ARTICLE 1 

In these unprecedented times, the profession has swiftly banded together to provide much-needed information and support, writes Mark Elkins. 

The physiotherapy profession’s responses to the COVID-19 pandemic have included examples of urgent cooperation, efficient repurposing of existing resources and the creation of new resources to support safety, reduce infection transmission and provide business support measures. 

An international group of physiotherapists collaborated to generate crucial recommendations for physiotherapists managing suspected or confirmed cases of COVID-19 in the acute hospital setting. The recommendations cover physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment.

These peer-reviewed recommendations were published in the Journal of Physiotherapy and have been endorsed by nine professional bodies, including the World Confederation for Physical Therapy and the Australian Physiotherapy Association. (A nice companion to these recommendations is a position paper released by the Italian Association of Respiratory Physiotherapists, which includes some additional guidance on acute respiratory physiotherapy intervention guidance.)

The urgency with which these recommendations were needed is apparent to anyone following the spread of the pandemic, but it is also evident in the response they have received. The paper has already been translated into 17 languages and discussed in blogs on Facebook, Weibo and PT in Motion. Its Twitter activity means that the paper sits in the top five per cent of all research outputs ever tracked by Altmetric.

The recommendations were generated with a combination of urgent cooperation and the repurposing of existing resources. This is precisely the approach advocated in an editorial that accompanies the recommendations, which was authored by Kimberley Haines and Sue Berney from Melbourne. Rather than being panicked into ‘reinventing the wheel’ by generating lots of new resources, we should identify existing resources that suffice. The editorial describes several relevant resources that should be drawn upon. For example, rather than starting from scratch to prepare lists of what physiotherapists need to know to redeploy to an intensive care unit, minimum standards of clinical practice for physiotherapists in critical care already exist.

Other responses might be characterised as unusual measures in unusual times. For example, the medical journal JAMA published a one-paragraph editorial calling for suggestions from readers for how to deal with limited supplies of personal protective equipment. Over 250 innovative ideas were posted from many professions in the comments section. Many allied health staff, including physiotherapists and respiratory therapists, became involved—either suggesting ideas or alerting hospital infection control staff to the rapidly growing list of ideas for consideration.

Even though the situation (and therefore the advice) is changing rapidly, telehealth is going to be a viable option to maintain many services such as virtual fracture clinics for individual hospital outpatients, or as an avenue for private practitioners to continue delivering treatments.

The APA has demonstrated enormous and rapid advocacy on physiotherapists’ behalf, to assist them to deal with the pandemic safely and sensibly:

• The APA was able to advise members in March that ‘the National Disability Insurance Scheme has advised that telehealth can be used where appropriate and with the agreement of the participant. Providers should ensure they meet the NDIS Code of Conduct to ensure quality service provision’. Physiotherapists should use the fact sheets and other resources linked in the NDIS Code before trying to figure out appropriate standards for themselves. 


• Collated information on the position of 16 private health insurers regarding telehealth.


• Webinars have been presented, recorded and posted online to assist physiotherapists to embed


• telehealth into their physiotherapy practices. These are available on the Telehealth page of the APA website, accompanied by some extremely helpful responses to frequently asked questions in relation to this model of service delivery.


• More recently, members were notified that bulk billing of MBS telehealth items is no longer required.


• Comprehensive telehealth guidelines for members.


• A list of compensable schemes and their conditions for use of telehealth


• Business continuity advice and details from ATO regarding JobKeeper program.


• Resources and webinars from APA partner William Buck on financial advisory matters and links to major bank support websites.


• Mental health resources to support stressed physiotherapists.


• Daily email updates to all members during height of the crisis to support information sharing and access to critical resources. 

This sort of advocacy work should be embraced by physiotherapists and mined for ways in which it can efficiently help them to respond to the pandemic. With the inevitable ongoing uncertainty, there is even greater value in the APA’s rapid advocacy and dissemination of information to members. 

Physiotherapists involved in research have made rapid amendments to their projects to accommodate distancing requirements. Some have moved projects wholly or partly online through remote contact, while other have amended the planned outcome assessments.​

Resources

Physiotherapy COVID-19 recommendations paper: sciencedirect. com/science/article/pii/S183695532030028X 

Italian Association of Respiratory Physiotherapists position paper: https://www.monaldi-archives.org/index.php/ macd/article/view/1285/1003 

Journal of Physiotherapy editorial: sciencedirect.com/science/article/pii/ S1836955320300291 

Minimum standards of clinical practice for physiotherapists in critical care: bit.ly/2XAWFgn journals.sagepub.com/doi/ pdf/10.1177/1751143718807019 

JAMA editorial on personal protective equipment: jamanetwork.com/journals/jama/ fullarticle/2763590 

NDIS Code of Conduct: ndiscommission.gov.au/providers/ndis-code-conduct 

Private Health Insurance and telehealth: australian.physio/sites/default/files/APA_PH-Insurance-and-Telehealth-metrix.pdf 

Telehealth page on the APA website: australian.physio/telehealth 

See FAQ ‘third party payers’ for compensable schemes and their conditions for use

ARTICLE 2 

The media began to talk about COVID-19 right after it broke out from China in January, but as for previous epidemics, such as SARS or MERS, we weren’t so worried because these epidemics were ‘local’ and never spread to other continents.

