Presented at Reframing Physiotherapy Live Session in Partnership with Physitrack Indonesia 2022

1. Touching an impossible thing
in physiotherapy practice
Firmansyah Purwanto
Pain Specialist Physiotherapist

2. What have we learned from COVID-19?

3. Architecture – society
At its roots, architecture exists to create the physical environment in which people live,
but architecture is more than just the built environment, it's also a part of our culture. It
stands as a representation of how we see ourselves, as well as how we see the world.

4. History of physiotherapy practice

5. Two distinct philosophies of physiotherapy’s
approach to touch
1. Touch is a bio- physical phenomenon — strong focus on tissue anatomy,
physiology, pathology, kinesiology, and biomechanics
2. Touch is an entirely subjective phenomenon that can only be
understood by the person experiencing it
Nicholls, 2022.

6. Integrating telephysio into practice
● Initial consultation
● During the normal course of care
● Exercise progression
● Promoting wellness
● Cancelations to telephysio visit
● Full virtual care
Make it all about
the patient!

7. Integrating telephysio into practice
In the digital arena, attitude is
everything and having your
providers communicate to
their patients that this is new
for everyone and be humble
about this new delivery
method will help everyone be
more patient and accepting.
Make it all about
the patient!

8. ● MSK rehab - reduce pain & improve physical function (Low Back Pain, Hip & KneeOsteoarthritis ,
Post Total Arthroplasty)
● Neuro rehab – contribute to balance & physical activitylevel (multiple sclerosis)
● Cardiac rehab – reducing mortality by any cause and also seems to contribute to a better ability
to exercise and health-related quality of life
● Pulmonary rehab – reducing dyspnea in patients with COPD
● Cancer rehab – reducing overweight and obesity as well as improving the physical capacity and
quality of life

9. “The available evidence shows that telerehabilitation
could be comparable or better than the conventional
methods of rehabilitation”
Seron et al. Phys Ther J. 2021

10. The challenge of telephysio implementation
● Reliability of assessment during virtual
consultation? How confident are we?
● How do we treat person (in virtual)?
● Legal & ethical procedure?
● Beliefs about “physiotherapy”?

11. A careful history will lead to the diagnosis
80% of the time!
Hampton et al. Br Med J. 1975

12. Listen, listen and listen!

13. Alston et al. NAM Perspectives. 2012
What matters most?

14. Stratified telephysio in MSK physio practice
● Current history
● Past history
● Medications
● Social history
● Previous imaging
● Red flags
screening

15. Stratified telephysio in MSK physio practice
Screening for potential radiculopathy:
3 or more = potential radiculopathy (fast tracked to face-to-face care)

16. Stratified telephysio in MSK physio practice

17. Stratified telephysio in MSK physio practice
Treatment sub-group for patient at low risk of persistent pain:
Criteria: Keele STarT MSK score : 0 - 4 and no potential radiculopathy
Treatment Protocol:
● Advice on daily walking
● Advice on activity modification
● Teaching about self-pain management/self-coping strategies
● Education that their condition has a good prognosis

18. Stratified telephysio in MSK physio practice
Treatment sub-group for patient at medium risk of persistent pain:
Criteria: Keele STarT MSK score : 5 - 8 and no potential radiculopathy
Treatment Protocol:
● Advice on activity modification
● Advice on to take simple pain medication (non-oral preferable)
● Teaching about self-pain management/self-coping strategies
● App-based exercise program / exercise tutorial / booklet

19. Stratified telephysio in MSK physio practice
Treatment sub-group for patient at high risk of persistent pain:
Criteria: Keele STarT MSK score : 9 - 12 and no potential radiculopathy
Treatment Protocol:
● Advice on activity modification
● Advice on to take simple pain medication (non-oral preferable)
● Interventions to address psychological barriers to recovery –
supervised graded exercise & exposure
● Teaching about self-pain management/self-coping strategies
● App-based exercise program / exercise tutorial /booklet
● Refer to specialist or psychologist if necessary

20. Stratified telephysio in MSK physio practice
Treatment sub-group for patient at with potential radiculopathy
Treatment Protocol:
● In person physiotherapy appointment (face-to-face care) for
initial treatment
● Graded activity & exposure
● Exercise program
● Manual therapy if necessary
● Intervention to address psychological barriers to recovery
● Mixed or follow up for telephysio in the next session
● Refer to specialist or psychologist if necessary

21. The “ACES” principle of rehabilitation
Lewis et al, Physiotherapy 2021.

22. Rehabilitation
is about creating
a story where
THE PATIENT IS
THE HERO,
not the clinician!