The hand therapy community has battled through the COVID 19 pandemic along with other healthcare professionals, upending practice patterns and creating external stressors, the likes of which we have not seen before. At the time of this survey distribution in December 2020, the United States (US) was on pace to experience the deadliest month from COVID-19 since its onset,,15

Hall D. U.S. Covid-19 Hospitalizations Top 125,000 for the First Time. Published online December 31, 2020. Accessed January 24, 2021. http://www.wsj.com

and the world had surpassed 100 million known virus cases.2The world reaches a staggering milestone of more than 100 million known virus cases. Despite the heightened concern, greater morbidity and mortality rates, and a mutating virus, our survey responses revealed an overall sense of things slowly returning to normal from a practice perspective. Most therapists have increased their number of work hours and do not expect to be facing financial difficulty in the upcoming weeks, there are more in-person visits and people are not restricted from these visits due to age or pre-existing conditions, people feel more comfortable with in-person visits, and telehealth use has decreased compared to the original survey in April 2020.This apparent return to pre-COVID times may indicate people are adapting with increased comfort levels for screening procedures, use of PPE and social distancing. Another factor may be that more is understood about the virus and effective treatments that are now available.17Necessity of 2 Doses of the Pfizer and Moderna COVID-19 Vaccines. At the time of the survey, the vaccine rollout had not really started and therapists had not been vaccinated, so that does not explain this slow return to normal. It is interesting to note that when the initial survey was distributed in April, 2020, the COVID-19 cases and deaths were not nearly at the levels as they are today, and many states were experiencing little to no cases. However, during that time frame in-person treatment was largely suspended, and work hours were drastically reduced.11Ivy CC Doerrer S Naughton N Priganc V. The Impact of COVID-19 on Hand Therapy Practice. This follow-up survey depicts how in-person practice is slowly returning to normal levels despite the fact that COVID-19 is very much present and still impacting daily life.Another practice trend that appears to be returning to pre-pandemic levels is telehealth. The use of telehealth among respondents jumped to 46% in April, 2020,11Ivy CC Doerrer S Naughton N Priganc V. The Impact of COVID-19 on Hand Therapy Practice. but has decreased in December, 2020 to 29% as more clients are being treated in-person. Prior to COVID-19 the reported utilization of telehealth was quite low, between 5-10%.11Ivy CC Doerrer S Naughton N Priganc V. The Impact of COVID-19 on Hand Therapy Practice. The overwhelming majority of free text responses regarding telehealth was that it was no longer necessary with return to in person treatment, and that its efficiency, effectiveness, and reimbursement were questionable. With the rapid rise to telehealth visits at the beginning of the pandemic and systems not yet in place to appropriately triage patients, it is understandable that some therapists would feel more efficient and productive with in person visits. This notion of efficiency is also expressed qualitatively by physicians.18Reeves JJ Ayers JW Longhurst CA. Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm.,19Saliba-Gustafsson EA Miller-Kuhlmann R Kling SMR et al.Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation. Telehealth is often most successful when there is a genuine need within the community for telehealth services, it is in the best interest of the client and their care, and there is an infrastructure that includes, funding, technology, technical support, consultation, and training.21Gifford V Niles B Rivkin I Koverola C Polaha J. Continuing education training focused on the development of behavioral telehealth competencies in behavioral healthcare providers. Health care practitioners may improve the effectiveness and acceptance of telehealth as they develop clearer guidelines for determining suitable cases for telehealth visits by taking into account visit types, patient characteristics and diagnoses. 18Reeves JJ Ayers JW Longhurst CA. Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm.,22Virtual Care, Telemedicine Visits, and Real Connection in the Era of COVID-19: Unforeseen Opportunity in the Face of Adversity. There are multiple studies that provide guidance on how to maintain quality of care18Reeves JJ Ayers JW Longhurst CA. Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm.,19Saliba-Gustafsson EA Miller-Kuhlmann R Kling SMR et al.Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation. and/or connectedness, 21Gifford V Niles B Rivkin I Koverola C Polaha J. Continuing education training focused on the development of behavioral telehealth competencies in behavioral healthcare providers., 22Virtual Care, Telemedicine Visits, and Real Connection in the Era of COVID-19: Unforeseen Opportunity in the Face of Adversity., 23Bergman D Bethell C Gombojav N Hassink S Stange KC. Physical Distancing With Social Connectedness., 24Access, Equity, and Neutral Space: Telehealth Beyond the Pandemic., 25Wade VA Eliott JA Hiller JE. Clinician Acceptance is the Key Factor for Sustainable Telehealth Services. over the telehealth platform.In addition to the infrastructure, for telehealth to be considered a sustainable health delivery system there must be acceptance of telehealth by both patients and providers. A study recently found that for patients in Brazil, their attitude toward telemedicine was the most explanatory variable in predicting their intention to use telemedicine.26Ramírez-Rivas C Alfaro-Pérez J Ramírez-Correa P Mariano-Melo A Predicting Telemedicine Adoption: An Empirical Study on the Moderating Effect of Plasticity in Brazilian Patients. In the current study, the two most chosen responses as to why hand therapists were not providing telehealth services were 1) that clients no longer wanted to receive telehealth services; and 2) that clients had not requested