Creatively Adapting Touch-Based Practices to an Online Format during COVID-19: A Thematic Synthesis of Qualitative Studies

Background: The COVID-19 pandemic has led to a rapid shift towards online delivery of services across many touch-based fields, such as manual therapy, psychotherapy, arts-therapy, creative arts practices, and the fitness industry. These fields have faced significant challenges in adapting their face-to-face working methods to an online format, particularly because they typically rely on physical touch and close proximity. Objective: The aim of this systematic review was to explore innovative and creative working methods that have been developed by touch-based fields to adapt to the new online format during the COVID-19 pandemic. Methods: Seven databases were searched, as well as grey literature. Eligible were studies that presented innovative and creative methods for online delivery, specifically considering the limitations posed by the absence of proximity and touch in online settings. As only qualitative studies were found, data were analysed using a thematic synthesis approach. Results: The review includes 17 studies and shows that touch-based fields were able to implement innovative and creative methods for online delivery. These methods were grouped into five main themes: Cross-field adaptations, creative use of online platform tools, adapted working methods to address the lack of touch, creative methods that utilized materials or additional tools, and creative methods that required preparation. While there were challenges due to the absence of physical touch and technological barriers, participants were generally open to adapting to the new format and appreciated the continuation of care and support during the pandemic.


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Original Manuscript
Introduction: During the coronavirus pandemic (COVID-19), many professionals had to adapt face-to-face working methods to suit online formats.This adaptation was particularly challenging in fields that normally rely on affective touch and physical closeness, such as manual therapy and other healthcare disciplines, art-therapy, many creative arts practices, and the fitness industry.Nonetheless, these fields rapidly implemented different methods to ensure access to services and care.Instead of face-to-face meetings, manual therapists delivered telehealth consultations, 5 fitness coaches and movement-based practitioners taught classes online, 6 and midwives offered virtual assessments. 7Sometimes, practitioners built on existing experiences in their field (e.g., in primary care 2 ), sometimes they explored online formats anew or learned from other fields. 8][10][11][12][13] While these publications acknowledged the challenge of the lack of physical closeness and touch-based practices in online settings, they rarely provided concrete resolutions to address this crucial aspect in remote sessions. 12is review aims to bring together diverse touch-based fields to examine and compare their distinct approaches for online practices.Despite their unique scopes of practice, aims and session lengths, these fields share a common feature -the utilization of affective touch to foster trust-based relationships.Before the pandemic, touch played a vital role in interactions within these fields.For instance, manual therapists, nurses, and midwives used touch for physical examinations, hands-on interventions, and displaying empathy and compassion. 14In dance therapy and practice, physical proximity is integral to interactions and serves as an artistic tool.6][17] Amidst the variations in practices, touch proved to be a powerful tool, enriching the overall experience for participants and patients alike.
Recent research in health shows that remote consultations are largely as safe as their face-to-face counterparts -and some evidence indicates comparable clinical effectiveness. 18,19However, the satisfaction levels of both participants and practitioners vary.Artists, for instance, encountered technological and financial challenges when delivering performances online, while manual therapists were resistant to the concept of hands-off care, and patients expressed unmet expectations. 20,21Conversely, benefits such as improved accessibility and lower costs are frequently highlighted by both health practitioners and participants of online fitness classes. 22,23,8ny touch-based professions face similar challenges when delivering services online.Building a sense of allegiance expressing empathy becomes more complex in virtual settings, as does effectively communicating on emotionally profound subjects. 21Nevertheless, online and telephone interventions have become firmly established in various fields, even in emotionally sensitive areas like psychotherapy for PTSD. 24The success of remote consultations is often influenced by preexisting relationships, as familiarity with the clinician can enhance the effectiveness of the interaction. 25Further, manual therapy practitioners also grapple with the complexities of touch during in-person sessions, as touch can trigger both positive and negative associations in patients. 26While online or remote sessions may offer increased accessibility and could be preferable for some individuals compared to direct in-person touch, the existing literature currently lacks information on the adverse effects of simulated touch in online sessions.This area requires further investigation in future studies.
Preliminary evidence suggests that individual practitioners and initiatives approached these challenges in innovative ways by making use of a variety of creative approaches.An online integrative oncology programme, for example, implemented breathing exercises with a spiritual care provider and the visualisation of previous touch-involving treatments has been a success for remote consultations. 9nally, beyond the immediate public health emergency of COVID-19, there is an ongoing need to enhance currently employed online methods. 2 The growing momentum of digital health interventions, as seen in the NHS plans for digital health and social care, exemplifies the significant potential for integrating technology in touch-based practices. 24,29Telehealth is likely to become increasingly dominant in healthcare systems, 19 especially in light of limited resources and for hardto-reach populations or people with reduced mobility 25,26 ; Arts performances and communication events such as conferences routinely happen online or as hybrid formats.Lastly, screen-based fitness or movement classes are firmly established 27 ; and online learning and virtual meetings have become the norm.

