key: cord-030149-hkpjnqm9 authors: Fioratti, Iuri; Fernandes, Lívia G.; Reis, Felipe J.; Saragiotto, Bruno T. title: Strategies for a safe and assertive telerehabilitation practice date: 2020-08-07 journal: Braz J Phys Ther DOI: 10.1016/j.bjpt.2020.07.009 sha: doc_id: 30149 cord_uid: hkpjnqm9 nan During the coronavirus disease (COVID-19) pandemic, many countries issued an unprecedented array of temporary regulatory changes to provide more flexibility for the healthcare system. In Brazil, there was emergency regulations for the delivery of telemedicine 1 and telerehabilitation. 2 However, the accelerated regulations aiming for rapid introduction of remotely delivered interventions were accompanied by poor guidance for implementation and insufficient professional training. Despite strategies to overcome potential barriers involved in the implementation of telerehabilitation in Brazil published in a recent editorial in the Brazilian Journal of Physical Therapy, 3 hesitation among clinicians remains. Therefore, we have developed a series of practical recommendations that may guide physical therapists throughout the use of technology for the treatment of their patients (Table 1 ). The term telerehabilitation will be employed henceforth to refer to remotely-delivered interventions used by physical therapists. Examples will focus on musculoskeletal pain conditions, such as low back pain and osteoarthritis, but recommendations may apply to a wide range of settings and conditions within physical therapy. Evidence-based treatment refers to interventions that are supported by scientific evidence, in combination with clinicians' experience, and patients' preferences. 4 This represents the foundation of physical therapy interventions and all professionals in the field should be encouraged to based their practice on evidence, independently of mode of delivery. 5, 6 Best practice for chronic musculoskeletal pain includes provision of education/information about the patients' condition and management strategies and encouragement to pursue physical activity or exercises. 7 In addition to promoting these strategies based on the best available evidence, telerehabilitation initiatives are an opportunity to encourage self-management and experimental learning strategies. Individuals with musculoskeletal conditions place great importance on patient-centered interventions. 7 Telerehabilitation allows for tailored interventions to be delivered through a variety of synchronous/real-time (eg, videoconference) and asynchronous/store-forward (eg, digital images) means. 8, 9 To date, the literature provides evidence of good outcomes for a variety of musculoskeletal conditions when using either synchronous or asynchronous strategies, 10---12 but the combination of both approaches offers a more complete and personalized treatment experience. Clinicians may use the digital environment to support self-management strategies according to patients' preferences. 13 Individuals with chronic pain often report a feeling of anxiety and catastrophizing due to little knowledge about pain, especially during onset of symptoms, and telerehabilitation can focus on the provision of information with regards to pain, pain physiology, and activity pacing, for example 13. Patients can be frustrated or confused if the mode of telerehabilitation delivery does not match their digital health literacy levels 14 or expectations, 15 and also if there is an overload of information. 16, 17 Communicate effectively Non-optimal communication may result in a breakdown in patient/therapist relationship and weakened therapeutic alliance, which can potentially result in poor clinical outcomes. 18 Conversely, clear communication with patients often leads to better engagement during treatment. 7, 19 Previous studies showed barriers to development of therapeutic alliance related to lack of visual cues and misunderstanding, therefore requiring advanced communication skills from clinicians to ensure best telerehabilitation practice. 20, 21 Beyond the provision of consistent information, patients prefer information delivered through an understandable language, avoiding technical terminology. 19 Therapists must prevent patient' frustration or confusion with information Table 1 Clinical recommendations for the use of telerehabilitation. Evidence-based is the foundation • Share evidence-based information with your patient through diverse media, in an understandable language; • Encourage active participation in discussions of health-related topics • Support a non-judgmental environment that encourage expressing personal beliefs; • Use teaching-back strategies for motivating participation. Choose the best way of communicating • Choose simple words to avoid misunderstanding, avoid technical language or use of medical jargon; • Give simple commands to avoid information-overload; • Use specific body regions and spatial references to guide exercises or meditation (eg, align your spine imagining your head wants to reach the ceiling); • Video material and videoconferences are good ways of demonstrating exercises: you can perform them to mirror your patient. Listen to your patients' preferences • Look forward to understand: your patient' preferred means for receiving care (eg, telephone, videoconference, text-messaging) or suggest trying different modes to understand patient' preference; your patient' expectations and acceptability for telerehabilitation; your patient' needs in terms of information content and physical activity/exercise program. • Use shared experiences to build and strengthen therapeutic alliance. Tackle demotivation • Include weekly challenges; • Send reminders such as tailored pre-recorded messages; • Provide useful information/strategies that patients' can easily put in practice; • Align your rehabilitation program to balance necessary activities with the patients' preferred activities (eg, include functional activities that he/she shows interest in). • Understand your patients' reality: sociodemographic condition, previous experience with technology; • Assess your patients' health and digital health literacy levels; • Adapt your interventions to encompass the type of medias he/she has access to. overload by adopting simple terminology (eg, for guiding the execution of exercises) and choosing complementary materials that match patients' health literacy level. 