telehealth services. Therefore, it is plausible that a lack of acceptance of telehealth by the patient may be one of the many driving forces as to why telehealth services have decreased.Although client factors play a large part in the delivery of telehealth, the hand therapists’ attitude towards telehealth is also a factor. In our survey, the third most chosen response as to why hand therapists were not providing telehealth was that they felt they could not provide quality care using this platform. Evidence supports that perceived usefulness is a predictor to positive intentions to use telerehabilitation.27Almojaibel AA Munk N Goodfellow LT et al.Health Care Practitioners’ Determinants of Telerehabilitation Acceptance. Dahl-Popolizio et al. examined the effectiveness of OT services during the COVID-19 pandemic, and reported that OTs felt that conditions of the hand and upper extremity could effectively be treated via telehealth and that therapeutic exercise and home programs could be delivered with telehealth.28Dahl-Popolizio S Carpenter H Coronado M Popolizio NJ Swanson C. Telehealth for the Provision of Occupational Therapy: Reflections on Experiences During the COVID-19 Pandemic. Currently, the evidence related to efficacy of telehealth in hand rehabilitation as it relates to certain conditions or treatment approaches is lacking. In both the April 2020 survey 11and in this survey, post-operative patients were significantly seen more in person than via telehealth. This signals that both the hand therapists and patients felt in person treatment was important after surgery despite the risk of COVID-19.According to the survey, those more likely to still be receiving telehealth services are people 65 years and older and people with non-traumatic, non-operative cases. Although there is a general assumption that people over age 65 may not be as comfortable with technology, perhaps they were most likely to use telehealth because during the pandemic they were included in the higher risk group for contracting COVID-19. We also found that therapists more likely to still be using telehealth were those in urban areas compared to suburban or rural areas. This was an unexpected finding given that the CDC saw similar or more cases and deaths in non-metropolitan areas compared to metropolitan areas during the timeframe this survey was open. No other literature has described differences in usage of hand therapy telehealth in urban, suburban, and rural areas. There is literature indicating that rural Americans see COVID-19 as less of a threat to personal and public health when compared to urban and suburban Americans with urban Americans feeling the most threat of COVID-19 to personal and public health. Therefore it is plausible that individuals in rural areas may not feel that attending hand therapy in person is a threat to their personal health and therefore are not requesting telehealth services.There were some interesting differences between the April 2020 initial survey and the December 2020 follow-up survey as it relates to practice patterns. Respondents in this recent survey reported an increased use in taking client temperatures as part of screening procedures, although there is little evidence to support the use of digital non-contact thermometers. The majority of infra-red thermometers have been found with low sensitivity and perform outside the accuracy range for body temperature as established by the International Temperature Scale of 1990 (ITS-90).31The non-contact handheld cutaneous infra-red thermometer for fever screening during the COVID-19 global emergency. Similarly, temperature taking is found questionable due to the incubations period, undetectable symptoms as well as training of the individuals operating the thermometer as to where the device is placed on the forehead or temple and distance of the thermometer to the skin.31The non-contact handheld cutaneous infra-red thermometer for fever screening during the COVID-19 global emergency.,32Gostic K Gomez AC Mummah RO Kucharski AJ Lloyd-Smith JO Estimated effectiveness of symptom and risk screening to prevent the spread of COVID-19. Also, many respondents in this survey have not returned to using shared equipment or modalities; treatment tools that people perceive cannot be easily cleaned or sanitized between patients. The authors did not find published evidence that supports or refutes the use of physical agent modalities during the pandemic.Most participants reported increased levels of stress compared to before the COVID-19 pandemic. This is similar to other authors who report an overall increase in psychological distress among the general population,33Qiu J Shen B Zhao M Wang Z Xie B Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations., 34Wang C Pan R Wan X et al.Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China., 35Zhang J Lu H Zeng H et al.The differential psychological distress of populations affected by the COVID-19 pandemic., 36Cooke JE Eirich R Racine N Madigan S. Prevalence of posttraumatic and general psychological stress during COVID-19: A rapid review and meta-analysis. regardless of whether or not people worked in healthcare or in an occupation that placed people at greater risk for contracting COVID-19.37Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. Development and initial validation of the COVID Stress Scales.,38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates. Despite what appears to be a plethora of evidence indicating an overall increase in stress levels as a result of the pandemic, the literature appears mixed related to variables that contribute to this overall increased stress. Higher levels of psychological distress during the COVID-19 pandemic have been reported among women,33Qiu J Shen B Zhao M Wang Z Xie B Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations.,34Wang C Pan R Wan X et al.Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China.,38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates., 39González-Sanguino C Ausín B Castellanos MA Saiz J Muñoz M. Mental health consequences of the Covid-19 outbreak in Spain. A longitudinal study of the alarm situation and return to the new normality., 40

