Abstract

The recovery of people affected by COVID-19 is a process that continues beyond the acute condition of infection by Sars-CoV-2. The impairment of several body systems can cause functional impacts and demand continuous physical therapy assistance both in outpatient care and in Primary Health Care (PHC). In this essay, we seek to discuss the challenges of organizing and offering Physical Therapy assistance in response to the COVID-19 pandemic in Brazil. The analysis was summarized in three dimensions: offering physical therapy assistance in PHC, outpatient care, via telehealth. It is concluded that functional rehabilitation depends on the PHC’s response capacity; there is a shortage of rehabilitation services that precedes the pandemic, and may not respond satisfactorily to the demands of the current epidemiological context; it is necessary to articulate the outpatient physiotherapy and PHC teams; although telehealth is a resource and an opportunity to increase the population’s access to functional rehabilitation, its use requires caution; the physiotherapist plays a crucial role in the entire COVID-19 care continuum.

Key words:
Physiotherapy; COVID-19; Primary health care; Rehabilitation; Telehealth

Introduction

COVID-19, a disease caused by Sars-Cov-2, is responsible for the biggest pandemic in the last 100 years. Worldwide, until mid-January 2022, data from the World Health Organization (WHO) present more than 308 million confirmed cases and more than 5.4 million deaths from COVID-19¹1 World Health Organization (WHO). WHO Coronavirus Disease (COVID-19) Dashboard. Geneva: WHO; 2020. [cited 2021 Ago 16]. Available from: https://covid19.who.int/. In the same period, Brazil was the third country in the world with the most cases and the second with the highest number of deaths confirmed by the new Coronavirus, with official statistics from the Ministry of Health indicating over 22 million cases and over 616 thousand deaths in the national territory²2 Brasil. Ministério da Saúde (MS). Painel de casos de doença pelo coronavírus 2019 (COVID-19) no Brasil pelo Ministério da Saúde. Brasília: MS; 2020. [acessado 2021 Ago 16]. Disponível em: https://covid.saude.gov.br/.

Although considered to have low lethality in the general population³3 Levin AT, Hanage WP, Owusu-Boaitey N, Cochran KB, Walsh SP, Meyerowitz-Katz G. Assessing the age specificity of infection fatality rates for COVID-19: systematic review, meta-analysis, and public policy implications. Eur J Epidemiol 2020; 35(12):1123-1138., the thousands of people recovered from the acute phase of infection by Sars-CoV-2 may present impairment in several body systems, such as the respiratory, neurological and musculoskeletal. In this scenario, the functional impacts resulting from clinical manifestations secondary to SARS-CoV-2 infection are multiple, and do not end with hospital discharge or resolution of the infectious condition⁴4 Stam HJ, Stucki G, Bickenbach J. COVID-19 and post intensive care syndrome: a call for action. J Rehabil Med. 2020; 52(4):jrm00044.^,55 Iannaccone S, Castellazzi P, Tettamanti A, Houdayer E, Brugliera L, Blasio F, Cimino P, Ripa M, Meloni C, Alemanno F, Scarpellini P. Role of rehabilitation department for adult individuals with COVID-19: the experience of the San Raffaele Hospital of Milan. Arch Phys Med Rehabil 2020; 101(9):1656-1661.. Therefore, there will be a need for continuous care encompassing different professionals and services, especially physical therapy assistance.

In addition to hospital care, especially related to hospitalizations in Intensive Care Units (ICU), the medium and long-term manifestations of COVID-19 are targets of physiotherapeutic interventions, both in outpatient care and in the follow-up of these individuals within the scope of primary health care (PHC). Physiotherapeutic assistance is essential to guarantee functionality, independence in performing daily living activities and quality of life for this population⁶6 Kalirathinam D, Guruchandran R, Subramani P. Comprehensive physiotherapy management in covid-19 - a narrative review. Sci Med 2020; 30(1):e38030.^,77 Sheery LM. Considerations for postacute rehabilitation for survivors of COVID-19. JMIR Public Health Surveill 2020; 6(2):e19462..

Physiotherapy is a profession whose main objective is the promotion of the individual’s general health, related to human functionality⁸8 World Confederation for Physical Therapy. What is physical therapy? 2020. [cited 2020 Nov 20]. Available from: https://www.wcpt.org/what-is-physical-therapy
https://www.wcpt.org/what-is-physical-th... . In its practical structure, it is consistent with values ​​reflected⁹9 Dean E. Physical therapy in the 21st century (part ii): evidence-based practice within the context of evidence-informed practice. Physiother Theory Pract 2009; 25(5-6):354-368. in the World Health Organization’s International Classification of Functioning, Disability and Health (ICF), a biopsychosocial model that considers the limitations of body structures and function, activity and participation, as well as, the assessment of contextual factors, such as the individual’s environment and personal factors related to living conditions¹⁰10 World Health Organization (WHO). International Classification of functioning, disability and health: ICF. Geneva: WHO; 2001.. Likewise, the scope of physical therapists’ practice has become comprehensive with the application of scientific principles and actions to prevent, identify, treat or rehabilitate movement dysfunction.