22 Patient engagement is a major issue limiting growth of telerehabilitation, 14, 23 and it can be affected by lack of acceptance by the elderly population or poor interaction with digital sources of information. 11, 24 Engagement success leads to better treatment outcomes and it depends largely on patient motivation. 14,17 Feeling of impersonality due to lack of face-to-face contact with the health professional, the presence of technical problems during telerehabilitation sessions, and the inability of performing proposed activities might lead to patient demotivation and further disengagement. 23, 25, 26 Nevertheless, patients who perceive the need to improve their health identify telerehabilitation interventions as a source of motivation, especially in cases when they are able to see their own improvement. 15 Studies show several techniques and strategies that might help tackling patient's demotivation, such as the use of reminders, 15 weekly challenges, and periodic feedback. 26 Barriers to access telerehabilitation might include one or more of the following: a) lack of proper device (eg, computer or smartphone), b) lack of stable, good quality broadband internet, and/or c) low familiarity with technology. 15, 27 In Brazil, the percentage of households with computers or notebooks has been dropping over the past 10 years in both urban and rural areas, despite the advance in internet access. 28 This contradiction is explained by the increase use of 3 G and 4 G technology through smartphones, 28 often accompanied by limited or prepaid internet package, not compatible with download of videos or video conferences. In addition, low familiarity with technology might lead to difficulties of use 27 and a burden for the patient and the clinician. 15 Clinicians must be aware of patients' background (ie, sociodemographic information and previous experiences with technology) to best design a telerehabilitation intervention that supports patient participation and engagement. 17 The evidence on acceptability of remote delivery of interventions for a diverse range of medical conditions (eg, pain management, post-surgery, cardiac and pulmonary conditions) 12,29---31 indicate mostly positive findings, including a feeling of closeness despite the distance, 11 ongoing support from health professionals, 32 and continuous motivation for learning. 33 With the outbreak of COVID-19, telerehabilitation has become an important option for physical therapists to continue assisting those in need. Presenting clear and practical recommendations for telerehabilitation may empower clinicians to better use technology as an alternative mode of delivering physical therapy. The authors declare no conflicts of interest. Dispõe sobre o uso da telemedicina durante a crise causada pelo coronavírus (SARS-CoV-2) Conselho Federal de Fisioterapia e Terapia Ocupacional. RESOLUÇÃO N o 516 Teleconsulta, Telemonitoramento e Teleconsultoria Digital physical therapy in the COVID-19 pandemic Essential evidence based medicine What do physical therapists think about evidence-based practice? A systematic review Evidence in practice: a new series for clinicians What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review The taxonomy of telemedicine Definitions of terms in telehealth An E-Pain intervention to spread modern pain education in Brazil Patients' experiences of telerehabilitation at home after shoulder joint replacement Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: a randomized trial Patients' needs and requirements for eHealth pain management interventions: Qualitative study Patient acceptance of a telemedicine service for rehabilitation care: a focus group study Experiences of a web-based nursing intervention-interviews with women with chronic musculoskeletal pain Attitudes towards the use and acceptance of eHealth technologies: a case study of older adults living with chronic pain and implications for rural healthcare Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies Predictors of communication preferences in patients with chronic low back pain People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review Enhancing communication skills for telehealth: development and implementation of a Teach-Back intervention for a national maternal and child health helpline in Australia Telephone cognitive behavioural therapy to prevent the development of chronic widespread pain: a qualitative study of patient perspectives and treatment acceptability Self-management of chronic low back pain: An exploration of the impact of a patientcentered website Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services How, when and why people seek health information online: qualitative study in Hong Kong Feasibility of applied gaming during interdisciplinary rehabilitation for patients with complex chronic pain and fatigue complaints: a mixed-methods study Adherence to a web-based physical activity intervention for patients with knee and/or hip osteoarthritis: a mixed method study Van Gaal BGI. qLessons learned from patients with access to an online self-management enhancing program for RA patients: qualitative analysis of interviews alongside a randomized clinical trial ICT households -survey on the use of information and communication technologies in Brazilian households Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis The pain course: a randomised controlled trial comparing a remote-delivered chronic pain management program when provided in online and workbook formats How health literacy and patient activation play their own unique role in self-management of chronic obstructive pulmonary disease (COPD)? But it worked really well: a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis Patient participation in chronic pain management through social media: a clinical study Brazil b Centre for Pain, Health and Lifestyle, Brazil c Department of Physical Therapy