Remote Physio: What’s working?

As health services across the UK attempt to tackle the latest wave of Covid-19, services are once again having to adapt and flex to ensure that patients can still be seen – even if not actually in person. For many physiotherapists, this will again mean an increased focus on using technology to deliver a range of interventions to bring services to those who need them.

But what works – and what doesn’t? What are the positives, and what are the barriers? What will be the lessons for the future?

In June of last year, the CSP commissioned researchers at the University of Manchester to undertake an evaluation of remote physiotherapy consultations during the pandemic, aiming to gain an increased understanding of the delivery of remote physiotherapy. The project is in several parts, including an online survey of 1,600 service leads working across all settings in the UK (early results from this last year were shared in the December issue of Frontline) and a rapid review of studies into remote delivery of physiotherapy. The next stages will involve development of in-depth case studies to understand how remote physiotherapy has been and is being delivered, and what is successful, and workshops that will aim to ‘sense check’ the findings. At the end of the study – scoping review, survey, case studies, workshops - the team will make recommendations.

Bridging an evidence gap

The rapid review of studies – essentially a review of the literature in the field – confirms that there is a real evidence gap in this area, says Fran Hallam, research into practice adviser with the CSP. She hopes that the CSP-commissioned research will begin to rectify that. ‘The literature review found limited evidence of remote physiotherapy in the UK, or looking at real-world implementation in practice,’ she says. ‘For me, this highlights the importance of the next stages of the project, because the case studies and workshops will allow in-depth exploration of services’ experiences of delivering physiotherapy remotely in real-life practice conditions and in different contexts, for example for a range of settings and patients.

‘Capturing the experiences and learning of physiotherapy services throughout the pandemic will help build recommendations to inform planning of services in the future.’

Helen Hawley-Hague, a National Institute of Health Research (NIHR) research fellow in the School of Health Sciences at the University of Manchester, and a member of the CSP’s Digital and Informatics Physiotherapy Group, is leading the research.

Whittling down the studies to be included was a big task, she says, because of the strict inclusion criteria – the focus on the papers had to be physiotherapy, and had to involve physiotherapists, and it also had to be on remote delivery. For example, several studies on initiatives using virtual reality technologies had to be excluded because they were not done remotely.

‘We identified 2,727 papers through the initial search through three databases, 536 papers were selected for further investigation with a final 36 included in the review,’ she says. ‘Of the studies included, only two were based in the UK, with six in Australia, five in the US, three in Canada, one in Singapore, one in Israel, and the remaining studies were in the rest of Europe.

The areas with the most evidence were stroke rehabilitation, neurological conditions, cardiac rehabilitation, COPD, orthopaedics and MSK.

‘It’s an ever-changing field, so we only looked at literature in the last five years,’ explains Dr Hawley-Hague.

‘Also, we know there are lots of papers out there on studies involving multi-disciplinary teams which are relevant to physiotherapy, but we focused directly on physiotherapy .’

The final studies (a mix of systematic reviews, randomised controlled trials, cohort studies and qualitative work) reveal a picture that was very similar to the survey: they show that remote services had similar positives and negatives to those reported. 

Positives and negatives

On the plus side, the studies overall indicated that remote delivery can improve adherence as it enables patients to carry out their therapy in their own homes more easily, and many people find it fun and motivating. Also it can improve access to services and therefore reach, as patients don’t need to travel to the clinic or the physio department for treatment. Barriers included infrastructure and technical issues; some groups of patients found it harder to use and lacked confidence in the technology.

‘In MSK, there’s some evidence around cost benefit, but it’s not massive,’ Hawley-Hague says. ‘However the evidence certainly suggests that remote delivery is no more expensive nor less effective than usual face-to-face care for many populations. The barriers around infrastructure and management support include things like connectivity, and quite a few studies had technical issues. It’s very similar to the qualitative evidence we got from the survey – that is, remote delivery can make it easier in terms of reach for people to access services, but it can also be a barrier. These are issues across the board – you’re not particularly finding it in one population, it can be across all the populations.’

One of the issues about extrapolating from the literature is that often the intervention was delivered by research therapists rather than those who would be doing it in ‘real life’. ‘Very few are delivered by clinical teams as part of usual care and alongside all other aspects of service delivery, and this is important. It might be delivered by a physiotherapist, but when it’s delivered by a physiotherapist employed to do it as part of a clinical trial, it’s very different to clinical teams doing it as part of standard practice, which is what happened during Covid-19. So a lot of the evidence from the studies isn’t evidence from the real world – it’s not the same as being out in the field.’

It is, however, reassuring that the evidence from the survey is similar to that from the scoping study, she adds.

‘I think it’s all part of the picture that we’re building here. One of the things that we’re finding is that there’s a gap [in the evidence]. I knew that from when we first started looking at it. We know there will be further papers coming out and the ones over the next six months will tell us more about what’s happening now.’

Hawley-Hague and her team are looking forward to working on the case studies which, building on the qualitative evidence from the survey, will reveal more information about remote physiotherapy in the real world. ‘It’s about looking at what works, what doesn’t work, can we gather people’s top tips about what you would want to do in different situations? Who could it potentially work for? Who is it really difficult for, and where are the barriers? How do we, say, influence government to improve connectivity and invest in infrastructure – if the staff haven’t got the equipment, they have no way to deliver the intervention. We’ve been thinking about the patient all the time and that’s what came out really strongly in the survey – how can we make things better for them?’

National evaluation of remote physiotherapy services: the background