Although the urgent and growing demand for functional rehabilitation services has been evidenced in the scope of the COVID-19 pandemic, it must be considered that this is not an isolated problem¹¹11 Dean E, Jones A, Yu HP, Gosselink R, Skinner M. Translating COVID-19 evidence to maximize physical therapists' impact and public health response. Phys Ther 2020; 100(9):1458-1464.. Added to this is the pre-existing demand for rehabilitation services resulting from chronic diseases, marked over the years by a deficient supply of services¹²12 Bispo-Junior JP. Fisioterapia e saúde coletiva: desafios e novas responsabilidades profissionais. Cien Saude Colet 2010; 15(supl. 1):1627-1636.. It is worth mentioning that the unequal distribution of physical therapists along macro and micro regions of the country¹³13 Matsumara ESS, Souza Júnior AS, Guedes JA, Teixeira RC, Kletzer KS, Castro LSF. Distribuição territorial dos profissionais fisioterapeutas no Brasil. Fisioter Pesqui 2018; 25(3):309-314. also compromises the provision of care, with a greater concentration of these professionals linked to specialized outpatient care and/or in hospitals/urgencies and emergencies predominantly in large cities¹⁴14 Costa LR, Costa JLR, Oishi J, Driusso P. Distribuição de fisioterapeutas entre estabelecimentos públicos e privados nos diferentes níveis de complexidade de atenção à saúde. Rev Bras Fisioter 2012; 16(5):422-430., while in small ones, the availability of these professionals is greater in PHC.

Measures to prevent and control COVID-19, especially social distancing and restricting the transit of people¹⁵15 Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JA, Rocha AS, Ferreira A, Victor A, Teixeira C, Machado DB, Paixão E, Alves FJO, Pilecco F, Menezes G, Gabrielli L, Leite L, Almeida MCC, Ortelan N, Fernandes QHRF, Ortiz RJF, Palmeira RN, Junior EPP, Aragão E, Souza LEPF, Netto MB, Teixeira MG, Barreto ML, Ichihara MY, Lima RTRS. Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil. Cien Saude Colet 2020; 25(Supl. 1):2423-2446., have contributed to promoting new modalities of health care for the most diverse population groups. In this scenario, telehealth initiatives have become an alternative to face-to-face care, given the need to offer continuous care, even remotely. From the perspective of Physiotherapy, assistance via Information and Communication Technologies (ICT), such as video calls, phone calls and the use of messaging applications, represents a new challenge to be faced in order to expand access to physical therapy care, without harm to the quality of care⁶6 Kalirathinam D, Guruchandran R, Subramani P. Comprehensive physiotherapy management in covid-19 - a narrative review. Sci Med 2020; 30(1):e38030.^,1616 Caetano R, Silva AB, Guedes ACCM, Paiva CCN, Ribeiro GR, Santos DL, Silva RM. Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro. Cad Saude Publica 2020; 36(5):e00088920..

It should be noted that the identification of needs in the planning of care provision should include not only the severity of the case, but also multimorbidity, functionality and individual vulnerability. Given the above, the objective of this essay is to discuss the challenges of organizing and offering physical therapy assistance in response to the COVID-19 pandemic in Brazil.

Offer of physical therapy assistance in Primary Health Care (PHC)

Physical Therapy practice has been focused in rehabilitation instead preventive care. Faced with the care demands imposed by the COVID-19 pandemic on health systems, it is essential to discuss new responsibilities and possibilities for physical therapy care, focused on health and not just on disability¹⁷17 Bispo Júnior JP. La fisioterapia en los sistemas de salud: marco teórico y fundamentos para una práctica integral. Salud Colect 2021;17:e3709. In this context, physical therapy in PHC presents itself as an alternative capable of strengthening the system’s resoluteness and contributing to guaranteeing comprehensive care¹²12 Bispo-Junior JP. Fisioterapia e saúde coletiva: desafios e novas responsabilidades profissionais. Cien Saude Colet 2010; 15(supl. 1):1627-1636..

