Learning fromCOVID-19 to improve access to physiotherapy

Funding for telehealth should continue post-COVID-19 and should include provision for tele-physiotherapy. There are several instances where tele-physiotherapy may be an appropriate form of primary care, including the early management of acute pain, which may otherwise become chronic. By extending the availability of tele-physiotherapy beyond 30 September 2020, we can improve the health of the population generally and, in particular, better serve remote or otherwise isolated people. Additional keywords: primary health care, rural health. Received 15 June 2020, accepted 7 July 2020, published online 16 July 2020 The COVID-19 pandemic has brought with it many challenges, but importantly several opportunities to improve healthcare in Australia. In Australian Journal of Primary Health, Duckett (2020) recently outlined the benefits of some of the strategies implemented during COVID-19 for improving primary healthcare in Australia, advocating for their continuation postCOVID-19. Telehealth was one such strategy. Although tele-physiotherapy has been used in the tertiary healthcare sector previously, particularly in the public system, physiotherapists in primary care have recently also been able to utilise telehealth, under limited conditions, during the pandemic. In Australia, COVID-19 has led to the availability of fee-forservice tele-physiotherapy consultations, funded through thirdparty payers, including Medicare and some private health insurers (Australian Physiotherapy Association 2020a), with various restrictions for some payers. For instance, to be eligible for funding from private health insurance the patientmust: (1) be undertaking an existing course of treatment and have seen a physiotherapist over the past 6 months or have had telephysiotherapy recommended by a physician; (2) have a chronic musculoskeletal condition, or be having rehabilitation following orthopaedic surgery, treatment for cardiac or pulmonary conditions, or be undertaking pelvic floor muscle training; (3) have individual physiotherapy sessions; and (4) have a session that follows the Australian Physiotherapy Association guidelines (Australian Physiotherapy Association 2020b; Private Healthcare Australia 2020). Importantly, tele-physiotherapy funding only applies for sessions from 14 April to 30 September 2020 (Private Healthcare Australia 2020). We, like Duckett (2020), believe that the funding for telehealth should continue, and that it should include a provision for tele-physiotherapy. It may be argued that the provision of physiotherapy is not appropriate via telehealth due to its focus on hands-on assessment and interventions; however, contemporary physiotherapists also play an important role in education, reassurance and screening for health conditions (e.g. mental illness). Physiotherapists are trained in primary care provision, and are equipped to decide, with their patients, when tele-physiotherapy may be appropriate. In fact, telehealth is now included in some Australian entry-level physiotherapy programs. Therefore, patients would benefit further from an ongoing tele-physiotherapy service that was not limited to specific health conditions, and that could operate without a referral from a physician (who may not have seen the patient in person either). There are several instances where tele-physiotherapy may be appropriate, but would not match the current criteria as listed above. For example, physiotherapists have an important role in the early management of acute conditions, and in many cases can recommend interventions that can be successfully and safely performed via tele-physiotherapy: Take a patient who has just experienced a motor vehicle accident, and has been cleared by a paramedic but is still in significant pain with associated anxiety. The patient might not be able to access physiotherapy in a timely manner (e.g. because of living in a remote area, or being fearful of car travel following the accident). Often in initial physiotherapy sessions followingmotor vehicle accidents, physical assessment and hands-on treatment will be limited by the patient’s pain, and interventions will therefore instead focus on reassurance and education. Such sessions could be conducted as effectively via tele-physiotherapy as they are in face-to-face sessions. Importantly, the enhanced opportunities for early intervention in such situations may reduce the chances of acute CSIRO PUBLISHING Australian Journal of Primary Health, 2020, 26, 271–272 https://doi.org/10.1071/PY20141 Journal compilation La Trobe University 2020 Open Access CC BY www.publish.csiro.au/journals/py Letter to the Editor

