Singapore Physiotherapy Association - Advisory for the Private Physiotherapy Sector (Version 4): Heightened Safe Distancing Measures. 8th April 2020
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Singapore
Physiotherapy
Association
Advisory for the
Private Physiotherapy Sector
(Version 4): Heightened Safe Distancing Measures.
8th April 2020
1ABOUT THE UPDATED ADVISORY (Version 4)
This updated advisory from the Singapore Physiotherapy Association, was adapted from the
MOH circular 32/2020, 39/2020, information for Primary Care Doctors (22nd Jan), the
Agency for Integrated Care (AIC) advisory to ILTC sector (6th Feb), information from the
Singapore government’s website (www.gov.sg), with addition of:
(i) AIC-MOH circular to community care partners (15th Feb),
(ii) MOH circular 54/2020 and 56/2020 on the revision of suspect case definition
(23rd Feb and 24th Feb)
(iii) MOH circular 60/2020 (27th Feb) and 62/2020 (3rd Mar)
(iv) MOH circular 76/2020 Revision of suspect case definition (10th Mar)
(v) MOH Press Release “Continuation of Essential Healthcare Services during Period
of Heightened Safe Distancing Measures” (4th April)
(vi) MOH circular 95/2020 “Guidance on Additional Precautionary Measures, Service
Operations and Personal Protective Equipment (PPE) Use for Healthcare Workers
for RHS-Led Community Care Services from 7th April to 4th May 2020 (7th April
2020)
Prior to writing this advisory, we have consulted the Ministry of Health Chief Allied Health
Officer’s Office (CAHOO), with sensing performed amongst the physiotherapy private
practitioners.
This advisory aims to provide a guideline for private practitioners, as to the steps to take
during this period of DORSCON ORANGE, in response to the COVID-19 situation.
Along with this advisory, MOH press release (4th April) and 95/2020, will be attached for
your reference.
Singapore Physiotherapy Association
First version, 16th Feb 2020
Second version, 24th Feb 2020
Third version, 10th Mar 2020
Fourth version, 8th April 2020
2SPA ADVISORY for the Private Physiotherapy Sector
On the COVID-19 situation
DEFINITIONS
• Suspect patient (as of MOH Circular 76/2020):
a) A person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection
with breathlessness AND who within 14 days before onset of illness had travelled abroad (i.e. to any
country outside of Singapore).
b) A person with an acute respiratory illness of any degree of severity who, within 14 days before onset
of illness had:
i. Been to any of the areas requiring heightened vigilance1 as listed on the Healthcare
Professionals Portal: https://www.moh.gov.sg/hpp/all-healthcare-professionals; OR
ii. Been to any hospital abroad; OR
iii. Close contact2 with a case of COVID-19 infection.
**Please note that: Transit only in an airport located in mainland China is not considered as having travelled
to mainland China.
1 Refers to affected areas with high disease load or high connectivity to Singapore. As of 9 March 2020,
these are: Mainland China, Republic of Korea, Italy, Iran, France, Germany, Spain, Japan and the United
Kingdom. Please check the Healthcare Professionals Portal regularly for updates.
2 Close contact is defined as:
• Anyone who provided care for the patient, including a health care worker or family member, or
who had other similarly close physical contact;
• Anyone who stayed (e.g. household members) at the same place as a confirmed person;
• Anyone who had close (i.e. less than 2m) and prolonged contact (30 min or more) with a
confirmed person (e.g. shared a meal).
• Stay Home Notice (SHN) (www.gov.sg website)
People on SHN, including healthcare workers must remain at home at all times. They are not to leave
the residence, even if it is to purchase food and essentials. Home delivery or help from others to
purchase daily necessities should be arranged.
Contact should be minimised with others, and avoid having visitors to your residence. A record of
persons you come in close contact with should be maintained. Monitor your health closely e.g. take
your temperature twice daily, and monitor other symptoms such as cough and breathlessness.
• Home quarantine order (www.gov.sg website) (HRO)
An individual on a quarantine order is isolated with the aim of limiting the spread of the virus in the
community. He or she will be isolated either at home, at Government Quarantine Facilities, or at a
hospital.
A quarantine order is a directive with legal force. It has severe penalties for non-compliance.