Aims and Objectives
This review aims to provide a systematically sourced overview of the literature concerning creative approaches for adapting touch-based practices to the online format in response to the COVID-19 pandemic.

Methods:
A systematic review was performed, as it offers a recognised methodology for the identification, appraisal, and synthesis of the best available evidence. 28The review protocol was prospectively registered on the International Prospective Register for Systematic Reviews (PROSPERO; available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=379731) The focus of this review are creatively adapted working methods from all touch-based fields to suit the new online format.For the review, adapted methods were considered 'innovative' and 'creative' if they considered the specific challenge of lack of proximity and lack of affective touch in online settings and aimed to achieve a similar outcome or goal as when meeting people in-person.Further, methods that were transferred without adaptation from in-person sessions to online meetings within the same profession were not deemed creative or innovative.We specifically focused on working methods implemented during the COVID-19 pandemic, supposing that the sudden and drastic disruption of in-person practice incubated most innovation from practitioners.

Eligibility Criteria:
To be included in this review, studies had to explore the online adaptation of an artistic, therapeutic or otherwise interactive practice that usually relies on affective touch by providers or physical closeness with participants."Affective touch" describes slowly moving, low-force touch which is often perceived as pleasant (as opposed to instrumental touch, for example used by surgeons). 27,28ategorisation, the review was expected to include physical therapists, manual therapists, fitness coaches, dance artists, dance therapists, body psychotherapists and art-therapists.
Further, articles were included that presented innovative and creative adapted working methods to suit the online format, not just the attempt to transfer offline working methods online and without specific adaptation of the otherwise hands-on element.For example, physiotherapists adapted their ways of working creatively if they used touch to identify an area of pain during face-to-face sessions, yet online they would ask for assistance from a housemate to locate the area of pain instead. 22The Oxford Dictionary defines "creative" as relating to or involving the use of the imagination or original ideas to create something.In the case of this review, adapted methods are considered "creative" if they consider the specific challenge of lack of proximity and lack of affective touch in online settings and aim to achieve a similar outcome or goal as when meeting people in person.
Given the variety of relevant fields and potentially relevant research designs, any study design was included.
The exclusion criteria for the review were studies that only reported on the technical aspects of online delivery and did not focus on the creative adaptations or the experiences of practitioner or participants.Studies that solely focused on online delivery of non-touch or non-interactive practices were also excluded.
No geographic restrictions were applied and primary outcome reports had to be published from 2020 onwards.Since 2020, the active time frame during the pandemic has likely driven the increased development and implementation of creative methods for online settings.Since identifying such methods from a vast and diverse literature can be challenging, we seized the opportunity presented by this brief but dynamic period to uncover and explore these innovative approaches.Publications in English and German were eligible, other languages also included if translations could be obtained.Studies were excluded if no full text could be retrieved, neither online nor through the corresponding author.Table 1 summarises all inclusion criteria.

Exclusion criteria
Not complying with the above inclusion criteria *Adapted methods were considered "creative" if they acknowledged the specific challenge of a lack of proximity and lack of affective touch in online settings, and developed or implemented with the aim of achieving a similar outcome as when meeting people in-person.

