This study aims to evaluate the relevance of telerehabilitation during the spread of the COVID-19 pandemic based on the prevalence of participation and activity International Classification of Functioning, Disability and Health (ICF) domains in a population with disabilities.
We perfomed an observational study of ICF files of people with disabilities pre- and post-three-months lockdown imposed by the government to stop the spread of the COVID-19 pandemic.
ICF qualifiers such as performing the daily routine (d230), using communication devices and techniques (d360) and doing housework (d640) showed a significant decrease of the disabilities (p < 0.05). Instead, a significant increase (p < 0.05) in disability was evident in relating with strangers (d730); informal social relationships (d750); acquiring, keeping and terminating a job (d845); complex economic transactions (d865); community life (d910); and recreation and leisure (d920).
Telerehabilitation should not be regarded as home-based rehabilitation delivered through technology. The results show how telerehabilitation should be a functional diagnostic tool and monitoring of patients’ rehabilitation needs.
Through a comprehensive classification scale of disability, it is possible to redefine the term telerehabilitation.
Marotta, N., Demeco, A., Moggio, L. and Ammendolia, A. (2021), "Why is telerehabilitation necessary? A pre-post COVID-19 comparative study of ICF activity and participation", Journal of Enabling Technologies, Vol. 15 No. 2, pp. 117-121. https://doi.org/10.1108/JET-11-2020-0047
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COVID-19 and its rapid spread and high morbidity have forced governments to impose the lockdown (Filetti, 2020), even those most powerful and economically strong (Atalan, 2020). People with disabilities because of COVID-19 express specific rehabilitation needs (Ceravolo et al., 2020). Governments have implemented combinations of “lockdown” strategies, including school and workplace closures, public event cancellations and restrictions on sporting activities, to protect high-risk individuals. But these operations could cause harm to physical health and psychological, social tensions and economic damage. Therefore, these policies can influence vulnerable populations, exacerbate preexisting inequalities but also generate new ones (Glover et al., 2020). Considering the high number of people affected by COVID-19 infection worldwide and the risk of new lockdowns, rehabilitation will be increasingly necessary for inpatient care (Demeco et al., 2020) but difficult to practice because of the restrictions imposed by law. Telerehabilitation can be an alternative rehabilitation approach that, using digital communication technology, allows both assessment and remote monitoring of patients during exercise efficiently and safely (Carda et al., 2020; Salawu et al., 2020). Telerehabilitation has proven to be a promising and useful model of care to be adopted as an alternative or in conjunction with face-to-face care for patients with disabilities during the COVID-19 pandemic (Turolla et al., 2020). The International Classification of Functioning, Disability and Health, more commonly known as ICF, is a domain classification that describes changes in body function and structure, so what a person with a health condition can do in a standard setting and what it does in their usual environment. These domains consist of a bodily, individual and social perspective through two lists: a list of body functions and structure and a list of activity and participation domains (World Health Organization, 2002). The ICF framework includes outcome measures that capture all components for a better understanding of the impact on people and the planning of interventions to maximize functional return (Patel et al., 2020). An adequate functional profile helps to identify a rehabilitation tailored to the patient (Marotta et al., 2020). This study aims to evaluate the relevance of telerehabilitation during the lockdown imposed by the government to stop the spread of the COVID-19 pandemic based on the prevalence of ICF domains in the activity and participation section in a population with disabilities, to understand whether this new therapeutic approach can be beneficial to patients and the health-care system.
The sample included all patients participating in our group multi-professional outpatient rehabilitation project for people with disabilities. We obtained permission to begin data analysis by submitting a study protocol to the local ethics committee, and we achieved approval before the start of the study. The inclusion criteria were as follows:
aged between 18 and 62 (inclusive) years; and
a confirmed diagnosis of multiple sclerosis, Parkinson’s disease and stroke.
The exclusion criterion was a functional independence measure (FIM) score of less than 40 (maximum assistance) or greater than 110 (independent). The FIM (Kwon et al., 2004) consists of 18 items: 13 sub-score motor and sub-score cognitive function. Each sub-score ranges from 1 to 7 (1 = complete assistance to perform basic activity day living (ADL), 7 = complete independence in performing basic ADL).
A total of 54 patients were enrolled in the analysis (y = 45.3 ± 15; FIM = 79.2 ± 10): 21 with multiple sclerosis (MS) (y = 36.8 ± 12; FIM = 85.9 ± 8), 16 with Parkinson’s disease (PD) (y = 55.4 ± 7; FIM = 74.9 ± 9) and 17 with stroke (y = 44.3 ± 14; FIM = 80.3 ± 8).
