Remote physical therapy during COVID-19 pandemic: guidelines in the Brazilian context

Introduction: On March 11, 2020, Covid-19 was characterized by the World Health Organization as a pandemic. In this context, different health professional councils have adopted initiatives to use communication technologies to provide services at a distance. Specifically, for physiotherapy, the Federal Council of Physiotherapy and Occupational Therapy (COFFITO) made possible the modalities of teleconsultation, teleconsulting, and telemonitoring. Objective: This study aimed to develop guidelines for physiotherapists who provide teleservices, which will help ensure the safety and quality of their professional practice during the COVID-19 pandemic. Methods: An integrative literature review was conducted through PubMed (National Library of Medicine), Cochrane Library, Higher Education Personnel Improvement Coordination Portal - CAPES, Virtual Health Library, Google Scholar, and personal experience within the team to develop guidelines for remote physical therapy during the COVID-19 pandemic. Results: Initially, 3,298 articles were selected from all cited search bases, scaled to 2,031 after exclusion due to repetition, 78 were in compliance with the proposed study, 73 of which were excluded for not answering the guiding question; therefore, 5 articles were accepted for the final analysis and used for the elaboration of the guidelines. Conclusion: The results provide an overview of the literature and guidelines for physiotherapists to implement physiotherapy teleconsultation, as well as some of the challenges that need to be considered.


Introduction
The coronavirus disease 2019 pandemic  was recognized by the World Health Organization (WHO) on March 11, 2020. 1 Since then, COVID-19 has been changing the way we live and interact, including in health. 2 Owing to the lack of specific preventive or therapeutic measures for COVID-19, the WHO recommended that governments adopt interventions that include individual measures (washing hands, use of masks, and social distancing), environmental measures (routine cleaning of environments and surfaces), and community restrictions (restriction or prohibition on the operation of schools and universities, places of community living, public transport, and other spaces where people may agglomerate). 1,[3][4][5][6] In this context, particularly in the case of social distancing, it is necessary to rethink an effective and efficient way of life, which means making quick decisions based on the best available evidence. During this rapidly changing situation, the field of physiotherapy needs to develop strategies and alternatives for physicians to monitor patients during the pandemic caused by the SARS-CoV-2 virus. [7][8][9] Different class councils of healthcare professional categories have already adopted initiatives for the use of Although still controversial, 11 there is evidence that the use of telemarketing can bring benefits, such as a reduction in travel costs for patients and health professionals, as well as improvements in the quality of care, by expediting access to health professionals. [12][13][14][15][16] The science and practice of physical therapy have grown rapidly in recent years and there has never been a better time than now to provide a quick solution, with adequate, accessible, patient-friendly, and innovative technolog. 17,18 The available technology provides physical therapists new ways of delivering efficacious treatments and ensuring continuity of care for patients as well as business continuity for professionals during this period. 15,18,19 However, questions still arise as to whether the reasons for the aversion to using telemarketing in the past are no longer valid today; or if the grounds are temporarily invalid, during the pandemic period, but will return when this critical period passes; or whether we can learn from previous concerns and current usage

Results
Initially, 3298 articles were chosen; of these, 1267 were excluded because they were duplicates in the databases. Thus, 2031 articles were selected for reading the title and abstract, resulting in a sample of 78 articles for reading the full text. Of these, 73 were excluded because they did not answer the guiding question, which resulted in 5 articles being chosen to prepare the proposa. 20-24 The titles, study types, and conclusions of the five articles are presented in Table 1.

Editorial
There is a need to develop specific guidance on the many issues surrounding the practice of telecare in physical therapy.
Musculoskeletal physical therapy during the COVID19 pandemic: is telerehabilitation the answer? 21 Point of view Physiotherapy telecare shows promise as a timely model of care to be adopted alternatively or in combination with the usual care for patients during the COVID-19 pandemic.
"Physio anywhere": digitally-enhanced outpatient care as a legacy of coronavirus 2020 22

Editorial
Telecare practices can be appropriate, well-received, and efficient in providing physical therapy care.
COVID-19 and the advancement of digital physical therapist practice and telehealth 23

Point of view
The guiding principles need a strong therapist-patient relationship, valid and reliable evidence, and research to show whether remote care has greater benefits than potential risks for physical therapist practice.

Telehealth for musculoskeletal physiotherapy 24
Review Telehealth should not be considered a temporary solution, but a sustainable alternative way in which patients can have safe access to healthcare. Table 2 -Factors to be considered for the decision to use telehealthcare and strategies to support safe practices

Clinics
The continuity of care and the best model of care for the patient.

Practice
Availability of appropriate technology and patient support. Ability to handle the tools and simultaneously manage the proposed technology.

Quality
The quality of technology at the remote site will play a significant role in the information obtained during the clinical consultation.
Familiarity with the area of clinical practice.

Security
The service can be provided securely in accordance with the General Data Protection Law (LGPD -Law 13,709/18). Ability to support the patient to use technology and solve problems with any difficulties encountered.

Ambient
A quiet place that is fit for purpose, where the increased noise associated with care will not be heard by others or disturb others. Simple decor that won't distract from on-screen images.  Is remote intervention appropriate for this patient?
Do I have the training and skills necessary to perform remote physical therapy services to my patients?
Am I able to provide remote physical therapy care using scientific evidence?
Does the patient have the necessary technology for this type of intervention?
Does the patient need technical or home support to facilitate remote physical therapy service?
What is the overall objective for the remote assessment/intervention? Education? Assess ment? Treatment Which electronic platform will allow me to offer the same quality as a face-to-face approach?
Does the patient context provide a safe, secure and confidential environment?
Am I following all t he regulations of the councils and committees that regulates the remote physical therapy intervention?
Is my environment suitable for this intervention model (high-speed internet, confidential configuration, consent and platform compliant with legal requirements, etc.)? Table 3 -Criteria for conduct and protection of the physical therapist and the patient in telehealthcare

Clinics
The nature of the patient's health condition.