Information Sources & Search Strategy:
A systematic search was carried out in November 2022 in the following databases: Medline, APAPsych, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), SportDiscus, the International Bibliography of Theatre & Dance, and the Allied and Complementary Medicine Database (AMED).These databases were selected to include the most relevant databases across a variety of fields that usually rely on physical closeness.Search terms were adapted to individual databases and librarian support obtained.The search strategy followed the 'PICO' (Population, Intervention, Control, Outcomes) framework as presented in the Cochrane Handbook 29 and was developed under consultation of published literature, experts who are part of the research team (health researcher, arts, and sociology researchers) as well as an expert in systematic review methodology.Indexing and free-text terms were used in combination.Following the suggestion by Butler et al. 30 , we utilized a modified version of the PICO framework to organize our research question and establish inclusion criteria.Appendix 2 presents the search strategy for Medline as an example.
The search terms covered the concepts "touch" AND "intervention terms" AND "profession names".The complete search string can be found in Supplementary Materials.Following iterative testing of the search strategy, terms like 'haptics,' 'tactile,' and 'palpation' yielded unresponsive search results.Consequently, only the term 'touch' was retained and utilised in the final search strategy.Appendix 2 shows how the PICO tool was used to structure the research question and search terms.
In addition, to capture all relevant work across this large variety of fields and because many artists do not publish their research in academic journals, grey literature was searched manually through Scopus, Google Scholar, the Google search engine, and Academia.edu.Searching for grey literature was similarly structured around the concepts of "adapted working methods during the pandemic", "telemedicine AND touch", "remote OR online AND dance performance", "artists AND adapted working methods AND pandemic".Known arts organisations were also searched for specifically, and relevant links followed up on (for example from blog entries or news articles to artists' primary websites).Further, a librarian of the Jerwood Library of the Performing Arts in London helped identify relevant arts-related resources from their collection.Finally, reference lists of included articles were searched. 31lection Process: Before screening, all resulting references from the database search were imported into EndNote and duplicates removed.
Title and abstract screening were conducted in duplicate and in a blinded manner blinded to the parallel reviewer's judgement.Two reviewers (GG, JW) screened the remaining articles using the Covidence platform for systematic reviews. 32In a first step, titles and abstracts were screened against the inclusion and exclusion criteria in Table 1.Next, the remaining articles were accessed in full and again screened by two independent reviewers (GG, DH).Conflicts were resolved by discussion and agreed by consensus.
After identifying studies via other methods discussed above, all additional records consisting of academic dissertations and published academic articles were recorded.These were screened by two reviewers and examined using the same inclusion criteria as for the database search screening.Remaining records were assessed for eligibility and were included in the review.By appraising each study against the same criteria and recording the results, the basis for the review's conclusions were made transparent.

Data Collection:
A data extraction form was created to capture pertinent information related to the review's research questions.To ensure its effectiveness, a draft extraction form was tested on three papers by one researcher (GG) and refined accordingly.Data extraction was then carried out by one reviewer (GG) and cross-checked by another (DH) using the standardized form, covering aims, study details, design, data collection, setting, study population, field of study, and country.The cross-checking process involves comparing the extracted data with the original sources to identify any discrepancies or variations, which are collaboratively resolved by the two reviewers.This quality assurance step strengthens the reliability and credibility of the review's findings, ensuring accurate data synthesis and analysis.
The following information was extracted from the Included articles: author(s), year of publication, research aim, design and data collection methods, study population, settings, country, field of study, practitioners backgrounds, telehealth methods, original method that underwent adaptation, participants experiences with adapted working methods, practitioners experiences with adapted ways of working, requested improvements for online sessions, adapted working methods: crossfield methods, adapted working methods for sensorial experiences and non-physical connections, tips to increase telehealth acceptability.

Quality Appraisal:
Methodological quality of the included studies was appraised using the tools by the Critical Appraisal Skills Programme (CASP), allowing for separate assessment of qualitative, quantitative, and mixed methods studies.The CASP tools do not have a numeric rating system because their primary aim is to promote a rigorous and comprehensive critical appraisal of research studies without oversimplifying the process.The CASP tool for appraising qualitative studies has been divided into ten sections including: Statement of aims, methodology, research design, recruitment strategy, data collection, research-participant relationship, ethical issues, data analysis, findings and valuable to us.Quality assessments were completed by one author (GG) and cross-checked by another (DHS) to ensure accuracy.Please see Table 3 for the included studies' quality assessments using the CASP tool.