In PHC, physiotherapists can work in Basic Health Units, in households¹⁸18 Fernandes JM, Rios TA, Sanches VS, Santos MLM. NASF's tools and practices in health of physical therapists. Fisioter Mov 2016; 29(4):741-750.^,1919 Souza MO, Santos KOB. Physical therapists role in Family Health Support Center. Fisioter Mov 2017; 30(2): 237-246., social facilities and community clinics, articulating clinical-assistance actions with health promotion and the prevention of impairments, risks factors and disabilities, integrating individual, socio-community, home and education actions²⁰20 Braghini CC, Ferretti F, Ferraz L. Physiotherapist's role in the NASF: perception of coordinators and staff. Fisioter Mov 2016; 29(4):767-776.^,2121 Barros JO, Goncalves RMA, Kaltner RP, Lancman S. Estratégia do apoio matricial: a experiência de duas equipes do Núcleo de Apoio à Saúde da Família (NASF) da cidade de São Paulo, Brasil. Cien Saude Colet 2015; 20(9):2847-2856.. Other strategies involve participation in team meetings, action planning, case discussions, construction of singular therapeutic projects (PTS), matrix support on human movement, expanded clinic, action in the territory, articulation with the population²⁰20 Braghini CC, Ferretti F, Ferraz L. Physiotherapist's role in the NASF: perception of coordinators and staff. Fisioter Mov 2016; 29(4):767-776.^,2222 Rodes CH, Kurebayashi R, Kondo VE, Luft VD, Góes AB, Schmitt ACB. O acesso e o fazer da reabilitação na Atenção Primária à Saúde. Fisioter Pesq 2017; 24(1):74-82., surveillance of the deficiencies and incapacities of the population, development of system management practices and supporting public policies development based on the approach of social determinants that affect human functioning¹⁷17 Bispo Júnior JP. La fisioterapia en los sistemas de salud: marco teórico y fundamentos para una práctica integral. Salud Colect 2021;17:e3709. Also noteworthy are educational health actions that can include guidance on exercises, encouraging lifestyle changes, inviting users and their families to be co-responsible in the recovery process or even in recommendations for caregivers to prevent injuries¹⁸18 Fernandes JM, Rios TA, Sanches VS, Santos MLM. NASF's tools and practices in health of physical therapists. Fisioter Mov 2016; 29(4):741-750.^,2323 Friedrich TL, Petermann XB, Miolo SB, Pivetta HMF. Motivações para práticas coletivas na Atenção Básica: percepção de usuários e profissionais. Interface (Botucatu). 2018; 22(65):373-385..

The process of reorganization of practices requires municipal managers to organize, expand and qualify health services, their infrastructure, the number of professionals and the model of care for new demands. Additionally, performance of PHC teams should not be limited to coping with COVID-19. It is essential that the work process be aware and able to respond to the demands arising from the epidemiological profile of the population¹⁸18 Fernandes JM, Rios TA, Sanches VS, Santos MLM. NASF's tools and practices in health of physical therapists. Fisioter Mov 2016; 29(4):741-750.

19 Souza MO, Santos KOB. Physical therapists role in Family Health Support Center. Fisioter Mov 2017; 30(2): 237-246.^-2020 Braghini CC, Ferretti F, Ferraz L. Physiotherapist's role in the NASF: perception of coordinators and staff. Fisioter Mov 2016; 29(4):767-776..

The rehabilitation of individuals with sequelae of COVID-19 will depend, among other aspects, on the PHC’s ability to respond to this new demand and on its role in coordinating the care responsible for directing the user’s itinerary in the health network. The identification of cases, the mapping, the classification of risks and the articulation between the primary level, specialized health network and the partnership with educational institutions will be crucial for the system to be able to deal with the upcoming challenges. Thus, it will be necessary to design referral and counter-referral flows, the reorganization of the Care Network for Persons with Disabilities²⁴24 Brasil. Portaria nº 793, de 24 de abril de 2012. Institui a Rede de Cuidados à Pessoa com Deficiência no âmbito do Sistema Único de Saúde. Diário Oficial da União 2012; 25 abr. and the Health Care Network for People with Chronic Diseases²⁵25 Brasil. Portaria nº 483, de 1 de abril de 2014. Redefine a Rede de Atenção à Saúde das Pessoas com Doenças Crônicas no âmbito do Sistema Único de Saúde (SUS) e estabelece diretrizes para a organização das suas linhas de cuidado. Diário Oficial da União 2014; 2 abr., or even the implementation of a new care liaison for COVID-19 in the Health Care Network (Rede de Atenção à Saúde - RAS), in the search for the provision of comprehensive and coordinated care²⁶26 Portela MC, Grabois V, Travassos C. Matriz linha de cuidado COVID-19 na rede de atenção à saúde. Observatório COVID-19 Fiocruz. 2020. [acessado 2020 Nov 20]. Disponível em: https://portal.fiocruz.br/documento/matriz-linha-de-cuidado-covid-19-na-rede-de-atencao-saude.
https://portal.fiocruz.br/documento/matr... . There are also propositions that defend organized systems with direct access by the population to primary physical therapy services, as a means of reducing organizational barriers to physical therapy care and better care coordination¹⁷17 Bispo Júnior JP. La fisioterapia en los sistemas de salud: marco teórico y fundamentos para una práctica integral. Salud Colect 2021;17:e3709.

