Physiotherapy service during the COVID-19 pandemic in Nepal: An onsite survey and the lived experience among clinicians

This study reveals that the COVID-19 pandemic significantly disrupted physiotherapy services in Nepal by reducing patient access and worsening conditions, while simultaneously prompting clinicians to adapt through expanded multidisciplinary roles, increased recognition of respiratory care, and the tentative exploration of tele-rehabilitation.

The Gist

Imagine the healthcare system as a massive, intricate orchestra. For years, the physiotherapists were the string section: essential for keeping the music flowing, helping people move, and recovering from injuries, but often playing in the background while the "conductors" (doctors) and "brass section" (emergency care) took the spotlight.

Then, the pandemic hit like a sudden, deafening storm. This paper is the story of how the string section of Nepal's orchestra tried to keep playing while the music hall was on fire, the instruments were locked away, and the audience was terrified to enter.

Here is the story of what happened, broken down simply:

1. The Great Silence (The Disruption)

When the pandemic lockdowns started in Nepal, it was like someone suddenly pulled the plug on the power grid for half the orchestra.

• The Stoppage: About one-third of the physiotherapy centers had to shut their doors completely. It was as if the musicians were told, "Stop playing; the hall is closed."
• The Fear: Even for the centers that stayed open, the "audience" (patients) was scared. People with broken knees, stroke survivors, and children with disabilities were afraid to leave their homes. They thought the hospital was a place where they might catch the virus, so they stayed home.
• The Result: Just like a plant that isn't watered, patients' conditions began to wither. People who needed movement to recover from surgery or manage disabilities started losing their strength. The paper notes that many patients came back later with worse problems than when they left, simply because they missed their "watering schedule" (therapy sessions).

2. The Shape-Shifting Musicians (Adaptation)

But the physiotherapists in Nepal didn't just sit idle. They were like jazz musicians who, when the sheet music disappeared, started improvising.

• New Roles: Suddenly, these movement experts weren't just fixing knees; they were wearing masks and gloves to help patients who were struggling to breathe from COVID-19. They became part of the "respiratory rescue team," working alongside doctors in the ICU. It was a huge shift: the string section was suddenly playing the drums and the horns to keep the band alive.
• The "Virtual" Band: Since they couldn't always see patients face-to-face, they tried a new trick: Tele-rehabilitation. They used phone calls and apps like WhatsApp to send video instructions, acting like a "remote control" for patients' exercises.
  • The Catch: It was like trying to fix a car engine over the phone. Sometimes it worked, but often, the patients couldn't do the exercises right without a therapist's hands-on guidance. Also, many patients didn't have good internet or the tech skills to join the "virtual band."

3. The Safety Gear (PPE and Safety)

The paper found that most centers (about 90%) had the necessary safety gear (masks, gowns, gloves), which is like the orchestra having fire extinguishers and raincoats. However, having the gear didn't mean the show could go on smoothly. The therapists were still terrified. They were worried about catching the virus and bringing it home to their families. It was a constant mental battle: "Do I go in to help, or do I stay safe?"

4. The Silver Lining (Recognition)

Here is the most hopeful part of the story. Before the storm, many people (even some doctors) didn't fully understand what physiotherapists did. They thought they were just "massage people."

• The Spotlight: Because the pandemic hit people's lungs so hard, everyone suddenly realized: "Wait, these movement experts are the ones helping people breathe again!"
• The pandemic forced the healthcare system to finally listen to the physiotherapists. They were no longer in the background; they were front and center, proving that rehabilitation is just as critical as emergency surgery.

The Bottom Line

The paper concludes that the pandemic was a stress test for Nepal's healthcare system.

• The Bad News: The system cracked. Many people with disabilities and chronic conditions suffered because their care was interrupted. The "remote control" (tele-rehab) wasn't a perfect replacement for the real thing.
• The Good News: The profession proved it is resilient. The therapists adapted, learned new skills, and finally got the recognition they deserved.

The Takeaway:
The authors say that for the future, Nepal (and the world) needs to build a "hybrid" orchestra. We need to keep the in-person connection because hands-on care is irreplaceable, but we also need to keep the "remote control" tools ready for the next storm. Most importantly, we need to make sure physiotherapists are invited to the planning meetings before the next crisis hits, so they are ready to play their part from day one.

Technical Summary

1. Problem Statement

The COVID-19 pandemic caused significant disruptions to global healthcare systems, particularly in low- and middle-income countries (LMICs) where rehabilitation capacity is already limited. In Nepal, government-imposed lockdowns, fear of infection, and resource constraints severely impacted access to essential health services, including physiotherapy.

• Core Issue: There was a lack of empirical data regarding how the pandemic specifically affected physiotherapy service delivery, patient outcomes, and the professional adaptation of clinicians in Nepal.
• Specific Gaps: The study sought to understand the extent of service suspension, the impact on patients with pre-existing disabilities and post-operative needs, the challenges faced by clinicians (e.g., PPE availability, role expansion), and the feasibility of alternative care models like tele-rehabilitation in a resource-constrained setting.

