Why Physiotherapy?

Musculoskeletal conditions and injuries are the leading contributor to disability worldwide, with low back pain being the single leading cause of disability globally.

They are not just conditions of older age; they are prevalent across the life-course (9). Estimates of prevalence vary but global data suggests between 20–33% of people live with a painful musculoskeletal condition (10) while a recent report suggests that one in two adult Americans live with a musculoskeletal condition – the same number as those with cardiovascular or chronic respiratory diseases combined (11).

The health and broader social costs of musculoskeletal conditions are significant:

  • They are commonly linked with depression and increase the risk of developing other chronic health conditions (9).

  • Musculoskeletal conditions account for the greatest proportion of lost productivity in the workplace (10).

Of the top 10 causes of disability in Canada (12):

  • 3 can often be successfully treated/cured with physiotherapy: low back pain (#1), other musculoskeletal (#6) and neck pain (#10)

  • 2 can be often improved with physiotherapy: headache disorders (#2 – depending on the cause of the headaches) and with rehabilitation from falls (#9).

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Physiotherapy is evidence-based care that can help without causing harm.

  • Reduce symptoms like pain while improving function enabling patients to return to work and activities they enjoy, while

    • Avoiding unnecessary diagnostic testing (e.g., imaging), specialist referrals, procedures, etc. (13)

    • Avoiding cost and adverse effects of medications (13-14)

    • Avoiding surgery altogether (avoiding surgical risks & potential for adverse outcomes) or optimizing surgical outcomes

Physiotherapy remains crucial, especially during a global pandemic such as COVID-19 (15)

  • maintains health & activity while preventing the need to access urgent or emergency services in-hospital

  • help people return from the medical system to their homes, communities, families, and employment faster, thus reducing the societal and financial impacts of illness/injury

If physiotherapy is so great, why isn’t everyone doing it?!

Only 1 in 3 Canadians with a pain-related disability (35%) use physiotherapy, massage therapy or chiropractic treatments. (16)

Why?

Physiotherapy has an accessibility problem.

  • It is not funded by OHIP for most patients

  • Most physiotherapy is paid for by extended health benefits provided by employers, and many Canadians don’t have such benefits (17)

  • People don’t always know that physiotherapists are considered primary care practitioners, so a referral is not needed from a physician to access care (since 1994, per the Ontario Regulated Health Professions Act) (*some insurance providers still require a referral for coverage but many do not)

  • People may not know that physiotherapy is based on science & research evidence, and may not be aware of the benefits of an active vs. passive treatment approach (e.g., receiving a diagnosis, knowing why it has occurred, how to make it feel better now and how to prevent it in future vs. receiving passive treatment only, such as massage)

Why Virtual Physiotherapy?

Virtual health care has arrived, and patients want it to stay.

Even before the COVID-19 pandemic, Canadians were embracing virtual care:

  • A recent evaluation of 14 317 virtual primary care visits, the largest known study of its kind in Canada, showed that “the majority of patients (87%, n=1495/1716) indicated that virtual visits were similar quality as in-person visits, 12% indicated that it was better and 1% indicated that it was worse. In addition, 99% (n=1460/1474) indicated that they would use virtual visits again.” (18)

During the COVID-19 pandemic, there has been an accelerated use of virtual care in Canada: as of April 2020, 1 month after the pandemic began, routine non-COVID-19 health care visits reached 50% virtual (19).

Early in the COVID-19 pandemic in Canada, major insurance providers confirmed coverage for virtual care by physiotherapists (20).

According to a national poll by Abacus Data and the Canadian Medical Association (CMA) Canadians are “embracing virtual care options and would like to not only see them continued after the COVID-19 crisis subsides, but improved and expanded in the future.”

  • 91% satisfaction rate for patients seeing MD virtually — 17 points higher than in-person emergency room visits

  • 46% would prefer a virtual method as a first point of contact with their doctor in future (21)

Virtual physiotherapy is more accessible, especially as work moves online for many of us.