Despite the significant advances made by PHC in improving the population’s living conditions, the Unified Health System (Sistema Único de Saúde - SUS) faces historical underfunding and regulatory centralization by the federal government, which limits the heterogeneity of the forms of organization of services in response to demands and population needs²⁷27 Giovanella L. Atenção básica ou atenção primária à saúde? Cad.Saude Publica 2018; 34(8):e00029818.. In addition, there is an ongoing project to undermine Brazilian primary care, based on the National Primary Care Policy (Política Nacional de Atenção Básica - PNAB) edited in 2017, which can compromise the reach of its attributes by its work teams and, also, the possibilities of municipal managers organize the provision of functional rehabilitation in PHC.

The new financing of primary care proposed by Previne Brasil denotes the risks circumscribed in this regulation, which strangles the contribution of resources to the Expanded Nucleus of Family Health and Primary Care, as a strategic component, and makes it optional for municipal managers keep the support teams in the clinical and care support. Such a measure may restrict the population’s access to rehabilitation and differentiated activities induced by the health professionals teams, such as the construction of comprehensiveness, expanded territorialized care, network articulation and exchange with services and policies from other sectors²⁸28 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.^,2929 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220.. Given this financial constraint, it was difficult for municipal managers to maintain existing teams and even expand functional rehabilitation actions for the sequelae of COVID-19 in PHC.

Offer of outpatient physical therapy care for functional rehabilitation in COVID-19

The increased demand for functional rehabilitation in the management of COVID-19 is already a reality in different countries such as Italy, Portugal and Spain³⁰30 Lozano RR, Ojeda AMA, Martínez MM, Espinoza NS. La fisioterapia española en tiempos de pandemia de la COVID-19. Fisioterapia (Madr. Ed.impr) 2020; 42(4):224-225.

31 Minghelli B, Soares A, Guerreiro A, Ribeiro A, Cabrita C, Vitoria C, Nunes C, Martins C, Gomes D, Goulart F, Santos RMD, Antunes R. Physiotherapy services in the face of a pandemic. Rev Assoc Med Bras 2020; 66(4):491-497.^-3232 Simonelli C, Paneroni M, Fokon AG, Saleri M, Speltoni I, Favero I, Garofali F, Scalvini S, Vitacca M. How the COVID-19 infection tsunami revolutionized the work of respiratory physiotherapists: an experience from Northern Italy. Monaldi Arch Chest Dis 2020; 90(2):292-298.. There is increasing notification of patients with a decline in cardiorespiratory capacity, musculoskeletal and neurological limitations and reduced quality of life, in the chronic phase of the disease³³33 Hall G, Laddu DR, Phillips SA, Lavie CJ, Arena R. A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another? Prog Cardiovasc Dis 2020; 64:108-110.^,3434 Jiméne-Pavón D, Carbonell-Baeza A, Lavie CJ. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people. Prog Cardiovasc Dis 2020; 63(3):386-388., but also, there is a significant shortage in the supply of rehabilitation care and insufficient infrastructure in outpatient care for rehabilitate people with sequelae of COVID-19³⁵35 Falvey JR, Krafft C, Kornetti D. The essential role of home- and community-based physical therapists during the COVID-19 pandemic. Phys Ther 2020; 100(7):1058-1061..

Therefore, it is evident not only the strategic role of outpatient physical therapy services in functional rehabilitation⁷7 Sheery LM. Considerations for postacute rehabilitation for survivors of COVID-19. JMIR Public Health Surveill 2020; 6(2):e19462.^,3636 Bim CR, González A. Distribuição territorial de fisioterapeutas no Paraná e inserção em equipes na atenção básica. Saude e Pesqui. 2020; 13(1):83-89.^,3737 Silva RMV, Sousa AVC. Fase crônica da COVID-19: desafios do fisioterapeuta diante das disfunções musculoesqueléticas. Fisioter Mov 2020; 3:e0033002., but the urgency of debates on the expansion of these services in the SUS, given that the majority of the Brazilian population depends directly on this system. In the Brazilian public health system, health is a guaranteed-by-law right, however, the debate on the provision of outpatient physiotherapy care for rehabilitation in COVID-19 can not ignore the historical challenges, which include the underfunding of regional distribution of health services and professionals³⁸38 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Cien Saude Colet 2018; 23(6): 1751-1762..

Outpatient physical therapy services are supported by Brazilian public policies, however, the provision of functional rehabilitation in COVID-19 should be carefully analyzed , given the historical fragility in the expansion and organization of health rehabilitation services in Brazil²²22 Rodes CH, Kurebayashi R, Kondo VE, Luft VD, Góes AB, Schmitt ACB. O acesso e o fazer da reabilitação na Atenção Primária à Saúde. Fisioter Pesq 2017; 24(1):74-82.^,3939 Dubow C, Garcia EL, Krug SBF. Percepções sobre a Rede de Cuidados à Pessoa com Deficiência em uma Região de Saúde. Saúde Debate 2018; 42(117):455-467.^,4040 Caetano LA, Sampaio RF, Costa LA. A expansão dos serviços de reabilitação no SUS à luz do arcabouço normativo federal. Rev Ter Ocup Univ 2018; 29(3):195-203.. This exposes two main questions: 1) the response capacity of states and municipalities to expand public services at a speed compatible with this new demand; 2) referring to the care model, which enables comprehensive and equitable care, due to the diversity of users with unique needs for functional rehabilitation.