3SPA ADVISORY for the Private Physiotherapy Sector
On the COVID-19 situation
(i) Private physiotherapy clinic services and private home therapy services can
continue services only if tele-consultations is provided. Face-to-face contact
sessions will be stopped.
(ii) You can apply for the exemption of service suspension for the following group of patients
(to allow for face-to-face consult):
• Patient(s)/client(s) with no caregiver; and
• Without therapy for a period of at least one month, patient(s)/client(s)’s conditions would
either likely deteriorate within one month, resulting in hospitalization e.g. progressive
motor neuron disease OR patient(s)/client(s) would suffer from permanent loss of
function.
A new portal has been set up specially for allied health services:
https://form.gov.sg/#!/5e8d4c9ea86b87001184c03b
Please submit all exemptions by 13th April 2020 (Monday)
Please need to furnish the MTI portal with the details in order to reinforce the patient’s needs, and aid in the
assessment for exemption.
• Surname and initials of patient(s)’s name
• Last 4 digits of the NRIC number(s);
• Age; and
• Relevant diagnosis and description of why the patient(s) would deteriorate within 1 month, resulting
in hospitalization/suffer from permanent loss of function.
• No. of home therapy provided to patient in last one month (if applicable)
• No. of therapists expected to be delivering services in the next month
(iii) You may use Annex 1 “Essential Physiotherapy Services” as a guide to identify patients who require
essential physiotherapy, before applying the 2 criteria above.
(iv) Annex 2 “Triaging Framework for Tele-consultation” will guide us to triage if the patient can be
reviewed via tele-consult.
• All physiotherapists should monitor your own temperature twice a day. Do not attend to patients, if
you are unwell. Wear a mask, seek medical attention if you feel unwell and rest at home.
• All physiotherapists must adhere to strict infection control practices and personal hygiene practices
(including hand hygiene practices).
o There should be frequent cleaning of your equipment and environment with use of 70% alcohol.
§ Do not spray cleaning agents as it may aerolise infective agents.
§ Cleaning agent should be applied using a damp cloth, left for at least 10 minute but no
longer than 30 min, thoroughly rinsed off and the area dried.
4o Personal protection equipment (such as surgical mask), should be used appropriately and
responsibly.
§ All staff should put on and dispose of surgical masks correctly. Refer to:
https://www.healthhub.sg/live-healthy/1204/when-a-mask-is-a-must
• All staff should be mask up within the clinical areas of the clinic. Surgical masks is
advised for “extended use for 6 hours” as per MOH circular 39/2020. Please change your
surgical mask if it becomes soggy or soiled.
§ For chest physiotherapy, please abide to standard precautions due to risk of fluid splash.
Please put on your surgical mask, gloves, apron and visor/googles (for eye protection).
§ For home visits, surgical mask needs to be worn and changed for every client.
§ If you do need to make a home visit to a household with the client or family member on
SHN/HRO, please wear full PPE (i.e. N95 mask, gown, gloves and eye protection). These
must be donned on prior to entering the house. PPE must be changed after each home
visit.
• All staff who are working in the physiotherapy clinic (if allowed to open to see specific clients face-to-
face) needs to abide by safe distancing measures including the following:
o If there are meal times, they should be staggered amongst staff or to allow sufficient distancing
of at least 1m. Avoid group meals.
o All staff should not be gather in groups of any size during or after work hours.
o If there are waiting lines in standing or sitting, 1m marking should be made to allow physical
distancing amongst clients as well.
• All home physiotherapy providers must perform phone triaging prior to home visit, in order to minimise
the risk of community spread through close contact.
o Phone triaging should check for both symptoms, travel history as well as close contact history (as
defined under “suspect patient” definition on page 3 of this advisory).
o Check if the patient or any family member/caregiver in the household is on SHN/QRO.
o If the patient mentions that he/she are unwell, advise them to visit the general practitioner (GP).
o If patient asks further questions about COVID-19, suggest for them to keep updated with
accurate information on the government website www.gov.sg, or sign up for the whatsapp
https://go.gov.sg.
o DO NOT visit the home if either the patient and/or household members has symptoms and/or
travel history/close contact history, or are on SHN/QRO unless absolutely necessary. Defer the
home visit and carry out tele-consultation if appropriate.
o If you do need to conduct the home visit if patient or family/caregiver is on SHN/QRO, please
refer to table 1, scenario A on what the process is.
o If you find that the patient or a close contact in the household is a possible suspect patient,
please contact MOH Surveillance Duty Officer at 98171463 (available 24-hours).
o If you are unsure after your phone triage whether to proceed with the home visit e.g. patients
with recent or existing pneumonia or acute respiratory symptoms, please seek medical advice
from a physician for further clarification and assessment.