González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental Health Consequences of the Coronavirus 2020 Pandemic (COVID-19) in Spain. A Longitudinal Study. Front Psychiatry. 2020;11:565474. doi:10.3389/fpsyt.2020.565474

, 41d'Ettorre G Ceccarelli G Santinelli L et al.Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review. migrant workers,33Qiu J Shen B Zhao M Wang Z Xie B Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. college age students,34Wang C Pan R Wan X et al.Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China.,39González-Sanguino C Ausín B Castellanos MA Saiz J Muñoz M. Mental health consequences of the Covid-19 outbreak in Spain. A longitudinal study of the alarm situation and return to the new normality., 40

González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental Health Consequences of the Coronavirus 2020 Pandemic (COVID-19) in Spain. A Longitudinal Study. Front Psychiatry. 2020;11:565474. doi:10.3389/fpsyt.2020.565474

, 41d'Ettorre G Ceccarelli G Santinelli L et al.Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review. people with less education,38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates. healthcare workers with less medical training,41d'Ettorre G Ceccarelli G Santinelli L et al.Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review. people who are lonely39González-Sanguino C Ausín B Castellanos MA Saiz J Muñoz M. Mental health consequences of the Covid-19 outbreak in Spain. A longitudinal study of the alarm situation and return to the new normality.,40

González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental Health Consequences of the Coronavirus 2020 Pandemic (COVID-19) in Spain. A Longitudinal Study. Front Psychiatry. 2020;11:565474. doi:10.3389/fpsyt.2020.565474

