Five brain injury professionals spanning dietetics, case management, physiotherapy and speech and language therapy share what they’ve learnt from to shift to virtual therapy.
At the start of the pandemic, many statutory rehab services were redeployed, and some independent therapy teams closed or therapists moved back into frontline work within the NHS and community.
A group of private therapists in the North West of England started keeping in touch on social media and in weekly group support sessions to share their fears and concerns, and identify the strengths that helped them survive in such challenging times.
They shared a desire to maintain a therapeutic relationship and meaningful rehab for their patients, all living with complex neurological conditions, while delivering remote therapy sessions online. This is what they – a dietitian, a speech and language therapist, two physiotherapists and a case manager with an occupational therapy background – learnt during that time.
Don’t Panic
As therapists and health care practitioners, our hands are often our primary tool; we use them to direct, feel, inform, instruct, measure. The inability to see our patients face to face took away these vital tools.
We knew we had to adopt a positive attitude of creativity, innovation, and practicality, and decided to continue as much as was practically possible, albeit remotely.
The pandemic thrust us into a new world where we soon learnt that we have a wide range of diverse skills beyond the use of our hands – as educators, problem-solvers, movement and task analysts, communication specialists and counsellors.
For some of us, the beginning of the COVID-19 pandemic saw a reduction in caseload by up to half, which affected morale as we tried to manage personal and professional stress and anxiety. For others, our case load dramatically increased as we maintained routine and aimed to prevent safety concerns around swallowing and malnutrition.
Working remotely by virtual platforms has required therapists to re-evaluate their roles and responsibilities and redesign pathways of rehab, all without a guidebook and almost overnight.
Sharing the challenges we were facing enabled us to embrace the new era of therapy provision, ensuring that a calm, professional and positive approach paved the way as we guided our teams and patients through what would become months of change.
Embrace core values
As we continued to meet regularly, we began to understand we were united by our shared views and values regarding duty of care, therapeutic relationship and safe and ethical practice.
Our common commitment was our duty of care to providing continued therapy input to our patients. We could develop novel approaches to practice quickly to reduce negative impacts on clients’ physical and mental wellbeing.
As independent health providers, we were able to rapidly try out new service delivery techniques and begin to rebuild a new virtual therapist identity to ensure ongoing rehab, delivered in a safe and realistic format.
One of the key factors enabling our speedy response was not being tied to a specific platform. Recognising the frustrations technologies can cause, however, administrative team members assisted families to ensure an effective technology connection to avoid this impacting on the therapeutic relationship.
The freedom of being at the helm of smaller, independent practices placed us in a position to respond quickly and invest time and resources into developing a new way of working, but this was not without financial risks. Our weekly group meetings helped identify the need for a supportive framework for professional staff to share and explore what we meant by ethical and safe practice.
Be innovative, creative and dynamic
Therapy is not a desk job, it’s active and engaged. Teams invested time working out the positioning of devices and how to use selfie sticks to ensure the optimum viewing angle.
We taught relatives and support workers techniques and assessment tools separately to the patient to ensure that they understood their responsibilities in the session. During physiotherapy, people reportedly became used to observing themselves on the video link, so they could see what the therapist meant when they were talking about making postural changes.
In dietetics, the continued use of eHealth communication apps maintained frequent dietetic communication, giving real-time feedback, accountability and encouraging confidence, control and mindful eating.
People working on developing their speech sounds or breath support had automatic feedback as they could see themselves on screen and could work to imitate lip patterns and breathing techniques as modelled by the speech and language therapist.
Our aim was to safely maintain and progress rehab goals while encouraging routine, structure and preventing development of new issues. Some have surpassed expectations and are continuing to make significant gains and progress. This in part is due to the adaptability that online delivery presents.
During a face to face session, we often have a fixed time period. However, through virtual sessions, we can be more adaptable to personal wants/needs, breaking sessions up into ‘bitesize’ chunks. This can assist people with limited attention or difficulty processing and is helpful in fatigue management.
Nevertheless, online therapy does not work for everyone, and many people and their families miss face to face input and support. Some people find multi-tasking prohibitive, some can find technology intimidating. Others find it difficult to follow the conversation, particularly where they are more dependent on non-verbal cues, or are challenged attentionally when people speak over each other.
We need to consider how we can embed online therapy in our routine practice; for who online therapy presents opportunity and for who it may create challenges.
Assessment of new clients was restricted. Many of our clients pose non-obvious difficulties. Assessing how a person interacts with their environment can be difficult, and it can be difficult to form that initial relationship which is key to good neurorehab.
Bridging a gap
During the pandemic, many people reached out to connect with us remotely. For others, the services they needed altered. We have seen an increase in dietetic referrals, perhaps due to reduced gym, and community healthcare provision.
The use of eHealth and virtual therapy has meant we were able to bridge the gap, ensuring minimal disruption to rehab through remote transfer of therapy skills, including educating and training other household members and support staff.
This training is a key part of our roles and online support, and voiceover Power Points and videos of ourselves disseminating information have been important. Attending a session virtually can empower both the person, the family, and their support teams. It can provide a positive forum to educate staff and monitor learning across the whole team.
Some support staff and families reported feeling more empowered during lockdown as they had clear connections between the therapy input and the person. We were able to bridge a gap for those who were able and willing to engage and found a new tool to add to our repertoire.
Forward-thinking and planning
As we move out of lockdown, our teams have reflected that remote therapy via video link is possible, but isn’t always preferable. The challenge will be to develop a hybrid system that puts the patient at the centre of their rehab.
Remote therapy via video link happened in a unique bubble and in response to a crisis and it is unclear at this stage how these external factors impacted on the success or otherwise of virtual rehab.
Used well, the barriers of geography and travel could enable specialist therapists to support local therapists to provide effective rehab for those with complex conditions. There is also more opportunity for therapists to benefit from ease of access to international perspectives and training resources that are rapidly developing online.
As we are returning to increasing direct engagement, we are facing the new challenge of working in and communicating in PPE, which introduces challenges in establishing and sustaining a therapeutic relationship.
Embracing change
This period has been challenges for therapists. However, we have learnt together, along with the people we support and their families, and want to make sure these learnings aren’t lost.
Virtual therapy spaces present an opportunity for us to provide services across longer distances and in diverse and flexible ways, that, for some, may enhance progress toward their goals. For the foreseeable future, while therapy services are resuming face to face intervention, there will likely be a continuation of some remote methods.
Physical distancing and personal protective equipment will likely present new learning for us, and requires ongoing reflexive practice as we continue to grapple with the shift from ‘hands on’ to ‘hands off’ service delivery.
We have seen that people are increasingly deteriorating; both physically and mentally, and the novelty of remote therapy becomes less effective as it becomes increasingly obvious that we are hands-on for a reason. As humans we need the subtle combination of touch, communication, concern, community, movement and freedom to keep us well.
This article was collectively written by:
- Jackie Dean, case manager at n-able Services Ltd
- Ann Pimm, physiotherapist at Summerseat Physiotherapy
- Hayley Power, speech and language therapist at A.T Therapy
- Sian Riley, dietitian at Red Pepper Nutrition
- Susan Pattison, physiotherapist at SP Therapy Services