**Please note that this number is NOT for use for general enquiries. Please do not call the number
unnecessarily as you will be potentially depriving another person’s important call to MOH.
• When outside patient’s home, reconfirm if the patient or any family member/caregiver in the
household is on SHN/QRO. Please reconfirm the patient’s and close contact’s travel history and close
contact history.
o If you find out that patient and/or close contact presents with symptoms, advise them to visit the
general practitioner (GP). Call the GP in advance to inform them of the situation.
5o You may also contact the home medical doctor you are working with, to assess the patient
and/or caregiver/close contact.
o If you find that the patient or a close contact in the household is a possible suspect patient,
please contact MOH Surveillance Duty Officer at 98171463 (available 24-hours).
• When you arrive inside the home, whenever possible, please check the temperature for your patient and
any close contact in the house. Screen your patient and close contact (if present in house) for any signs
and symptoms such as:
o Fever and/or Cough, and/or Sore throat (common presenting symptoms of COVID-19 locally)
o And/or Running nose, and/or Breathlessness
• All patient interaction should be limited to no more than 60 min without compromising care for home
therapy services.
• Please take note of additional precautionary measures to manage home visits for patient or household
members living in the same premise is on SHN/HRO, as in table 1 below (MOH circular 95/2020).
Table 1: Additional precautionary measures to manage home visits for patient or household member/s living in
same premise is on SHN/HRO
Notified by patient/caregiver before home Notified by patient/caregiver upon arrival Notified by patient/caregiver after
Scenario
visit for home visit completing the home visit
Scenario A
Continue to provide service remotely via Defer non-urgent and/or non-critical
teleconsultation if suitable. If remote services till after the SHN/HQO period. If
• Patient on
service delivery is not possible, to defer the need is urgent, to contact MOH
SHN/HQO
non-urgent and/or non- critical services till emergency Ops Cell POC at contacts
after the SHN/HQO period. provided below and continue home visit
• Household with full PPE. If no access to appropriate
Healthcare staff may continue to attend
member staying on PPE on hand, to defer the visit to next
To conduct home visit with full PPE to other clients, if appropriate
same premise on suitable date.
following email notification to MOH precautionary measures were taken
SHN/HQO
Emergency Ops Cell POC at during home visit for affected patient.
EPR_Operations_Cell@moh.gov.sg and Email: EPR_Operations_cell@moh.gov .sg
[Refer to workflow 3 Contact No:
below for such state the time and date of home 91298046 (8am to 8pm)
cases] visit/follow up.
97123410 (8pm to 8am)
Healthcare staff should not provide
Defer any service at patient’s home till Defer any service at patient’s home till service to any other patients until
patient received test outcomes. patient received test outcomes. patient’s test outcomes is out.
Scenario B If patient is tested positive, no visit is If patient is tested positive, no visit is If patient is tested positive, healthcare
needed as patient will be hospitalised. needed as patient will be hospitalised. staff will be quarantined.
Patient is a suspect
If patient is tested negative, to proceed to If patient is tested negative, to proceed to If patient is tested negative, healthcare
provide service with precautionary provide service with precautionary staff may continue to provide service to
measures. measures. other patients.
Scenario C Healthcare staff should not provide
Defer any service at patient’s home till Defer any service at patient’s home till service to any other patients until
household member received test household member received test household member’s test outcomes is
Household member outcomes. outcomes. out.
staying in same
premise is a suspect
If household member is tested positive, to If household member is tested positive, to If tested positive for those with direct
follow guidelines for scenario A. follow guidelines for scenario A. contact with healthcare staff during the
home
3
Home Visits should preferably be arranged in the morning before 12pm to de-conflict with routine visits from Certis CISCO
officers on those on SHN/HQO. The Certis CISCO visits are usually scheduled daily at 12-3pm, 3-6pm, 6-9pm (i.e. total of 3
surveillance calls).