The COVID-19 pandemic has brought with it many challenges, but importantly several opportunities to improve healthcare in Australia. In Australian Journal of Primary Health, Duckett (2020) recently outlined the benefits of some of the strategies implemented during COVID-19 for improving primary healthcare in Australia, advocating for their continuation post-COVID-19. Telehealth was one such strategy.
Although tele-physiotherapy has been used in the tertiary healthcare sector previously, particularly in the public system, physiotherapists in primary care have recently also been able to utilise telehealth, under limited conditions, during the pandemic. In Australia, COVID-19 has led to the availability of fee-forservice tele-physiotherapy consultations, funded through thirdparty payers, including Medicare and some private health insurers (Australian Physiotherapy Association 2020a), with various restrictions for some payers. For instance, to be eligible for funding from private health insurance the patient must: (1) be undertaking an existing course of treatment and have seen a physiotherapist over the past 6 months or have had telephysiotherapy recommended by a physician; (2) have a chronic musculoskeletal condition, or be having rehabilitation following orthopaedic surgery, treatment for cardiac or pulmonary conditions, or be undertaking pelvic floor muscle training; (3) have individual physiotherapy sessions; and (4) have a session that follows the Australian Physiotherapy Association guidelines (Australian Physiotherapy Association 2020b; Private Healthcare Australia 2020). Importantly, tele-physiotherapy funding only applies for sessions from 14 April to 30 September 2020 (Private Healthcare Australia 2020). We, like Duckett (2020), believe that the funding for telehealth should continue, and that it should include a provision for tele-physiotherapy.
It may be argued that the provision of physiotherapy is not appropriate via telehealth due to its focus on hands-on assessment and interventions; however, contemporary physiotherapists also play an important role in education, reassurance and screening for health conditions (e.g. mental illness). Physiotherapists are trained in primary care provision, and are equipped to decide, with their patients, when tele-physiotherapy may be appropriate. In fact, telehealth is now included in some Australian entry-level physiotherapy programs. Therefore, patients would benefit further from an ongoing tele-physiotherapy service that was not limited to specific health conditions, and that could operate without a referral from a physician (who may not have seen the patient in person either).
There are several instances where tele-physiotherapy may be appropriate, but would not match the current criteria as listed above. For example, physiotherapists have an important role in the early management of acute conditions, and in many cases can recommend interventions that can be successfully and safely performed via tele-physiotherapy: Take a patient who has just experienced a motor vehicle accident, and has been cleared by a paramedic but is still in significant pain with associated anxiety. The patient might not be able to access physiotherapy in a timely manner (e.g. because of living in a remote area, or being fearful of car travel following the accident). Often in initial physiotherapy sessions following motor vehicle accidents, physical assessment and hands-on treatment will be limited by the patient's pain, and interventions will therefore instead focus on reassurance and education. Such sessions could be conducted as effectively via tele-physiotherapy as they are in face-to-face sessions. Importantly, the enhanced opportunities for early intervention in such situations may reduce the chances of acute pain transitioning to chronic pain, thereby contributing to a reduction in the community disease burden of this latter very common and debilitating condition. Similarly, patients who have had an initial face-to-face consult with a physiotherapist, may benefit from follow-up sessions via tele-physiotherapy, where, for instance, their movements or exercises can be assessed, corrected or progressed. This approach may be particularly beneficial for patients living in rural and remote areas, also reducing geographical healthcare disparities.
The historical lack of acceptance of tele-physiotherapy has meant that research regarding its effective administration is limited compared with other health services. Such research is nevertheless on the increase. For example, a recent systematic review and meta-analysis of real-time tele-physiotherapy for patients with primary musculoskeletal conditions showing that tele-physiotherapy was superior to conventional physiotherapy in terms of function and disability, and comparable in effectiveness for pain outcomes (Cottrell et al. 2017). Developing the evidence base for the provision of tele-physiotherapy should be a priority to inform the optimisation of these important services. By extending the availability of tele-physiotherapy beyond 30 September 2020, and increasing flexibility and training in tele-physiotherapy, we can improve the health of the population generally and, in particular, better serve remote or otherwise isolated people.

Conflicts of interest
The authors declare no conflicts of interest.