Working from home increased dramatically during COVID-19 pandemic, and is predicted to continue as a permanent solution with some large tech companies already offering extended work from home options (22-24)

  • Approximately 4.7 million Canadians who do not usually work from home did so during the week of March 22 to 28. (24)

  • When those who usually work from home are included, 4 in 10 workers (39.1% or 6.8 million) worked from home during the week of March 22. (24)

With virtual physiotherapy, cost of and time spent traveling to and from clinic is eliminated, the need for childcare is reduced, and the focus can shift to a more active vs. passive approach, which is likely more effective (see below).

Research supports effectiveness of virtual physiotherapy

Research demonstrates that Virtual Physio provides the same diagnostic accuracy and treatment outcomes as standard in-person care (1-4).

Four studies in post-surgical populations have shown virtual physiotherapy rehabilitative treatment to be non-inferior to traditional in-clinic rehab for patients post- total knee arthroplasty and subacromial decompression.  This new approach challenges the conventional position held by many clinicians that hands on treatment is always necessary (5-8).

For the Planet

Virtual care has been identified as a key component of an environmentally sustainable health system, as it reduces carbon emissions through:

  • Reduced travel (for patients, caregivers and staff)

  • Reduced physical infrastructure by reducing need to maintain existing or construct new health facilities (25)

Virtual care can improve access to preventative care and information, which reduces the need for health services overall (25). A 2014 study by Holmner et al on telerehabilitation showed it to be carbon cost-effective when traveling a distance of just 3.6 km or more for a 1-hour appointment (26).

Why CARYphysio?

CARYphysio is improving access to and utilization of evidence-based physiotherapy while also improving care and outcomes by focusing on an active approach to care which can help patients feel better faster, experience sustained benefits after their course of treatment ends, and play an active role in their care.

Here’s how it works

Anatomy of a Physio Appointment:

Comparing CARYphysio Virtual Care to Traditional In-Clinic Care

In-Clinic

CARYphysio Virtual

In-Clinic: Conduct an Assessment

(structured interview includes detailed description of chief concern in context of medical history + physical exam)

CARYphysio: Assessment is identical

  • more in-depth interview given no hands on

  • physical exam modified for videoconference – guide patient through range of motion, strength, & special tests*

In-Clinic: Communicate a Diagnosis

Physiotherapist diagnosis includes:

  • WHAT is happening (e.g., rotator cuff tendonitis)

  • WHY it is happening… (e.g., scapular dyskinesis)

  • …for this SPECIFIC patient (e.g., dysfunctional movement patterns with daily gardening)

CARYphysio: No difference

In-Clinic: Treatment

  • Manual therapy (joint mobilization & manipulation, dry needling, etc.)

  • Soft tissue release / dry needling

  • Activity modification

  • Exercise prescription

  • Ergonomic / Postural modifications

  • Motor pattern re-training

  • Assistive devices (e.g., taping, braces)

CARYphysio: No difference except:

  • Rather than performing hands on therapy, can teach patients to do it themselves:

    • Manual therapy >> patient self-joint mobilization

    • Soft tissue release >> patient self-massage

    • Assistive devices can be mailed to patient’s home & physiotherapist can instruct on proper use via videoconference

Patient self-care is potentially more effective because patients can do it on their own time, more frequently, for more relief.

(*Virtual physiotherapy potentially reduces subjective interpretation of hands on findings by physiotherapists using manual therapy testing in clinic which have been shown to have low intra- and inter-rater reliability (27) (28). Assessing and diagnosing MSK issues virtually has been shown to be just as valid and reliable as in person assessment in recent studies (1-4).)

Beyond the Appointment: Care Pathways Promote Patient Empowerment

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Patients receive:

  • Detailed Patient-Oriented Note including session summary, assessment, diagnosis, treatment plan

  • Personalized Exercises including instructions, videos

  • Follow-up emails to track progress

  • Option for phone calls & emails between sessions

Clinicians receive (with patient consent):

  • Detailed Clinician-Oriented Note

  • Option for videoconference consultation including patient

This increased communication is designed to build trust with patients allowing them to be active in their care and evaluate their care for themselves, increasing the likelihood of returning to evidence-informed provider like a physiotherapist in the future.