6SPA ADVISORY for the Private Physiotherapy Sector
On the COVID-19 situation
• What happens if I come in contact with a patient with confirmed COVID-19?
There is a risk assessment framework that MOH uses to assess healthcare workers’ exposure to confirmed
patients, and inform follow-up actions.
The follow-up actions that need to be taken by the healthcare workers’ and/or the employer will depend on
the contact type/procedure, as well as PPE worn by the healthcare worker during the patient encounter/s.
Please refer to MOH circular 62/2020, attached for further information.
• HELPFUL RESOURCES & CONTACTS
1) MOH website for updates on COVID-19
https://www.moh.gov.sg/2019-ncov-wuhan
2) MOH website for advisories for various sectors including healthcare.
https://www.moh.gov.sg/2019-ncov-wuhan/advisories-for-various-sectors
3) MOH circular no. 39/2020
https://www.healthprofessionals.gov.sg/docs/librariesprovider11/default-document-library/moh-cir-
no-39_2020_7feb20_pte_dental_ppe-guidance.PDF
4) Gov.sg WhatsApp: Sign up with https://go.gov.sg/whatsapp.
5) List of areas requiring heightened vigilance included in suspect case definition
https://www.moh.gov.sg/hpp/all-healthcare-professionals
6) SPA website: https://www.physiotherapy.org.sg/covid-19-together-we-stand/
Please contact SPA at secretary@physiotherapy.org.sg, if you would require further
clarifications. We will do our best to support you.
7ANNEX 1 (for use across all physiotherapy sectors)
Essential services/procedures refer to those, if not provided or performed, would result in
significant or rapid deterioration of the patient’s medical condition, and potentially threaten
their health and well-being.
Essential services Target Group Potential consequences
Physiotherapy Patients with respiratory symptoms with conditions Deterioration in respiratory
Interventions to such as: condition that could result in poor
prevent (i) COVID-193 outcomes, including readmissions
deterioration of (ii) acute/chronic neuromuscular conditions1,2 e.g. and even death.
respiratory spinal cord injury patients on home ventilators Increase caregiver stress.
function
Physiotherapy Patients with co-morbidities and frailty that are at risk Deterioration in respiratory
Interventions for of deterioration and poor outcomes without sustained condition and functional mobility,
surgical patients rehabilitation including: with potential delay in recovery
with complex (i) Trauma patients4 and long term disability.
needs (ii) Major surgeries e.g. emergency thoracic and Increase caregiver stress.
abdominal surgeries5, orthopaedic surgeries6,
cardiac surgeries
(iii) Neurosurgeries
Patients who underwent surgeries who require in- Prevent complication risk like
person full assessment for pain and swelling control and scarring and limitation of range of
effective exercise prescription, including: motion, with potential delay in
(i) Joint replacement surgeries recovery and long term disability.
(ii) Breast surgeries9
(iii) Ligament reconstruction surgeries7
(iv) Recent fractures with surgery
Physiotherapy Patients who are diagnosed with acute stroke8 and Deterioration in respiratory
Interventions for other chronic neurological conditions that are at risk of condition and functional mobility,
patients with deterioration and poor outcomes without sustained with risk of readmissions, potential
neurological rehabilitation. delay in recovery and long term
conditions disability.
Increase caregiver stress.
Physiotherapy Patients who have: Deterioration in functional
interventions for (i) Acute pain10 (including severe unremitting pain mobility, with risk of readmissions,
other non- that are poorly relieved by pain medications) potential delay in recovery and
surgical (ii) Lymphedema11 long term disability.
conditions (iii) Acute vestibular disorders e.g. benign Increase caregiver stress.
paroxysmal positional vertigo12
(iv) Older adults who have poor social support, at
risk of injurious falls, deconditioning and
functional decline.
*Essential Physiotherapy Interventions include the following:
(i) Face-to-face assessments that are critical to provide safe and adequate care
(ii) Manual and Hands-on techniques
(iii) Caregiver training, that is critical for patient safety and care at home
8ANNEX 2: Triaging Framework for Tele-consultation
Does the patient require essential physiotherapy services (Annex 1) AND fulfill the criteria of:
• Patient(s)/client(s) with no caregiver; and
• Without therapy for a period of at least one month, patient(s)/client(s)’s conditions would
either likely deteriorate within one month, resulting in hospitalization e.g. progressive motor
neuron disease OR patient(s)/client(s) would suffer from permanent loss of function.