Synthesis:
Thematic synthesis 33 was used, which is an approach that mirrors thematic analysis used in primary qualitative studies.In brief, thematic synthesis is a three-stage process that moves iteratively between the coding of text identified as relevant from primary studies, the identification of descriptive themes, and the generation of analytical themes across the analysed studies. 33ecifically, the first analysis stage involved line-by-line colour coding of creatively adapted working methodology one reviewer (GG).Coding was inductive, with the set of codes expanded as additional studies were added. 33At least one code was given to all statements relating to creatively adapted working methods However, statements often had multiple codes.The preliminary codes were discussed and refined by the review team (GG, DH, RC).Example codes included 'self-touch exercises' and 'interested patients'.An example for the line-by-line coding can be found in the Appendix (1).
In the second stage, groups of related codes were identified, and combined into broader descriptive themes by one reviewer (GG) and cross-checked by another (DH).To ensure coherence, the process involved repeated reference back to the papers from which codes had been derived.The third synthesis stage involved comparing the descriptive themes across fields and analysing findings in relation to overarching topics.

Role of the core research team
We considered and acknowledged the influence of our individual perspectives on the findings and their presentation: We are all UK-based researchers, with GG and JW having a background in the creative arts, currently undertaking postgraduate training in the arts and having qualitative research experience.RC has a background in the creative-arts and sociology and is currently an assistant research professor at Coventry University.DH is a clinician-academic with backgrounds in osteopathy and clinical pain research and an expert in systematic review methodology.All researchers have individually led projects on online performance arts, online community dance projects, or remote consultations for manual therapists, respectively, during the early phase of the COVID-19 pandemic.

Description of included studies
We identified 916 records from our database search after excluding duplicates.After screening the papers for title and abstract, 66 papers were accessed in full and again screened.6 papers met the review inclusion criteria.We identified a further 17 records by searching via other methods mentioned above.After screening the records against inclusion and exclusion criteria, 11 of those records met the inclusion criteria.Please see Figure 1, displaying the Prisma Flow Diagram for the search.
In total, 17 publications were included in the review.A detailed overview of the characteristics of individual included studies can be found in Appendix 3.All study designs were considered, however only qualitative papers were found to be relevant after the screening process.All studies were published between 2020 and 2022, with the majority of studies being published in 2022.Studies were mainly conducted in the US and most were case studies.Further, studies included a large range of fields with art-therapists and dance artists being the most included fields.Online platforms being used for remote sessions varied.For a detailed description of studies, see Table 2.All methods were appropriate for qualitative designs, presenting clear aims, results, and implications.Lower-scoring papers usually provided less information on ethics, data collection, or research-participant relationship considerations.Generally, data collection methods were suitable, although sometimes important details were missing: Authors rarely commented on their relationship with participants or the implementation of ethical procedures, even though approval had been granted.Nine studies mentioned the number of their study participants which on average involved 320 people.Number of participants ranged from a minimum of two to a maximum of 15,334.Eight studies did not mention the exact number of study participants because the number was not reported.Information about the study population of all included studies and their number of participants can be found in Table 4.

Qualitative results
Creatively adapted working methods to suit the new online format were identified and grouped into five reoccurring themes that are described below and summarised in Appendix 7. Studies contributing to each theme are shown in Appendix 6.A minimum of five studies contributed to each theme.Themes included: Cross-field adaptations; Adapted working methods for sensorial experiences and non-physical connections; Creative methods that made use of materials or additional tools; Creative use of Online Platforms tools/ Additional Technologies ; Creative Methods that required preparation.Themes will be discussed below.'Original methods that underwent adaptation' was another analysis theme but will only be presented as part of the summary table and found in Appendix 7 to contextualize findings for readers.
While there may be some overlap between the themes, each offers unique insights into the innovative responses adopted during the pandemic.They all explore various methods employed by practitioners to recreate a sense of touch and connection online.The themes serve as a way to categorize these methods, although some could be combined or interlinked with one another.For instance, an arts-therapy group utilized different objects in participants' homes while simultaneously connecting through the online platform WhatsApp.They shared their creative outcomes as part of an online WhatsApp exhibition.In this case, both materials and technology played a role in fostering connection and creating a sense of touch despite the physical distance, so that this method informed two different themes.Table 5 provides an overview of the themes, along with their descriptions and examples.For an online performance, participants had to hide underneath a blanket before joining the online performance.
Throughout the following section, we present participants' and practitioners' experiences alongside the above-named themes of creatively adapted working methods, where relevant.