International Classification of Functioning, Disability and Health
The patients’ ICF files were analyzed by evaluating part 2: activity limitations and participation restriction. Activity limitations are difficulties an individual may encounter in carrying out activities, whereas participation limits are problems an individual may have in engaging in life situations. The Performance qualifier indicates the extent of Participation restriction by describing the actual performance of a task or action in its current environment. Conversely, the Capacity qualifier indicates the extent of Activity limitation by describing the person’s ability to perform a task or action. The Capacity qualifier focuses on difficulties because of extrinsic or intrinsic characteristics of the person. To assess the impact of COVID-19 blockade on patients’ Activity and Participation performance qualifier, a pre-/post-approach based on an ICF framework registry was used. The outcome ranged from 0 (no limitation) to 4 (total limitation), resulting from a problem present more than 95% of the time and intensity, altering daily life in the past 30 days. Perceived concerns in ICF Activity and Participation were assessed (Khan and Pallant, 2007; Karhula et al., 2013): d2 General tasks and demands; d3 Communication; d6 Domestic life; d7 Interpersonal interaction; d8 Major life areas; and d9 Community, social and civic life.
The Italian Government imposed a strict lockdown between March 8 and May 3, 2020, during which public health authorities advised people to restrict access to hospitals and emergency rooms (ERs). All this blocking period was considered at the index event (T0 – March 8, 2020) and compared with the ICF file in the revaluations following the block (T1 – May 3, 2020). We analyzed data using SPSS version 16 (SPSS Inc; Chicago, IL). Paired t-tests were used for comparison of mean values of the pre- and post-lockdown. The significance level was set at p < 0.05.
Figure 1 presents the limitations in the pre- and post-lockdown domains of patient Activity and Participation using a four-point hot–cold graph. Qualifiers such as: performing the daily routine (d230), using communication devices and techniques (d360) and doing housework (d640) showed a significant decrease of the limitations (p < 0.05). Instead, a significant increase (p < 0.05) in disability was evident in relating with strangers (d730), informal social relationships (d750), acquiring, keeping and terminating a job (d845), complex economic transactions (d865), community life (d910) and recreation and leisure (d920).
This study through the analysis of ICF records of patients with disabilities aims to evaluate the relevance of telerehabilitation. The results showed two different trends in the ICF section on Activity limitation and Participation in people with disabilities. The pre-block limitations decreased for household tasks and activities, whereas they increased in participatory and community life after the end of the block. Pandemic appears to cause psychological trauma, but most caregivers have grown up psychologically under pressure (Sun et al., 2020). It is known that after physiotherapy, performance qualifiers greatly improve in movements and self-care in the home, so the rehabilitation service helps to improve the activity and participation of people with home disabilities, less than the function and structure of ICF (Park et al., 2012; Randström et al., 2012). Considering that during the period of lockdown it is not possible to activate the home rehabilitation service, can telerehabilitation be considered as a valid alternative? Over the years, comprehensive guidelines for telerehabilitation have been defined, and various softwares have been developed that allow remote connection with the bedridden patient at home with chronic respiratory (Jácome et al., 2020), cardiac (Scherrenberg et al., 2020) and musculoskeletal diseases (Turolla et al., 2020). The generic use of the term telerehabilitation is confusing because it defines diversified approaches delivered through technology (Appleby et al., 2019). So far in the literature, there is no consensus on the use of conventional tools for telerehabilitation, such as cell phones and Skype, as well as on the intensity, duration and frequency of sessions, or the degree or value of the physiotherapist’s supervision (Appleby et al., 2019). However, telerehabilitation does not aim to treat patients through remote consultation, replacing rehabilitation clinics. But, where it is necessary to interrupt the outpatient and home rehabilitation service, it may be useful to reduce hospitalization rates, provide specific immediate home rehabilitation services, guaranteeing continuous monitoring of patients and improving not only the state of health but above all the quality of life (Turolla et al., 2020). Once again, the ICF focuses on the relevance of telerehabilitation not only on cure but on overall patient care.
In conclusion, we suggest that telerehabilitation was important for people with disabilities during the COVID-19 pandemic and may also be so in the future for similar situations. Physical therapy is essential for patients with severe disabilities, and given the results, we believe that telerehabilitation should not only allow the physiotherapist to enter the patient’s home but, on the contrary, allow the individual to get out of lockdown.
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About the authors
Nicola Marotta is based at Universita degli Studi Magna Graecia di Catanzaro, Catanzaro, Italy.
Andrea Demeco is based at Universita degli Studi Magna Graecia di Catanzaro, Catanzaro, Italy.
Lucrezia Moggio is based at Universita degli Studi Magna Graecia di Catanzaro, Catanzaro, Italy.
Antonio Ammendolia is based at Universita degli Studi Magna Graecia di Catanzaro, Catanzaro, Italy.