CARYphysio is an exciting new option to help patients with their neuromusculoskeletal symptoms because it is:

  • More accessible (virtually & through free physio program)

  • More aligned with what patients want (a more active role in their care, virtual care)

  • Potentially MORE effective because of focus on active vs. passive care >> potential to improve outcomes in fewer sessions

  • Another new and different referral option for clinicians + patients >> relief of patients’ neuromusculoskeletal symptoms, with the doctor as part of the team

References

  1. Richardson, B., Truter, P., & Russell, T. (2017). Physiotherapy assessment and diagnosis of knee via telerehabilitation. J Telemed Telecare, 23(1), 88-95.

  2. Lade, H., McKenzie, S., Steele, L., & Russell, T. (n.d.). Validity and reliability of the assessment and diagnosis of musculoskeletal elbow disorders using telerehabilitation. J Telemed Telecare, 18(7), 413-418.

  3. Russell, T., Blumke, R., Richardson, B., & Truter, P. (2010). Telerehabilitation mediated physiotherapy assessment of ankle disorders. Physiother Res Int, 15(3), 167-175.

  4. Mani, S., Sharma, S., & Singh, D. (2019). Concurrent validity and reliability of telerehabilitation-based physiotherapy assessment of cervical spine in adults with non-specific neck pain. J Telemed Telecare.

  5. Russell, T. G., Buttrum, P., Wootton, R., & Jull, G. A. (2011, Jan 19). Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am, 93(2), 113-20.

  6. Bettger, J. P., Green, C. L., Holmes, D. N., Chokshi, A., Mather, R. C., Hoch, B. T., . . . Peterson, E. D. (2020, Jan 15). Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial. J Bone Joint Surg Am, 102(2), 101-109.

  7. Pastora-Bernal, J. M., Martín-Valero, R., Barón-López, F., Moyano, N. G., & Estebanez-Pérez, M.-J. (2018, Jul). Telerehabilitation after arthroscopic subacromial decompression is effective and not inferior to standard practice: Preliminary results. J Telemed Telecare, 24(6), 428-433.

  8. Jiang, S., Xiang, J., Gao, X., Guo, K., & Liu, B. (2018, May). The comparison of telerehabilitation and face-to-face rehabilitation after total knee arthroplasty: A systematic review and meta-analysis. J Telemed Telecare, 24(4), 257-262.

  9. World Health Organization. (2019, Nov 26). Musculoskeletal conditions. Retrieved Jun 25, 2020, from https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions

  10. James, S., Abate, D., & Abate, K. e. (2018). 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. 392, 1789-858.

  11. Bone and Joint Initiative USA. (2016). The Impact of Musculoskeletal Disorders on Americans — Opportunities for Action. Retrieved Jun 25, 2020, from https://www.boneandjointburden.org/docs/BMUSExecutiveSummary2016.pdf

  12. Institute for Health Metrics and Evaluation (IHME). (2018). Canada profile. Retrieved Jun 25, 2020, from http://www.healthdata.org/canada

  13. Canadian Academy of Sport and Exercise Medicine. (2019, Jul). Sport and Exercise Medicine: Five Things Physicians and Patients Should Question. Retrieved Jul 30, 2020, from https://choosingwiselycanada.org/sport-exercise-medicine/

  14. Canadian Association of Physical Medicine and Rehabilitation. (2019, Jul). Physical Medicine and Rehabilitation: Six Things Physicians and Patients Should Question. Retrieved Jul 30, 2020, from https://choosingwiselycanada.org/physical-medicine-rehabilitation/

  15. Canadian Physiotherapy Association. (2020, Mar 17). CPA Update: Advocacy Statement - The Role of Physiotherapy in Keeping Canadians Safe During the COVID-19 Pandemic. Retrieved Jun 25, 2020, from https://physiotherapy.ca/cpa-update-advocacy-statement-role-physiotherapy-keeping-canadians-safe-during-covid-19-pandemic

  16. Canadian Survey on Disabilities, 2017. (2019, Dec 3). Canadians with a pain-related disability. Retrieved Jun 25, 2020, from https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2019078-eng.htm