Adapted working method: Cross-Field Methods
Five of the included studies presented creative working methods from other fields to adapt practice to the new online format.5][36] These techniques required participants to become active and to focus on their internal states rather than on external feelings or perceptions: 34(p.26)p.7)This shift required participants to become active and engaged, especially when trying techniques that focused on 'felt' or 'sensorial' experiences. 22,36p.6)Some of these methods such as breathing exercises also required the support of a caregivers or household member, triggering new forms of communication and ways to feel connected to one another, for example during online couple therapy:

Inspired by meditation activities to shift the body's attention to its relationship with the surroundings and to re-shift the body's attention to its sensorial imagination[…]
p.204)Notably, only a study from integrative oncology specified that experts from other fields were involved in delivering these techniques borrowed from other fields as part of their online sessions. 9For all other studies, it was unclear whether experts from other fields were involved in either the planning or implementation of cross-field methods.Nevertheless, practitioners appreciated the support of inperson caregivers or other therapists performing home visits, as they could be instructed to help with the treatment even though they were not themselves considered expert. 35

Adapted working methods to recreate sensorial experiences and nonphysical connections
Many practitioners chose to include self-guided and self-administered exercises involving self-touch, self-massage, self-holding, self-acupressure, self-acupuncture, self-delivered palpation, and self-administered manual touch therapies to address the challenge of not being able to touch participants directly during online sessions. 9,22,37Most studies mentioned that participants enjoyed learning new skills and that they were open to self-treat or willing to adapt.However, some participants found it difficult to adapt.For example, patients of manual therapists were worried about self-administering touch-involving exercises, art-therapists' patients often mentioned the lack of personal connections due to screens as a barrier, 9,15,22 and dance or fitness class participants missed contact-based corrections of movements or postures. 6,23Practitioners welcomed having to upskill their communication skills in order to offer precise and direct instructions via the screen. 22evertheless, practitioners also often mentioned the lack of support or training when having to guide touch-based exercises.Consequently, they highlighted the need to develop new working methods and adequate training. 9,22,31,34,38,39other way to deal with the challenge of 'no touch' online was to ask carers, family-members or housemates to support the treatment by administering guided touch-involving methods.For example, they were asked to locate acupressure points or to report back about how a body area feels.Further, to enhance treatments, people present at the participant's location were often encouraged to participate in tasks such as relaxation exercises or to sit back-to-back with the participant to show support and to enable physical connections. 9,35,36me practitioners also chose to involve objects or materials to create sensorial opportunities for their participants. 6,15,15,40Touching objects or props and even other household members were methods used to recall past encounters and to evoke sensorial memories.Especially, when other household members were not present, pushing or leaning against walls was used as a method to re-create touch-like sensations and physical boundaries. 41Two studies made use of different scents while encouraging their participants to touch objects such as a blanket or the surrounding environment to draw associations between the sensations of the body at a specific location of the room and the memory of a sensation that the scent triggered. 34,42For example, an apple spice scent placed inside a pre-arranged safe environment brought about a sense of familiarity and comfort, which reinforced the experience of an enclosed space and state of equilibrium. 34t-therapists mentioned that some materials were particularly impactful when creating sensorial experiences for participants, such as clay or blankets, towels, and pillows. 15,41Authors stated that these objects were used to 'contain', 'center' and 'move' energy.By manipulating these objects with eyes closed, sensory experiences were triggered for participants that related to past experiences. 41