At the international level, there is a heated debate in countries such as Spain and Italy on the need to structure physiotherapy services for the rehabilitation of COVID-19 complications³⁵35 Falvey JR, Krafft C, Kornetti D. The essential role of home- and community-based physical therapists during the COVID-19 pandemic. Phys Ther 2020; 100(7):1058-1061.. In some articles, there are notes defending the expansion of the offer of community services (home and outpatient), considering the low access to specialized services in most cases that are discharged from hospital⁷7 Sheery LM. Considerations for postacute rehabilitation for survivors of COVID-19. JMIR Public Health Surveill 2020; 6(2):e19462.; and other ones, even so, defending its expansion in the specialized outpatient scope⁴¹41 Smith JM, Lee AC, Zeleznik H, Scott JPC, Fatima A, Needham DM, Ohtake PJ. Home and community-based physical therapist management of adults with post-intensive care syndrome. Phys Ther 2020; 100(7):1062-1073.. In Brazil, this debate has not yet taken hold and is evident only in superficial mentions of COVID-19 care protocols⁴²42 Conselho Nacional de Secretários de Saúde. COVID-19: guia orientador para o enfrentamento da pandemia na Rede de Atenção à Saúde. 2020.^,4343 Engstrom E, Melo E, Giovanella L, Mendes A, Grabois V, Mendonça MHM. Recomendações para a organização da Atenção Primária à Saúde no SUS no enfrentamento da COVID-19. Observatório Covid-19 Fiocruz; 2020., without deeper reflections in favor of expanding outpatient physical therapy services for rehabilitation in COVID-19²⁶26 Portela MC, Grabois V, Travassos C. Matriz linha de cuidado COVID-19 na rede de atenção à saúde. Observatório COVID-19 Fiocruz. 2020. [acessado 2020 Nov 20]. Disponível em: https://portal.fiocruz.br/documento/matriz-linha-de-cuidado-covid-19-na-rede-de-atencao-saude.
https://portal.fiocruz.br/documento/matr... .

Inequalities in the public provision of outpatient physical therapy services have been a major obstacle to ensuring access to functional rehabilitation in COVID-19. In Spain, this has been recurrent due to the greater concentration of physical therapists in the private sector and asymmetry in the professional/inhabitant ratio in the public system³⁰30 Lozano RR, Ojeda AMA, Martínez MM, Espinoza NS. La fisioterapia española en tiempos de pandemia de la COVID-19. Fisioterapia (Madr. Ed.impr) 2020; 42(4):224-225.. Faced with the scenario of community transmission and the accelerated internalization of the pandemic to rural and remote regions⁴⁴44 Floss M, Franco CM, Malvezzi C, Silva KV, Costa BR, Silva VXL, Werreria NS, Duarte DR. A pandemia de COVID-19 em territórios rurais e remotos: perspectiva de médicas e médicos de família e comunidade sobre a atenção primária à saúde. Cad Saude Publica 2020; 36(7):e00108920., this inequality in the offer of physical therapy services highlights an alert for countries in situations of economic crisis, where there are health regions with great social inequalities and public health system’s dependent³⁰30 Lozano RR, Ojeda AMA, Martínez MM, Espinoza NS. La fisioterapia española en tiempos de pandemia de la COVID-19. Fisioterapia (Madr. Ed.impr) 2020; 42(4):224-225.. In Brazil, the scenario of significant regional socioeconomic inequality has been an obstacle to the expansion and agreement of the offer of health services, especially in the North and Northeast regions⁴⁵45 Viana ALD, Bousquat A, Melo GA, Negri-Filho A, Medina MG. Regionalização e redes de saúde. Cien Saude Colet 2018; 23(6):1791-1798., which requires taking this reality into account when considering the recent needs for expansion of outpatient physical therapy services in COVID-19.

In Brazil, the challenges for offering functional rehabilitation do not encompass only the regional expansion of services, but their nature (whether public, private or philanthropic). More recent articles indicate the significant number of outpatient physical therapy establishments in the country⁴⁶46 Araújo RV, Aleluia IRS, Fontoura FCS, Santana AF. Aplicação de um instrumento de auditoria em serviços de fisioterapia do SUS na Bahia. Cad.Edu Saude e Fis 2020; 7(13):e071305.^,4747 Aleluia IRS, Barreto A, Sodré N, Santo FC, Pinto-Junior EP. Análise da produção ambulatorial de fisioterapia no SUS, Bahia, 2008-2014. Revista Gestão e Saúde 2017; 8:254-269.. However, the characteristics of outpatient physiotherapy production revealed that great part of the services is offered in the private/philanthropic sector, contracted with public resources through the SUS⁴⁷47 Aleluia IRS, Barreto A, Sodré N, Santo FC, Pinto-Junior EP. Análise da produção ambulatorial de fisioterapia no SUS, Bahia, 2008-2014. Revista Gestão e Saúde 2017; 8:254-269., which is a critical challenge for public managers who do not have their own network services to guarantee the expansion of public offering of functional rehabilitation services for COVID-19.