YES
NO
Review the patient face-to-face for Will the patient benefit from tele-consultation as interim
first session. measure to ensure that their condition does not deteriorate?
(MTI portal filled up and approved)
NO
To postpone patient’s
appointment as appropriate. YES
Can subsequent sessions be carried
out using tele-consultation?
YES NO
To follow up with tele-consult
as first visit.
Review patient face-to-face
(MTI portal filled up and approved)
To follow up with tele-consult
as appropriate.
Annex 1 and 2 are written based on the definition of “Essential Services” in the MOH circular
“Continuation of Essential Healthcare Services During Period of Heightened Safe Distancing Measures”
published on 4th April 2020)
9REFERENCES
1) Berlowitz DJ, Wadsworth B & Ross J 2016, Respiratory Problems and
Management in People with Spinal Cord Injury, Breathe, vol.12, pp.328-340
2) Ward K, Rao P, Reilly CC, Rafferty GF, Polkey MI, Kalra L & Moxham J 2017, ‘Poor
cough flow in acute stroke patients is associated with reduced functional residual
capacity and low cough inspired volume’, BMJ Open Respiratory Research
3) Physiotherapy Management for COVID-19 in the Acute Hospital Setting:
Recommendations to Guide Clinical Practice, version 1
https://www.sciencedirect.com/science/article/pii/S183695532030028X
4) Bouman AIE, Hemmen B, Evers SMAA, van de meent H, Ambergen T, Vos PE,
Brink PRG & Seelen HAM 2017, ‘Effects of an Integrated ‘Fast Track’
Rehabilitation Service for Multi-Trauma Patients: A Non-Randomised Clinical Trial
in the Netherlands’, PLoS ONE, vol. 12, no.1
5) Lee L, Tran Tung, Mayo NE, Carli F & Feldman 2014, ‘What does it really mean to
“recover” from an operation?’, Surgery, vol.155, pp.211-216
6) Rutenberg TF, Vitenberg M, Haviv B & Velkes S 2018, ‘Timing of Physiotherapy
following fragility hip fracture: delays cost lives’, Archoves of Orthopaedic and
Trauma Surgery, vol.138, pp.1519-1524
7) Christensen JC, Goldfine LR, Barker T & Collingridge DS 2015, ‘What can the First 2
Months Tell Us about Outcomes after Anterior Cruciate Ligament
Reconstruction’, Journal of Athletic Training, vol.50, no.2, pp. 508-515
8) Coleman ER, Moudgal R, Lang K, Kathryn Lang, Hyacinth HI, Awosika OO, Kissela
BM & Feng WW 2017, ‘Early Rehabilitation After Stroke: A Narrative Review’,
Current Atherosclerosis, vol.19, no.12
9) Lu S-R, Hong R-B, Chou W & Hsiao P-C 2015, ‘Role of physiotherapy and patient
education in lymphedema control following breast cancer surgery’, Therapeutics
and Clinical Risk Management’ vol.11, pp.319-327
10) Liu X, Hanney WJ, Masaracchio M, Kolber MJ, Zhao M, Spaulding AC, Gabriel MH
2018, ‘Immediate Physical Therapy Initiation in Patients with Acute Low Back Pain
is Associated With a Reduction in Downstream Health Care Utilization and Costs’,
Physical Therapy, vol.98, pp.336-347
11) Kim S-J, Yi C-H, Kwon O-Y 2007, ‘Effect of Complex Decongestive Therapy and the
Quality of Life in Breast Cancer Patients with Unilateral Lymphedema’,
Lymphology, vol.40.pp.143-151
12) Bressi F, Vella P, Casale M, Moffa A, Sabatino L, Lopez MA, Carinci F, Papalia R,
Salvinelli F & Sterzi S 2017, ‘Vestibular Rehabilitation in Benign Paroxyzmal
Positional Vertigo: Reality or Fiction?’, vol.30, no.2, pp.113-122
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