Practice
Difficulty accessing the internet. Technology issues: past experiences and your confidence in using communication systems, as well as reading ability. Access to support to configure the devices and applications used and for solving technical problems. Your socioeconomic status, age, and digital literacy.

Quality
Confidence that physical therapy, through a videoconference, is at least as good as face-to-face. Perception that physical therapy should include manual or "touch" therapies. Your views on health, self-care, and addiction.

Security
Security of using technology to access care. Ability to support the patient to use technology and solve problems with any difficulties encountered. The telecare service is private. The technology and platforms that are secure, with end-to-end encryption, must be chosen.

Recording
Declare that the session will not be recorded without the explicit and informed consent of the patient or guardian.

Exams
Declare that any photograph of a complementary exam report or imaging exam that is shared will be attached to the patient's physical or electronic record, and its use outside this purpose will only happen with the explicit and informed consent of the patient or guardian.

Charging
The charging modalities for the costs of telecare assistance must be transparent and agreed upon.

Security technology
The telecare therapy is private.

Factors Description
Care given Both patients and the physical therapist must ensure that their location is private and free from harm. Communication technologies, computer-based or cellular, must be charged, working and free of viruses, trojans, and malware. Cell phone numbers must be available, and phones turned on so that communication is available in the event of a technical failure or delay. The patient's address for consultation must be known so that some assistance can be sent for any undesirable event; for example, an ambulance can be called in an emergency.

Emergency
Guide the family member or companion to activate the SAMU emergency service (192). Immediately call SAMU emergency service (192) to discuss the case with the regulation and shared decision of the most appropriate conduct, if it is not possible to turn to the family member or companion during the service. Contact a close family member and guide them to the place where the patient is.

Ending the session
A summary of what happened. A summary of the next treatment steps and the treatment plan with the patient. Preparation of complementary material for remote monitoring by the physical therapist. Planning of the next telecare service and scheduling. Request any feedback from the patient about the session. Write the record of care in the patient's medical record, including the results achieved and the evolution. Record any technical events that disrupted service.

Feedback from patients
Were you able to see and hear the physical therapist clearly during the consultation? Was there a connection drop, video, or sound failure? Did you receive the care and information requested? Would you like to have another telecare service using the same technologies in the future? If not, what can be done to improve the service?
In addition to confirming that the parties are satisfied to proceed with all the criteria that have been presented, it will be important, as with face-to-face consultations at the clinic, to confirm that all parties are aware that the service meets the criteria of conduct and protection of the physical therapist and patient (Table 3). 23 Physiotherapists (and their workplaces) must put a number of simple safeguards in place to ensure that faceto-face sessions are safe and effective. The identification of risks and hazards ( In health care, trust is important for both intrinsic and instrumental reasons. The patient needs to be confident that the physical therapist has adhered to the same strict data security and privacy protocols they follow in nondigital practice when collecting, storing and sharing their data. 35 In addition, the physical therapist must continue to adhere to ethical principles to do no harm, act justly, and use health resources wisely. In order to fulfill these obligations, they must consider ways to ensure equity in the digital environment. 10,36 Physiotherapists and the organizations they work for must maintain their focus on ensuring the safety of patients and their close caregivers by providing highquality care. It is necessary to consider the specific risks that accompany the use of digital technologies, as data security and privacy standards are crucial ( Table 2). In this sense, when adhering to the ethical principle of doing no harm, professionals need to consider a valid and reliable assessment. 28 An important option is the use of questionnaires on functional performance and physical capacity. In these validated questionnaires, the patient will be able to respond objectively to qualitative questions that, at the end of the evaluation, will be converted into quantitative data that can be used as a reference for the evolution of treatment. 30 Thus, it is important for physical therapists to consider their ability to use technology as a support for assessment activities. 19 When deciding whether or not to use video consultations, physical therapists need to consider the likelihood of an adverse event or worsening of their patient's functional condition. 27 As with face-toface care at the clinic, this involves preparatory actions such as creating contingency plans for any event. 37 It is important to consider, for example, whether the patient will be able to safely perform all necessary activities during the consultation. Before consultation, it is important to consider how these risks can be mitigated.
For example, risks of falls can be mitigated by ensuring that a family member or caregiver is physically present and properly positioned during the therapy session, 37 and it is necessary to educate them about this possibility so that they participate in the process of accompaniment in a conscious way. The first point to highlight regarding patient data security is the protection of the triad of confidentiality, integrity, and availability. These three fundamentals gained even greater consideration with the General Data Protection Law (LGPD -Law 13,709/18), which came into force in August 2020. 39 Misuse is considered to be the unauthorized sharing of personal information, the sale of user data (a common practice today among marketing companies), and the carelessness in collecting, storing, using, or disposing of this sensitive personal data.
Therefore, for physical therapists, the exchange of patient information between professionals and clinics or hospitals, or between telecare services and clinics cannot occur without written authorization from the patient. In addition, it is important to use advanced intelligence services that offer systems secure against the actions of hackers, as the leakage of information due to system fragility will also be penalized. 39 According to the LGPD, data processing includes any operation carried out with personal data such as collection, production, reception, classification,

Conclusion
Physiotherapists have had to quickly adjust the way patients access care during the COVID-19 pandemic, which has led to the widespread adoption of telecare.
The results provide an overview of the literature and guidelines for physical therapists to implement physical therapy telecare, as well as some of the broader challenges that need to be considered. Thus, as services evolve, additional research should be undertaken to explore the costs and benefits of face-to-face physical therapy in different settings, as well as difficulties and facilitators.