But when it became clear that the situation in China was becoming uncontrollable and the virus was rapidly spreading to different countries, Italy began to pay more attention. It was within a month that the local news and newspapers disseminated some pieces of information about COVID-19, when a man, with symptoms of pneumonia, tested positive to the coronavirus.

At the beginning when the rate of infection was still low, the Italian government began to adopt several countermeasures to fight the emergency—and so did the local physiotherapy association, which began adopting some advice for every clinical context.

I have been holding a double job since January 2017: I work as a physiotherapist in a private practice clinic and I am also a researcher for the IRCCS Fondazione Don Carlo Gnocchi institution in Milan, Italy. Usually my working days are very busy, beginning in the morning at 8 am through to 2 pm, whenI work as researcher in my institution. Here I cooperate with my research group and I’m involved in several research projects about musculoskeletal disease associated with pain. From 2 pm to 8 pm I work as physiotherapist treating patients affected by musculoskeletal problems, general neuromusculoskeletal disorders and chronic pain.

When the situation got worse

When COVID-19 hit, the clinical trials at my institution stopped, and it was recommended that each researcher adopt smart working practices to continue their activity. In the clinic, we immediately began to use personal protective equipment (such as gloves and masks) but since the beginning of March we decided to suspend all non-essential treatments.to reduce the spread of the infection and minimise the travel of our patients.

As the epidemic evolved, a lot of patients decided, of their own free will, to interrupt their treatments, while others still required therapy sessions. For the latter, a useful approach was to continue the treatments through telerehabilitation. The use of telerehabilitation was something that was not considered much before this emergency, because it was far from our clinical practice and not accessible to everyone. However, we discovered that it was a useful means to guarantee the continuousness of rehabilitation services in compliance with the directives released by the Italian government.

I think that the challenge posed by this epidemic emergency is, and will be, to the relationships we have with the patients. In my opinion, this situation will change our profession because the contact and the hands-on treatment are prerogatives in rehabilitation.

In the first phase of the epidemic, when I was still active in the clinic, I knew that my patients felt vulnerable and were afraid of getting sick at any time, and that’s why they cancelled their appointments. They needed to be reassured, and one of our main tasks was to try to encourage them and give some advice or exercises for their pain that they could manage by themselves.

We are facing the biggest health emergency in recent decades, an event of exceptional magnitude, which has required the government to implement extraordinary measures, ranging from the reorganisation of the hospital network, to the quarantine of the entire country. In Italy, a lot of people have lost their loved ones and the saddest thing was that those people have died in hospitals alone, without having anyone near them.

This is what hurts me more, seeing so much suffering and knowing I could not help in any way. But it was also very emotional, and this made me proud to be an Italian, to see how people are trying to help in this situation, for example many famous Italian brands are beginning to produce masks or white coats to help the doctors and other health professionals to fight this battle.

My principal advice is not to underestimate the situation beyond the fact that the growth of the contagion is low, because the situation can worsen in only a few days. Health professionals are more at risk as they are in contact with patients more often than the general population. In the healthcare field, in addition to the general principle of social distancing, physiotherapists must adopt key hygiene and safety rules to avoid getting sick and being vectors for virus transmission.

At this time, however, rehabilitation should not be stopped, especially for those patients who urgently need treatments, for example posttraumatic or post-surgery patients. In my opinion, a fundamental concept plays a key role, and this is telerehabilitation. The delivery of rehabilitation services over telecommunication networks and the internet is vital to maintain the continuity of treatment without feeding the COVID-19 infection.

One of the most important things is to keep informed, especially through reliable sources. The spread of the epidemic and some guidelines are provided by the World Health Organization (WHO) on its website (who.int).

For the Italian citizens living day-to-day, the main advice is stay at home, leave home only to go to work, or for health or other necessary reasons, wash your hands often, avoid contact with people with acute respiratory infections, maintain an interpersonal distance of at least three feet in social contact and do not touch your eyes, nose and mouth with your hands.

The WHO recommends that you need to wear a mask if you suspect you have contracted COVID-19, if you have symptoms such as coughing or sneezing or if you are taking care of a person with a suspected COVID-19 infection. Another important piece of advice from the WHO is not to get obsessed or frightened, because panic cannot help in this already stressful situation.

I hope that we will learn from our mistakes. Surely those who have experienced this situation will be aware that we are all vulnerable and that no one is excluded. We will have to tackle the reconstruction of Italy from an economic and social point of view. I think that in general we will have to review our individual priorities but also know that we are not alone—that people from all around the world are always there to help, as we saw when doctors from China, Cuba, Poland, Spanish and Albania came to Italy to assist the patients in our hospitals. This situation, if it was not already clear, makes us understand the importance of having efficient health systems that put citizens’ health first.

