Adapted Clinical Practice in Rehabilitation of Neuropathic Pain amidst the COVID19 pandemic: A paradigm shift

Joshua Samuel RAJKUMAR

MPT (Neuro), CSTP®

The novel corona virus outbreak was declared a pandemic and considered a public health emergency on January 30, 2020. COVID19 is an infectious disease caused by the coronavirus, SARS-CoV-2, which is a respiratory pathogen (Ghosh & Das, 2020; Cheng et al., 2007). The devastating effect was not only in the healthcare front, but also affected the economy due to the effect of lockdown that was used as an integral strategy to prevent the spread of the virus. Although we are still fighting through it at varying degrees in different parts of the world, the impact of COVID19 has affected many other healthcare clinical practices, notably the Rehabilitation domain. Rehabilitation domain that deals with acute and long term neurological or musculoskeletal conditions requires close proximity and regular manual contact with patients for assessment, intervention, support, etc. By the beginning of February 2020, different countries across the globe started enforcing lockdown of non-essential services. The strict lockdown rules and measures to maintain social distancing have made the rehabilitation service tasks difficult to perform as on one side there is a danger of the spread of COVID19 and on the other side a majority of the patients who require rehabilitation are fragile and at higher risk of acquiring the infections (Bobdey & Ray, 2020). Amidst this situation, certain groups of patients who are critical, availed rehabilitation services with adequate precautions carried out by the Rehabilitation professionals, ensuring the safety of the patients. This period was a tough one for all of us with respect to offering effective in-person rehabilitation services and thereby affecting our clinical practice to a greater extent (IMF World Economic Outlook, 2020). Gradually by the end of June 2020, many countries across the globe slowly relaxed the strict lockdown rules facilitating cautious movements and contacts among the public. This facilitated beginning the in-person rehabilitation services while at the same time maintaining the advised COVID19 safety protocols in the out-patient clinics. One of the common chronic pain conditions is Neuropathic pain, causing somatosensory abnormalities that affects an individual at varied levels ranging from physical to psychological, economical and social domains. Neuropathic pain needs long term regular rehabilitation follow-up to ensure the level of recovery and advice on the interventions accordingly. However, during the lockdown phase, many patients with chronic neuropathic pain weren’t able to avail the services and were also hesitant on in-person services with the risk due to physical contact.

Survey among CSTPs
A short 5-item survey was done among the Certified Somatosensory Therapists for pain - CSTPs in the month of August 2020 to understand the impact of COVID19 on their clinical practice, especially neuropathic pain. The survey’s outcome gave interesting outcomes from the respondents across different CSTPs located in Canada, Netherlands, Switzerland and India.

Did COVID19 affect clinical practice?
All of them responded that COVID19 affected their clinical practice. This can be attributed to the enforced lockdown rules and campaigns encouraging social distancing and isolation that might have made the out-patient departments and clinics to shutdown and patients hesitant to visit the clinic for pain related reasons.

Barriers or Challenges faced in the general clinical practice?
Majority of the respondents didn’t do in-person clinical practice during the lockdown phase which was the major barrier in providing an effective intervention. In general, the key barriers or challenges post lockdown for in-person rehabilitation were scheduling appointments as time is required for disinfection between patients.

Barriers or Challenges faced specific to Neuropathic pain?
Assessing patients with neuropathic pain online is challenging especially when the severity of pain is high. The manual somatosensory examination couldn’t be carried out online as it required a professional interference. Even if the desensitization self-treatments were possible, it was limited. Disinfecting the materials and tools used for assessment and treatment during the in-persons visits is also quite challenging.

Strategies adopted to overcome the challenges?
A lot of education and explanation by the therapists to the patients was required to ensure a good patient-therapist relationship for delivering the treatments and certain self-tests online. For very severe pain, pain patches and splints were recommended to give rest and aid in healing. Self touch with varying pressures was used to assess the allodynia in the online mode. Exercises were given during the live sessions and also watching the patients perform in the same manner. To take in patients without COVID19 symptoms, use of personal protective equipments and adequate disinfection of reusable assessment materials was carried to overcome the challenge of infection spread. Most of the materials used for desensitization are personalized and carried by the patients themselves thereby preventing cross-infections.

The survey also gave out a few key points that can help in our clinical practice, especially for neuropathic pain. During assessments, a plastic screen between the therapist and patient can be used to maintain the physical distance, through which the therapist can assess. This is crucial because with the mask on, it is quite difficult to observe the patient’s expressions while testing. With a plastic screen during the assessment, the patient can briefly take the mask off while maintaining the safety. Secondly, the online mode helps the therapists keep in touch with the patients and acts as a source of encouragement to providing the needy advice whenever required.

Paradigm shift towards Telerehabilitation
While the Rehabilitation clinics are gradually opening up and the patient flow has started, in many parts of the world clinical practice is still not the same as before. Adaptations and changes in regards of close proximity and manual contacts with the patients being limited, more professionals shift towards a hybrid mode practice consisting of both, in-person and online sessions. This process invariably helps not only in the safety aspects by reducing the risk due to physical contact, but also in offering a better follow-up of the patients and connect with them from distant locations, providing the best possible rehabilitation solutions.

Online rehabilitation is conventionally called Telerehabilitation it comes under the umbrella term Telemedicine. Several studies have reported positive effects of Telerehabilitation on chronic pain conditions like neuropathic pain. A Systematic review by Bender et al., 2011 and Macea et al., 2010 evaluating 17 and 11 Randomised Controlled Trials indicated that online or internet mode of Rehabilitation provides outcomes that are similar to clinic-based outcomes. The key reasons behind these positive effects can be attributed to the following (Bodenheimer et al., 2002; Amorim et al., 2016; Ritterband et al., 2009):
1. Enhance self management – especially crucial for a long-term chronic pain condition;
2. Perform at their own living environment – able to translate the gains in their setup;
3. Access to rehabilitation – ease to access, time saving and less of travel.

Future Directions
However, based on the survey as well as the published literature, there are gaps in the effective assessment and treatment of neuropathic pain, which are scarcely reported. A step forward in this direction would be to come up with an effective battery of assessment tests that can be administered by the patient themselves or by caregivers, to evaluate the presence of neuropathic pain and quantify it. This could come in handy not only during a situation like a pandemic but also in general clinical practice to be able to provide better accessibility to the patients and effective follow up treatment programs.

The COVID19 pandemic, even though it had an impact on the Rehabilitation professionals’ clinical practice, still paved a way for exploring alternate modes of practice incorporating certain adaptations in the assessment and treatment protocols. This has led to a definitive paradigm shift towards a patient-centered telerehabilitation model of clinical practice going forward that would be helpful for both the professionals and patients.

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