  17. Hogg-Johnson, S., Cole, D., Lee, H., Beaton, D., Kennedy, C., & Subrata, P. (2011, Mar). Changes in Physiotherapy Utilization in One Workforce: Implications for Accessibility among Canadian Working-Age Adults. Healthcare Policy, 6(3), 93-108. Retrieved Jun 25, 2020, from https://www.longwoods.com/content/22180/healthcare-policy/changes-in-physiotherapy-utilization-in-one-workforce-implications-for-accessibility-among-canadian

  18. Stamenova, V., Agarwal, P., Kelley, L., Fuijoka, J., Nguyen, M., Phung, M., . . . Bhattacharyya, O. (2020, Jul 6). Uptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in Canada. BMJ Open, 10, e037064.

  19. Canada Health Infoway. (2020). Virtual Primary Care Analysis. How the Rise of Virtual Care is Contributing to Sustainable Health Care Webinar. Retrieved Jun 28, 2020, from https://www.infoway-inforoute.ca/en/what-we-do/news-events/webinars/3821-how-the-rise-of-virtual-care-is-contributing-to-sustainable-health-care

  20. Canadian Physiotherapy Association. (2020, Mar 24). Sun Life Announces Tele-Rehabilitation Coverage. Retrieved Jun 25, 2020, from https://physiotherapy.ca/sun-life-announces-tele-rehabilitation-coverage

  21. Canadian Medical Association. (2020, May). What Canadians Think About Virtual Health Care. Retrieved Jul 30, 2020, from https://www.cma.ca/sites/default/files/pdf/virtual-care/cma-virtual-care-public-poll-june-2020-e.pdf

  22. Sachedina, O., & Cousins, B. (2020, May 25). Will the COVID-19 pandemic lead to a permanent revolution in working from home? Retrieved Jun 25, 2020, from https://www.ctvnews.ca/business/will-the-covid-19-pandemic-lead-to-a-permanent-revolution-in-working-from-home-1.4954518

  23. McGuckin, A. (2020, May 7). Work-from-home ‘revolution’ possible as companies adapt to coronavirus measures, says HR expert. Retrieved Jun 25, 2020, from https://globalnews.ca/news/6911552/work-from-home-coronavirus-office-changes/

  24. Statistics Canada. (2020, Apr 17). Canadian Perspectives Survey Series 1: COVID-19 and working from home, 2020. Retrieved Jun 25, 2020, from https://www150.statcan.gc.ca/n1/daily-quotidien/200417/dq200417a-eng.htm

  25. University of Toronto's Centre for Sustainable Health Systems. (2020). The case for virtual care as a key component of environmentally sustainable health systems. How the Rise of Virtual Care is Contributing to Sustainable Health Care Webinar. Canada Health Infoway. Retrieved Jun 28, 2020, from https://www.infoway-inforoute.ca/en/what-we-do/news-events/webinars/3821-how-the-rise-of-virtual-care-is-contributing-to-sustainable-health-care

  26. Holmer, A., Ebi, K., Lazuardi, L., & Nilsson, M. (n.d.). Carbon Footprint of Telemedicine Solutions - Unexplored Opportunity for Reducing Carbon Emissions in the Health Sector. PLoS One, 9(9), e105040.

  27. van Trijffel, E., van de Pol, R. J., Oostendorp, R. A., & Lucas, C. (2010). Inter-rater reliability for measurement of passive physiological movements in lower extremity joints is generally low: a systematic review. Journal of Physiotherapy, 56(4), 223-235.

  28. Binkley, J., Stratford, P. W., & Gill, C. (1995, Sep 1). Interrater Reliability of Lumbar Accessory Motion Mobility Testing. Physical Therapy, 75(9), 786–792.

  29. Canadian Physiotherapy Association. (2020, Apr 7). Resource: Telehealth Partners’ Offers. Retrieved Jul 12, 2020, from https://physiotherapy.ca/tele-health-partners-offers

  30. College of Physiotherapists of Ontario. (n.d.). Virtual Practice - Expectations Regarding Tele-rehabilitation (Virtual Practice) Based on Existing College of Physiotherapists of Ontario Standards and Rules. Retrieved Jul 12, 2020, from https://www.collegept.org/registrants/virtual-practice-in-physiotherapy.