Could hands-off physio be the new normal?
Seeing the physio or sports doctor in the future could be completely different, thanks to coronavirus. And a lesser known area of physiotherapy is helping Covid-19 patients to breathe easy again.
Although it’s strictly hands-off, physiotherapy treatment has been in demand throughout lockdown.
Distinct groups of patients needing care have evolved in these unprecedented times. Like the home gym exerciser who rushed out and bought equipment before lockdown, and is doing a lot more activity than before, but now has an angry achilles.
Or the runner who’s had a sore knee for months, but had been flat-out at work and didn’t have time to do anything about it – until now.
Then there are those who’ve hurt themselves while stuck at home: the DIY injuries, or the over-enthusiastic dad who fell off the kids’ scooter.
Don’t forget the self-employed tradie who caught up on paperwork in Level 4, and has an aching back from working on the floor, the couch or the island bench.
And then there are those who’ve had Covid-19 and need rehabilitation for the fatigue and breathing problems that linger long after the virus. That treatment is delivered by a specialised group of cardio-respiratory physios.
During Levels 4 and 3, the majority of these painful complaints are being dealt with by physios and sports medicine physicians on-line. They’re seeing or talking to patients using technology to deliver consultations, rather than face-to-face.
And these medical practitioners believe this pandemic could change the way people receive treatment in the future.
When the medical community uses technology, they do so through a system called telehealth, which is governed by regulations and standards ensuring patient safety and confidentiality.
It's not new - they've been using telehealth to consult with patients since the early 2000s. But it’s taken on new momentum during the Covid-19 pandemic, in times of social distancing and lockdown.
Physiotherapy NZ president Liz Binns says telehealth is adding value to a health system which has access issues across New Zealand.
“It’s the best way right now for you to get in contact, get advice and be treated by a physio remotely. It can be through an internet video platform - that’s ideal - but if you haven’t got it, a phone call,” she says.
Most of New Zealand’s 5400 registered physiotherapists have been working during lockdown; some in hospitals, others from home – where they can.
“There are some very strong guidelines around the telehealth platform - you need to be in a private space for the safety and privacy of a patient,” Binns says.
Among those working in hospitals are cardio-respiratory physiotherapists, helping coronavirus patients recover from the after-effects of the illness.
Brigitte Eastwood, a physio at Tauranga Hospital and a member of Physiotherapy NZ’s cardio-respiratory special interest group, says fatigue and shortness of breath are proving to be “big issues” for those recuperating.
“Every Covid-19 patient is assessed and treated based on need, and they are all presenting differently. We are very mindful that people are going to need to rehab; we know post these kinds of conditions, fatigue and getting back to normal can take quite a while,” she says.
“People can deal with it in one of two ways: they can push through it, but it lasts much longer. Or they can be guided to pace themselves through it.”
Seriously unwell patients will have physio in ICU, and people with respiratory secretion problems (like moving phlegm, which is around 30 percent of patients, Eastwood says) will also be seen in hospital. But patients who’ve managed the illness at home may need physio treatment.
“You can actually do a lot over a telehealth session. While people often think physios are mostly hands-on, our skill set is actually in communication and education; talking people through things and our observation skills. And all of those can be used very well through telehealth,” says Eastwood.
“I do respiratory breathing sessions over telehealth, and I’m surprised at how much I can see of the patient – whether they’re using their chest or their stomach to breathe. That’s a big one post-Covid, the calm breathing pattern – trying to get your breathing back to a nice regular pattern, or it can be shallow for quite a while.”
Dr Mark Fulcher, a sports and exercise physician at Axis Sports Medicine in Auckland, says his practice is operating almost at “business as usual” - but it’s being delivered in a different way.
“We’re still seeing patients, doing diagnoses, and sending people off to scans - but almost all of that is through telehealth. We usually see people out of Auckland, so about five percent [of consultations] were through telehealth before.
“From a sports medicine doctor’s point of view, you can still be pretty effective. About 80 percent of patient diagnosis is through conversation, asking how you’re feeling, how things have changed over time.
“The biggest impact is on physios, because a lot of their treatment is hands-on. But I think the physiotherapy science is now around exercise prescription.”
Under Level 3, only an ‘urgent care’ patient can have face-to-face treatment from a physio. The Ministry of Health defines urgent care as a condition that is life or limb-threatening, where treatment is required to maintain the basic necessities of life, or treatment that can’t be delayed without risk of significant harm, or permanent or significant disability.
“If someone ruptures their achilles tendon, that’s a diagnosis you really can’t make over the phone,” Fulcher explains. “If you miss it, it will have a long-term impact on that person’s health. They may not be about to lose that limb, but it could have a significant and profound impact on their life.
“Another thing we’ve seen a bit of is people with sciatica, in severe leg pain. An injection can make a tangible difference to their lives.”
Fulcher has been to three Olympics as a New Zealand team doctor, and is now the medical director for New Zealand Football. Athletes in isolation have been doing Zoom sessions with trainers and physios to ensure they are on top of their fitness and health.
“Their problem lies ahead, with increased training loads when they finally go back to competition. Sports have to make sure there are sufficient lead-in times to competing again,” he says.
Fulcher believes this pandemic will influence the way New Zealanders are seen for injuries and illness from now on.
“In the last two weeks I’ve seen half a dozen patients from the Coromandel on video calls and they love it. Before I would have said ‘you have to come up to Auckland’, but I’ll never do that now,” he says.
“They might have to come in for the first consultation and a scan. But I can’t really see the point in making them drive across the city, then sit in the waiting room just to review an MRI scan. So that will be a tangible change.”
Liz Binns also hopes telehealth becomes “a normal mechanism in our healthcare”.
“On the West Coast, there would be handful of physiotherapists available. With telehealth, people who live there can immediately access physiotherapy help instead of driving for hours to see someone. It removes the access issue,” she says.
Throughout Levels 3 and 4, ACC are funding telehealth sessions as they would a face-to-face consultation.
Binns doesn’t know yet whether physios will be able to return to in-person meetings with patients at Level 2. But she encourages people in need of treatment to seek help now.
“If you put off being treated for something, it can get worse with time. The longer you wait, the more difficult it will be to treat.”
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