With a loss of person-to-person touch due to the distancing measures following COVID-19, the sensorial opportunities provided by the art materials, particularly clay, have become even more of a consideration when planning the session (Art-therapist)
. 15(p.195) Lastly, many practitioners from different fields, such as dance, art-therapy and theatre chose imagination as a tool to let participants re-engage with their sense of touch.To support participants in imagining touch-like sensations, practitioners used different methods.These included the use of guided imagery or voice recordings involving sensory imagery, and sounds of objects touching.34,37,39   Regarding the lack of shared physical space, creating online spaces for people to connect and to build communities was an effective way of dealing with loneliness or separation anxieties.Here, screens and new technologies offered participants new ways to connect with friends, colleagues or other participants, producing new sensory experiences of touch, connection, and care: Because even though you are not physically there with each other, you can still push each other through the screen.p.10)Another creative way to connect to participants online was to inquire about participants emotions, feelings, hobbies, experiences or senses (e.g., What is your heart telling you?What are you sensing in your room?). 43urther, by covering and uncovering the camera to explore transparency, opacity, closeness or distance, theatre practitioners tried to address social distance and physical separation. 40During online theatre performances, artists chose to divide the screen into four active panes but only one was occupied by an actor.The other panes displayed objects or materials relevant to the actor's scene, however the actors were not visible in the screens, yet audible.This created a sense of coexistence even though all artists were in separate locations. 44See Figure 2 for a visual demonstration of the four panes:

Creative methods that made use of materials or additional tools
All practitioners made use of some materials, objects or additional tools to creatively adapt to the new online format and to engage their participants effectively.
40]45 The sharing of personal items helped practitioners to connect personally with their participants.Also, practitioners believed that the personal environment of their participants helped participants to foster imagination and to make them more comfortable.
p.9)In art-therapy, practitioners used materials from patients' homes to make costumes for digital role plays.In dance training and fitness, they encouraged participants to share personal materials such as photographs. 23[40] Engaging many participants across the globe, a project initiated the creation of a digital quilt.Here participants were invited to create a square with materials available in their own homes in response to social and political concerns: p.185)Practitioners appreciated to be able to work with participants from different areas, making their sessions more accessible to a larger population without geographic or temporal barriers. 15,34,36,37,40,41,43,44e way for participants to choose materials or objects in their homes was to create a treasure hunt as part of online fitness classes.Here, participants were asked to, for example, find an object that helped them through lockdown and to share it with the group. 4The sharing of personal items fostered the connection to other participants and practitioners.
In a few cases, practitioners included objects from their own homes, with one study mentioning the use of a doll as a communication tool, to model what the physiotherapists wanted the parents/caregivers to do with their children. 35r some practitioners, it was relevant to send out materials to participants homes to ensure equal accessibility or to enable group work with similar materials. 15For example, to take part in an online multi-sensory performance, participants were sent a box that included a score, a booklet, two soundtracks, two jars with perfumes in solid state, and a blindfold. 34art from using objects or materials, practitioners included creative methods to keep their participants physically and mentally engaged.During an online couple therapy session, participants were asked to stand on a foam roller while being supported by their partner to foster trust. 36Allied health clinicians often included walking and running exercises for patients to perform in their own time, 22 and art-therapists provided seated stretches or 'freeze dances' to keep their participants actively engaged and emotionally aware via a screen. 45In one case, physiotherapists started singing to their underage patients to keep their attention: She (mum) was able to put the laptop with my face on it right in front of him.p.6)To further enhance the experience of all participants during online sessions, one study also points to the importance of acknowledging different learning styles.Visual, auditory and tactile learners all experience online working methods differently, with visual learners thought to benefit most from online sessions as they are more focused on the visual aspect of online platforms and more engaged with the practitioner.One study found that tactile learners, however, experienced their biggest gains in their affective state and auditory learners generally preferred in-person methods over online learning.Therefore, when preparing online sessions, practitioners might be well-advised to consider a variety of exercises geared towards a range of learning styles (i.e., visual, tactile, and auditory). 6