, and people who were unemployed .38 Some report higher stress levels in people that have poor health 34, or preexisting mental health conditions38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates., while others state preexisting general medical conditions do not correlate with increased stress.38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates. In our study, we found that older therapists experienced more stress related to eldercare concerns. We also found that younger therapists experienced more stress related to childcare concerns and job security concerns. Similarly, Taylor & Landry38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates. also found small, negative correlations related to age and income levels and COVID-19 stress indicating that younger individuals do feel stress associated with the pandemic.Since our original survey much has been written about women and mothers and stress and the unique effect it has had on them. 33Qiu J Shen B Zhao M Wang Z Xie B Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations.,42Mattioli AV Sciomer S Maffei S Gallina S. Lifestyle and Stress Management in Women During COVID-19 Pandemic: Impact on Cardiovascular Risk Burden., Women make up approximately 80% of the healthcare workforce according to the Bureau of Labor and Statistics, and this percentage is even greater in the membership of the ASHT (85% female; 15% male). (Luci Patalano MBA, email communication, February 2021). In a European survey it was found that 66.5% of women had to stop working during the pandemic to assist with changes in childcare due to shutdown45Di Giorgio E Di Riso D Mioni G Cellini N. The interplay between mothers’ and children behavioral and psychological factors during COVID-19: an Italian study. and when having to choose which parent stays home, the burden of care taking and childcare tends to fall on the woman.46COVID-19 HEALTHCARE WORKERS: 70% ARE WOMEN. These changes were found to impact the women's sleep quality and emotional symptoms including sadness and frustration.46COVID-19 HEALTHCARE WORKERS: 70% ARE WOMEN. There is speculation that these additional changes in the home life may contribute to the higher stress levels in women during the pandemic.40

González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental Health Consequences of the Coronavirus 2020 Pandemic (COVID-19) in Spain. A Longitudinal Study. Front Psychiatry. 2020;11:565474. doi:10.3389/fpsyt.2020.565474

,41d'Ettorre G Ceccarelli G Santinelli L et al.Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review. Although we did not ask about sleep quality or emotional symptoms, we had similar findings from a statistical perspective, as childcare and eldercare were two variables that contributed to increased stress among our respondents, most of whom were women.Although not statistically significant, free text from open-ended questions revealed that private practice owners expressed additional and unique stressors. For private practice owners the obvious reasons had to do with sustainability due to decreased volume and reimbursement. However, some less obvious stressors included navigating and securing the Paycheck Protection Program (PPP loan) application and the unexpected cost of cleaning supplies and PPE. The stress found in our survey is brought to light in a recent Gallup poll which reported that female business owners have a daily worry and stress level of 62% compared 38% prior to the onset of COVID 19.47Stress and Worry Rise for Small-Business Owners, Particularly Women. Likewise when comparing women to their male counterparts, 31% of women report their mental health has worsened during the pandemic versus only 20% for men.The increased stress reported by many during these times appears to be a multi-factorial issue. Some of the top stressors reported in the literature include fear of getting COVID-19 or bringing it home to family,38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates.,,50Coto J Restrepo A Cejas I Prentiss S The impact of COVID-19 on allied health professions. Frey R, ed.. overall fatigue from long hours and shifts among healthcare workers, changes in family responsibilities, ,51Park CL Russell BS Fendrich M Finkelstein-Fox L Hutchison M Becker J. Americans’ COVID-19 Stress, Coping, and Adherence to CDC Guidelines. lack of job security and economic consequences,38Taylor S Landry CA Paluszek MM Fergus TA McKay D Asmundson GJG. COVID stress syndrome: Concept, structure, and correlates.,,51Park CL Russell BS Fendrich M Finkelstein-Fox L Hutchison M Becker J. Americans’ COVID-19 Stress, Coping, and Adherence to CDC Guidelines. and the United States election. In this current survey, the open-ended statements illuminate the vast breadth of stress experienced. Answers varied from obvious and somewhat expected answers such as fear of sickness and exhaustion from juggling children suddenly home and learning on-line, to less obvious stressors such as the political environment in the US, the lack of vacation time, an inability to travel, and the fatigue of constantly wearing a mask and cleaning. Some of these free texts statements provide valuable insight into some of the more obscure stressors that may impact people during a pandemic, highlighting the fact that stress experienced during these times may have many facets, people may not be seeking necessary help to deal with the stress,38Taylor S L