The Interruption of physiotherapeutic care due to restrictions used to reduce the spread of Sars-Cov-2 can negatively affect the continuity of care, increasing risk of hospitalization, falls, fractures and other consequences of immobility induced by quarantine³¹31 Minghelli B, Soares A, Guerreiro A, Ribeiro A, Cabrita C, Vitoria C, Nunes C, Martins C, Gomes D, Goulart F, Santos RMD, Antunes R. Physiotherapy services in the face of a pandemic. Rev Assoc Med Bras 2020; 66(4):491-497.^,3535 Falvey JR, Krafft C, Kornetti D. The essential role of home- and community-based physical therapists during the COVID-19 pandemic. Phys Ther 2020; 100(7):1058-1061.. At the beginning of the pandemic, the shortage of professionals due to absences and the changes in the team/user ratio signaled as a challenge, the creation of new organizational routines of outpatient services, including the redefinition of work shifts and the dynamics of physical therapy appointments and care³²32 Simonelli C, Paneroni M, Fokon AG, Saleri M, Speltoni I, Favero I, Garofali F, Scalvini S, Vitacca M. How the COVID-19 infection tsunami revolutionized the work of respiratory physiotherapists: an experience from Northern Italy. Monaldi Arch Chest Dis 2020; 90(2):292-298.^,4848 Amatya B, Khan F. Rehabilitation response in pandemics. Am J Phys Med Rehabil 2020; 99(8):663-668., with the objective of guaranteeing health safety for both users and physiotherapists, as occurred in Spain and Portugal⁷7 Sheery LM. Considerations for postacute rehabilitation for survivors of COVID-19. JMIR Public Health Surveill 2020; 6(2):e19462..

Physiotherapy is one of the professions most vulnerable to contamination by SARS-CoV-2, given that its work process requires very close contact with patients. The insufficiency of Personal Protective Equipment (PPE) limits the offer of functional rehabilitation in ideal safety conditions for professionals and users³⁰30 Lozano RR, Ojeda AMA, Martínez MM, Espinoza NS. La fisioterapia española en tiempos de pandemia de la COVID-19. Fisioterapia (Madr. Ed.impr) 2020; 42(4):224-225.^,4949 Bousquat A, Giovanella L, Medina MG, Mendonça MHM, Facchini LA, Tasca R. Desafios da Atenção Básica no enfrentamento da pandemia da Covid-19 no SUS. In: Anais do 4º Congresso Brasileiro de Política, Planejamento e Gestão da Saúde. Campinas: Galoá; 2021.. There are also challenges related to both the availability of PPE and the dedication of time required by professionals for training and updates on its use, as well as the provision of quality equipment, especially in situations of greater exposure, such as respiratory rehabilitation⁷7 Sheery LM. Considerations for postacute rehabilitation for survivors of COVID-19. JMIR Public Health Surveill 2020; 6(2):e19462..

Finally, the challenge of ensuring functional rehabilitation in COVID-19, integrated with other RAS services, which allows for the continuity of care, should be based on the interaction between professionals, family and community. It is necessary to link outpatient physical therapy teams to physical therapy teams in primary care, which can use telehealth as a resource to offer technical support in patient care⁴²42 Conselho Nacional de Secretários de Saúde. COVID-19: guia orientador para o enfrentamento da pandemia na Rede de Atenção à Saúde. 2020..

Offer of physiotherapeutic care by Telehealth and the COVID -19 pandemic

The suspension of face-to-face physiotherapeutic care due to the social distancing recommended by the WHO caused significant changes in the organization and offer of health care, challenging services, health professionals and users to incorporate technological resources that enable remote health care. Therefore, new modalities of care called teleconsultation, telemonitoring and teleconsultation were authorized by the Federal Council of Physiotherapy and Occupational Therapy (Conselho Federal de Fisioterapia e Terapia Ocupacional - COFFITO) through Resolution No. 516, of March 2020, allowing the continuity of the physiotherapeutic follow-up of patients with previous health conditions, as well as the care of patients recovered from the acute phase of COVID -19 who may present complications and dysfunctions in different systems⁶6 Kalirathinam D, Guruchandran R, Subramani P. Comprehensive physiotherapy management in covid-19 - a narrative review. Sci Med 2020; 30(1):e38030.^,5151 Silva CMS, Andrade AN, Nepomuceno B, Xavier DS, Lima E, Gonzalez I, Santos JC, Esquivel MS, Novais MCM, Magalhães P, Almeida RS, Gomes VA, Carvalho VO, Lima Filho WC, Moura Filho OF, Gomes Neto M. Evidence-based physiotherapy and functionality in adult and pediatric patients with COVID-19. J Hum Growth Dev 2020; 30(1):148-155..

