P. Adherence to and the maintenance of self-management behaviour in older people with musculoskeletal pain – a scoping review and theoretical models.J Clin Med. 2021; 15: 303Crossref Scopus (12) Google Scholar]. It requires physiotherapists to have the appropriate time and skills to develop a strong therapeutic relationship, to explore patients' capability, opportunities and motivations to change their behaviour [13Babatunde F. MacDermid J. MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.BMC Health Serv Res. 2017; 17: 375Crossref PubMed Scopus (135) Google Scholar, 24Michie S. van Stralen M.M. West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions.Implement Sci. 2011; 6: 42Crossref PubMed Scopus (6445) Google Scholar]. Providing appropriate time for patient interaction is necessary to build successful therapeutic relationship and engage in shared decision making which are critical in achieving optimal outcomes and adherence [13Babatunde F. MacDermid J. MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature.BMC Health Serv Res. 2017; 17: 375Crossref PubMed Scopus (135) Google Scholar, 20Moore A.J. Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study.J Physiother. 2020; 66: 45-53Crossref PubMed Scopus (57) Google Scholar]. The mode of service delivery is also important. Provision of group delivery provides opportunities for peer support and can help patients transition to long-term physical activity participation [34Hurley M.V. Walsh N.E. Mitchell H.L. Pimm T.J. Patel A. Williamson E. et al.Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial.Arthritis Rheum. 2007; 57: 1211-1219Crossref PubMed Scopus (196) Google Scholar]. Group exercise opportunities should be consistent, accessible and underpinned by evidence based practice. Delivering quality, person centred physiotherapy interactions within reducing episodes of care also potentially risks physiotherapist burnout which has been shown to be a problem particularly when managing patients with chronic conditions [35Rogan S. Verhavert Y. Zinzen E. Rey F. Scherer A. Luijckx E. Risk factor and symptoms of burnout in physiotherapists in the canton of Bern.Arch Physiotherapy. 2019; 9: 19Crossref PubMed Scopus (6) Google Scholar]. If we were starting from the beginning how would we design out-patient physiotherapy services for now and for the future? How can we support physiotherapists to ensure they deliver safe and effective assessment, whilst utilising technologies to engage patients in the ways they prefer? How can we provide patients with peer support and build transition into longer-term physical activity in their communities? We propose that physiotherapy service structure should enable physiotherapists to have adequate time for debriefing and reflection to support their wellbeing and learning. Our study utilised video observation which, with current use of video consultations, provides an effective tool to record consultations (in line with consent and information governance policies) and could allow easy opportunity for self-reflection and peer review for physiotherapists [36Fukkink R.G. Trienekens N. Kramer L.J.C. Video feedback in education and training: putting learning in the picture.Educ Psychol Rev. 2011; 23: 45-63Crossref Scopus (156) Google Scholar]. O'Caithain et al. (2019) sets out 5 principles in their guidance on developing healthcare interventions which provide a sound basis for us to consider as we re-set; being dynamic, being iterative, being creative, being open and looking ahead [37O'Cathain A. Croot L. Duncan E. Rousseau N. Sworn K. Turner K.M. et al.Guidance on how to develop complex interventions to improve health and healthcare.BMJ Open. 2019; 9https://doi.org/10.1136/bmjopen-2019-029954Crossref Scopus (655) Google Scholar]. Tack et al. (2020) also remind us of the need for the post COVID-19 service delivery era to be determined as a result of careful and robust evaluation that is built around service user views and staff wellbeing [31Tack C, Grodon J, Shorthouse F, Spahr N. "Physio anywhere": digitally-enhanced outpatient care as a legacy of coronavirus. Physiotherapy; 2020 [in press].Google Scholar]. The COVID-19 pandemic provides our profession with unique opportunities to re-design physiotherapy services to better support personalised care and patients' long-term adherence to self-management. This should build on behavioural science theory and adherence research to maximise the physiotherapist's contribution and ensures their health and wellbeing. We must seize the opportunity to review the evidence base, engage with service users, transform and evaluate out-patient physiotherapy care for the future. A new normal for physiotherapy care is within all of our gift.