2. Methodology

The study employed a mixed-methods cross-sectional design conducted in Province III (the second most populous province, including the capital, Kathmandu) between 2020 and 2022.

• Qualitative Component (Lived Experience):
  • Participants: 12 physiotherapists recruited via purposive sampling.
  • Criteria: Minimum one year of experience; diverse workplace settings (hospitals, rehab centers, schools).
  • Data Collection: Semi-structured online interviews conducted in Nepali (June 2020–May 2021).
  • Analysis: Inductive thematic analysis following the six-step approach (familiarization, coding, theme generation) and adhering to COREQ guidelines.
• Quantitative Component (Onsite Survey):
  • Participants: 29 health facilities (25 urban, 4 rural) across six districts in Province III.
  • Sampling: Stratified purposive sampling to include all levels of the healthcare system (tertiary, secondary, medical colleges, rehab centers).
  • Data Collection: Onsite survey (September 2021–February 2022) using a questionnaire adapted from Canadian and World Physiotherapy surveys.
  • Analysis: Descriptive statistics using SPSS Version 27.
• Ethical Considerations: Approved by the Nepal Health Research Council and institutional review boards; informed consent obtained; data anonymized and compliant with GDPR.

3. Key Contributions

• Contextual Insight: Provides the first comprehensive mixed-methods assessment of physiotherapy service disruption in a South Asian LMIC context during the pandemic.
• Dual Reality Identification: Highlights the paradox where routine rehabilitation services were severely disrupted, yet the profession gained visibility and integration into acute respiratory and multidisciplinary care.
• Policy Relevance: Identifies critical gaps in emergency preparedness and the need for integrating rehabilitation into national health emergency plans.
• Tele-rehabilitation Reality Check: Offers empirical evidence on the limitations of tele-rehabilitation in low-resource settings, noting it as a compensatory strategy rather than a sustainable hybrid model.

4. Key Results

A. Service Disruption and Patient Impact

• Service Availability: 62.07% of centers reported uninterrupted services, while 31.03% experienced complete suspension. Outpatient (OPD) services were more severely impacted than inpatient (IPD) services.
• Patient Flow: Significant decline in patient visits due to fear of infection, transportation issues, and lockdown restrictions.
• Clinical Outcomes: Patients with pre-existing disabilities, neurological conditions, and post-operative needs experienced worsening functional status, delayed recovery, and secondary complications due to lack of follow-up and hands-on care.
• Quality of Care: Reduction in hands-on techniques (e.g., mobilization) and a shift toward home exercise programs and priority-based care.

B. Clinician Challenges and Adaptation

• Workforce Stress: Clinicians reported high levels of fear regarding infection transmission to families, physical exhaustion from working in PPE, and psychological stress.
• Role Expansion: 86.21% of facilities reported physiotherapists working in multidisciplinary teams. Roles expanded to include fever clinics, triage, emergency care, and direct respiratory management for COVID-19 patients.
• PPE Availability: 89.7% of centers had PPE available, though shortages were noted in some instances. Despite PPE availability, nearly one-third of facilities still suspended services.

C. Tele-rehabilitation and Innovation

• Adoption: Only 37.93% of centers implemented virtual care. The primary modality was telephone consultation (90.91%), followed by social media apps (Viber, WhatsApp).
• Limitations: Virtual care was largely discontinued in 63.6% of the centers that tried it. Barriers included lack of digital literacy, poor infrastructure, inability to perform hands-on assessments, and the perception that virtual care was inadequate for complex conditions.
• Correlation: Virtual services were mostly absent in centers where in-person services remained operational, suggesting tele-rehab was used primarily as a stop-gap measure.

D. Perception Shifts

• There was a notable shift in the perception of physiotherapy among other healthcare professionals and the public, particularly regarding its critical role in respiratory management and post-COVID recovery.

5. Significance and Conclusion

The study concludes that while the pandemic severely disrupted routine physiotherapy services in Nepal, leading to compromised patient care and increased disability burdens, it also catalyzed professional adaptation and recognition.

• Systemic Implications: The findings underscore the urgent need to integrate physiotherapy into national emergency preparedness and health system planning. Currently, rehabilitation is often undervalued in crisis planning.
• Future Directions:
  • Hybrid Models: While tele-rehabilitation is a valuable tool, it cannot fully replace in-person care, especially for manual interventions. Future models must address infrastructure and digital literacy gaps.
  • Policy Integration: The development of clinical guidelines (e.g., Post-COVID rehabilitation protocols) is a positive step, but widespread dissemination and implementation across diverse facilities are required.
  • Workforce Resilience: Strengthening the rehabilitation workforce through training, mental health support, and clear protocols is essential for future pandemics.

This research serves as a critical evidence base for policymakers and health administrators in Nepal and similar LMICs to build more resilient, inclusive, and adaptable rehabilitation systems.