Physiotherapeutic care through telehealth represents a resource and opportunity to expand access to rehabilitation for some population groups. Travel costs, as well as the time taken to get to the place of care can be reduced with the use of telehealth⁵²52 Flumignan CDQ, Rocha AP, Pinto ACPN, Milby KMM, Batista MR, Atallah NA, Saconato H. What do Cochrane systematic reviews say about telemedicine for healthcare? Sao Paulo Med J 2019; 137(2):184-92.^,5353 Udsen FW, Hejlesen O, Ehlers LH. A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease. J Telemed Telecare 2014; 20(4):212-220.. In addition, it can increase access to health care for populations that, historically, have had difficulty in accessing Physiotherapy services, including populations deprived of liberty and those living in rural areas¹³13 Matsumara ESS, Souza Júnior AS, Guedes JA, Teixeira RC, Kletzer KS, Castro LSF. Distribuição territorial dos profissionais fisioterapeutas no Brasil. Fisioter Pesqui 2018; 25(3):309-314..

Physiotherapists have been especially active in monitoring symptoms, secondary prevention of complications and functional decline, offering assistance through video calls, telephone calls for individualized consultations and sharing information material for health education and support to family members and caregivers. To date, there are no official guidelines or recommendations on procedures and conduct to ensure the quality of care and the safety of patients undergoing remote care. Researchers suggest that telehealth strategies be interspersed with face-to-face consultations for functional reassessment and maintenance of the bond and that they be indicated for specific cases, so that they constitute a resource to be added to physical therapy practice⁵⁴54 Fioratti I, Fernandes LG, Reis FJ, Saragiotto T. Strategies for a safe and assertive telerehabilitation practice. Braz J Phys Ther 2021; 25(2):113-116..

The planning and implementation of telehealth must consider socioeconomic, cultural, epidemiological and environmental aspects that influence the access, understanding and adherence of users to the services offered. Telehealth physiotherapy requires the availability of equipment for communication, such as a landline and mobile phone, tablet, computer and satisfactory internet connection. Although access to these resources has increased in recent decades in the Brazilian population, it cannot be assumed that all users have the same level of connectivity to the services and facilities offered by telehealth. The digital exclusion, which overlaps with social and use of health services inequalities, certainly constitutes a source of the main limitations regarding the implementation and use of telehealth in the SUS⁵¹51 Silva CMS, Andrade AN, Nepomuceno B, Xavier DS, Lima E, Gonzalez I, Santos JC, Esquivel MS, Novais MCM, Magalhães P, Almeida RS, Gomes VA, Carvalho VO, Lima Filho WC, Moura Filho OF, Gomes Neto M. Evidence-based physiotherapy and functionality in adult and pediatric patients with COVID-19. J Hum Growth Dev 2020; 30(1):148-155.^,5555 Carvalho RBM, Ferreira KR, Modesto FC. A fisioterapia digital em oncoginecologia durante a pandemia de Covid-19. Rev Bras Cancerol 2020; 66:e-1082..

According to the National Population home-based Study performed between 2017 and 2018, 79.1% of Brazilians have access to the internet, and this occurs mostly through smartphones (93.2%). However, it presents important differences between the urban area (79.4%) and the rural area (46.5%), and between the regions of the country, being greater in the South and Southeast regions (81.1% and 84.8%), when compared with the North and Northeast regions (72.1% and 69.1%). These inequalities are also accentuated in the groups of sex, age and income⁵⁶56 Instituto Brasileiro de Geografia e Estatística (IBGE). Acesso à internet e à televisão e posse de telefone móvel celular para uso pessoal 2018 [Relatório de pesquisa]. [acessado 2020 Nov 8]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/17270-pnad-continua.html?edicao=23205&t=sobre.
https://www.ibge.gov.br/estatisticas/soc... , giving greater vulnerability to women, the older and low-income people.

The disparities, inequities and inequalities experienced in Brazil characterize the socioeconomic and cultural scenario in which technologies are often inaccessible, incomprehensible or impractical for a considerable part of the population. Furthermore, specific prescribing criteria for telehealth care should consider limitations resulting from physical and sensory dysfunctions that result in disabilities for communication (speech, hearing), understanding (cognitive)⁵⁷57 Leochico CFD, Espiritu AI, Ignacio SD, Mojica JAP. Challenges to the emergence of telerehabilitation in a developing country: a systematic review. Front Neurol 2020; 11:1007. and motivation (mood disorders)⁵⁸58 Hoaas H, Andreassen HK, Lien LA, Hjalmarsen A, Zanaboni P. Adherence and factors affecting satisfaction in long-term telerehabilitation for patients with chronic obstructive pulmonary disease: a mixed methods study. BMC Med Inform Decis Mak 2016; 16:26..