In Italy, we have received support from many colleagues worldwide and many physiotherapists are working to help in this emergency. I think that we are a wonderful category of health professionals, and the Italian response is showing it. Personally, I have not been affected to the point of having to mourn, but my thoughts go out to all those who have suffered and are suffering from this situation. This night is lasting long enough, but soon the sun will rise again. 

Paolo Pedersini studied physiotherapy at the University of Brescia, graduating in 2016. Paolo has recently completed his master’s degree in science and technology for population health and wealth.

ARTICLE 3 

Three non-practising physiotherapists, all of whom now work at the APA, share their thoughts regarding the call out for physiotherapists to return to the fold and assist in the fight against COVID-19. 

Einat Bardea

My clinical background was very broad—rural and remote work, ICU, CCU and HDU, general medical and surgical wards, neurological rehabilitation and tertiary pain management clinics, women’s health and private practice.

I think returning to the workforce is a great opportunity for physios on an individual level, as well as the profession. As an individual, this is a chance for us to contribute to the community in a time of crisis, which could also be a great opportunity to deepen our knowledge and skills for future career opportunities. As a profession, the ‘call up,’ so to speak, of physiotherapists to assist with the COVID-19 crisis really emphasises the importance and value of our profession and will no doubt cement this value into the minds of the community for the future.

I have completed the DHHS paperwork to apply to work as part of the surge response several times and each time I falter at the ‘submit’ stage. While I am very keen to be involved in the crisis response—I am conscious that many physiotherapists now are losing work and would likely be looking for new work opportunities. As a physio who is currently fortunate to be in employment, I wouldn’t want to take a position that could otherwise be available for someone who has reduced work and income.

A few physios have told me they have filled out the expression of interest and not received a response yet, so my intention is to wait until I hear that the demand for returning physios exceeds the current supply. On that, I don’t feel any sense of external pressure to return. The only pressure I feel is the internal sense that if I have a skill or capability to contribute to this crisis, then I should, and would, do so. However, there is certainly some risk involved in physios who are no longer experienced returning to clinical work. To mitigate this risk, I think it is important that refresher courses, as well as adequate supervision, are provided.

Returning is a very personal decision that needs to be made according to individual circumstances. I know there are some physios who would love to assist in the crisis but may have a partner or relative who is immuno-compromised and so this option would carry great risk. We all have our own personal and family situations to consider when making these decisions and it is not something to be embarked upon lightly.

Lowana Williams

I’m a bit of an allrounder. Most of my practice has been in the hospital sector working on acute medical wards. My most recent work was in community health, which was predominantly musculoskeletal injuries.

With the potential downsizing of the current health workforce I think having the option for retired physios to return to the workforce is a good idea. Whether someone decides to start practising again I feel is an individual decision. For some, recommencing practice would come quite naturally, and they may feel they could be of assistance to the health system. For others, I imagine return to practice could be quite stressful. 

I am still registered and have contemplated whether I should volunteer to return; however, I haven’t made any steps towards this yet. I don’t currently feel any pressure to start practising again as the hospital systems don’t appear to be struggling. There are also private practice physiotherapists who may have been let off or had their hours reduced who would benefit more from the work than myself. If the situation changed and there was a desperate need for more physiotherapists, then I would consider rejoining the workforce.

There is a risk of having healthcare professionals working in an area they are unfamiliar with. This I think would need to be managed by the health service. However, for some physiotherapists they would be returning to an area of practice they had worked in for many years. They might need to dust off a few cobwebs, but their knowledge would likely be an asset to the team they’re working with.

Physiotherapists returning, again, I think is a personal choice. It really is dependent on the seriousness of a situation. Healthcare professionals in general, I feel, take the responsibility of their knowledge quite seriously. This can be seen in accidents in the community where they will often attend to a situation by providing first aid, etc. If the situation arose where there was a need for retired healthcare professionals to return to work, I feel most would take it upon themselves to return. 

Dan Miles

My background is mainly in private practice within musculoskeletal and sports conditions.

I believe that offering to support front-line healthcare workers is a positive move, symbolically and practically for physiotherapy as a profession. Whether retired physiotherapists return to working in healthcare or not is almost a secondary issue when looking at the bigger picture.

It is a personal decision that needs to be made and for me, I feel I should be be true to my ideology—when I saw that there was a request for retired physios to go back, I thought I’ll just stick my hand up and do whatever I can to help. Ultimately, my belief is that if you want to make a difference in the world we live in and make it a better place for us all, a starting question could be: what can you do to help?

On this, I have not felt pressured at all and honestly, I feel like I am doing the right thing by showing my support of my fellow healthcare workers and making sure I am prepared. I have already sent in my paperwork to have my registration renewed so I am able to go back when needed. Right now, I’m just waiting for a return from AHPRA to allow me to be a registered provider again.

I think combatting COVID-19 is like fighting a war, and if we were ever going to go to war, I think about what I would do. I’d like to think I would go to help. In general, I honestly believe that anyone who is putting their hand up to help should be commended. That being said, all attempts at having up-to-date training in line with the evidence base is vitally important.

If you are confident in the area you are returning to work in, and have ensured to refresh your skills, this is a great exercise in keeping up to date with best practice.