Thus, the telehealth strategy must be carefully incorporated, in order to not accentuate existing inequalities⁵⁹59 Krug RR, Xavier AJ, D'Orsi E. Fatores associados à manutenção do uso da internet, estudo longitudinal EpiFloripa Idoso. Rev Saude Publica 2018; 52:37.. With the advancement in the use of health technologies, the expansion of the exploitation of private companies that prioritize profit over caring for people’s lives is discussed, which threatens universal health care policies. Health services can be attracted by promises of cost reduction and improvement in patient prognosis and outcomes, however, there is lack of scientific evidence⁵³53 Udsen FW, Hejlesen O, Ehlers LH. A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease. J Telemed Telecare 2014; 20(4):212-220..

In general, the expansion of telehealth can be seen as something positive and promising for many sectors and services in the health care system, but the planning and implementation require comprehensive public policies to reduce social and digital inequality, with an emphasis on the democratization of the Internet, as well as the development of specific guidelines (still lacking) to train and guide health professionals. In fact, the problems of accessing the internet and devices for its use in response to the demands generated by COVID -19 in Brazil are not restricted to users, but are also experienced by health professionals and managers of PHC units.

In a report on the challenges of primary care in facing the COVID-19 pandemic in the SUS, Bousquat et al.⁴⁹49 Bousquat A, Giovanella L, Medina MG, Mendonça MHM, Facchini LA, Tasca R. Desafios da Atenção Básica no enfrentamento da pandemia da Covid-19 no SUS. In: Anais do 4º Congresso Brasileiro de Política, Planejamento e Gestão da Saúde. Campinas: Galoá; 2021., described that the most frequent strategy of adaptation to the pandemic context was the incorporation of distance contact, mainly by telephone, which was mentioned by 50.8% of professionals and 37.7% of managers, followed by the WhatsApp. These authors highlighted that, with such actions, the SUS is reinventing itself, but technological devices and internet are lacking. The internet was precarious or almost non-existent for approximately 60% of the survey respondents. There was still little availability of institutional cell phones, implying the need to use the personal devices of professionals to contact users. One of the main recommendations is to expand the availability of cell phones and internet access for professionals and users, thus enabling the new forms of distance communication that have been developed.

The development, expansion and democratization of telehealth for the Brazilian population are essential aspects for the modernization and continuous improvement of the health system, however, its insertion must be complementary to the care already offered in the SUS in person, working as a support tool for professionals, caregivers and users in health care. In this way, the increase in the number of professionals with permanent training for physical therapy assistance, remote or face-to-face, with adequate working conditions that allow both maintenance of the professional bond and resolutive care to users, are essential strategies for the implementation of public health policies. Thus, investments aimed at expanding the population’s access to Physiotherapy need to be included in the policy agenda to face the COVID-19 pandemic.

Final considerations

COVID-19 has ratified to society the relevance of the SUS, how the health system has been working in an integrated way, the need for a strong and universal PHC, facing the ongoing project of its neo-selectivity and commodification, as well as the struggle for guarantee of the right to health, life and quality Physiotherapy services. Physiotherapists have an indisputable role across the entire continuum of care for COVID-19, which includes prevention of infection, care in the acute phase of the disease, surveillance of risk factors for functional decline, and interventions for maximizing long-term functional results.

The organization and provision of physical therapy assistance in response to the COVID-9 pandemic requires strategies that act on the inequity of the regional distribution of physical therapists in Brazil and that guarantee the maintenance and expansion of the accumulated experiences of physical therapy care in PHC and in the specialized outpatient setting. However, the new Brazilian fiscal regime, added to the economic and political crisis, threatens not only the continuity of care, but, mainly, its public expansion at a speed compatible with demand.

Although the telehealth resource is an opportunity to expand the population’s access to functional rehabilitation in COVID-19, its availability does not depend only on hiring professionals, but on an implementation process that is allied to overcoming cultural and technological barriers of the Brazilian population. Telehealth care programs should be developed avoid worsening inequalities in health care access, not becoming an object of dominance by the private sector, with imposition of economic barriers to the care process, nor influence the quality of care offered.

The pandemic revealed the need for the development of new skills by health professionals, managers, political authorities, class associations and Universities. In this process, Physiotherapy in health services has strengthened its social role and commitment to the maintenance/enhancement of human and life movement.

Further studies are encouraged on the distribution and inequalities in the provision of physical therapy assistance in Covid-19, on the strategies for organizing Physiotherapy services in response to the pandemic in PHC and in specialized outpatient care, as well as on the possibilities of organization of care through telehealth.

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