Creative use of Online Platforms tools/ Additional Technologies
Practitioners often used the tools available on different online platforms in creative ways to decrease the otherwise felt distance via screens and to create personal connections online.
For example, during online dance sessions, practitioners utilized the spatial framing of the Zoom screen as an aesthetically engaging teaching tool.They played with proximity and distance as well as different angles or framing: p.16)Similarly, the screen was turned into a theatre, where the performer can disappear and only share certain parts of the body or pre-selected objects in a certain order to create a storyline. 38,40rther, platforms were used to share videos, photos, documents, and links to additional online tools, including YouTube videos.A creative way of utilizing an online platform was to use the gallery feature of WhatsApp as a virtual gallery, echoing the original approach of exhibiting artworks 15 .Further, virtual backgrounds were used to enhance the aesthetic experience of participants. 38ing beyond the features available on the online platform Zoom, screen recordings were used as film material to create collage films 37 and TikTok's video editing tools were used to create essays in the form of short videos: p.22)In order to engage participants more directly, the chat function of online platforms such as Zoom or Microsoft Teams was used, where participants were encouraged to chat, use emojis, share emotions or to participate in polling. 44Further, TikTok's 'duet' or 'react' functions were used to add on to other participants' uploaded videos: p.22)Regarding group sessions, the break-out room feature on the online platform Zoom was a creative way to keep participants engaged and enable separate groups to work together.Further, a virtual foyer after online performances allowed participants to connect and to share experiences: (…) not only sharing their experience but also becoming actively curious about other people's experiences, critically evaluating the work, and more importantly voicing their concerns and/or suggestions. 34nother successful way to engage participants online was to utilize additional software tools such as Adobe, Canva, Power Point, network games, and whiteboards to make art together or to engage groups of people in one activity. 38,45metimes, additional equipment was used to enhance the experience.Connecting external cameras allowed for a larger field of vision and software tools such as QLab were used for an online theatre production to control sound and video effects.A remote-control software was also used so that a member of the technical crew could log into another person's computer to control the computer over distance. 44,46During hybrid art-therapy sessions, a projector and a screen were employed at the front of a room with dual webcam coverage to help create context and to maintain flow for participants in other locations. 46egarding the use of technology, many participants from different fields were worried about not being able to use new technologies without prior instruction and some were not able to due to a lack of technology available in their homes.This highlighted inequalities and the need to secure further funding or adequate equipment for online sessions.On the other hand, whenever participants had access to the right technology and prior knowledge, many accepted the use of new technology as it offered new solutions and they sometimes acquired new skills. 6,9,15,15,22,35,40,45,46pecially practitioners mentioned many challenges regarding the use of technology, such as screen fatigue, technological issues, limitations of the camera, distraction and the self-view problematic.Yet most practitioners agreed that technologies enabled them to be able to continue with their online sessions.They also felt that they were largely able to read facial expressions and body language via screen. 6,9,15,22,35,36,39,40,43eative Methods requiring prior preparation of practitioner or participant Some creatively adapted working methods required the practitioner or participant to prepare before the actual online session.Preparing participants, family members or caregivers for specific telehealth services and creative methods prior to the online session ensured participant safety, less interruptions, and clearer expectations. 35,37For example, an online multi-sensory performance delivered written instructions and sketches to the participants to prepare the room (e.g., clear the space to move around in) and to look for additional materials in advance of the actual performance. 34Another online performance asked participants to prepare and set-up their phone on their bed in order to then listen to pre-recorded sound recordings covered underneath a blanket. 37actitioners from healthcare included pre-appointment medical imaging such as MRIs and arttherapists used survey-style questionnaires for assessments prior to the online session.This allowed practitioners to prepare for the session in advance.These ideas were specifically added for their online practice and were not necessarily included during in-person sessions. 22,45rther, practitioners sometimes had to prepare additional digital materials, for example to guide self-treatment or to offer video documentations about how to make specific materials such as dough to then use during their next online sessions.
p.9)In some instances, such as during online theatre performances, participants were also invited to change their setting on the platform they were using during the online session, for example they had to keep their screens on or off, keep their microphones turned on or off or chose a certain virtual background.All these considerations helped practitioners to ensure less disruptions during their sessions and to create a better online experience for their participants. 40,46scussion: Many touch-based fields developed or implemented creative working methods since the beginning of the COVID-19 pandemic to adapt their in-person sessions to the new online format, including physiotherapists, creative-arts practitioners, art-therapists, and fitness coaches.Our review showed that each field implemented unique and innovative ways of working, which enriched participants' experiences during a difficult time.Some professions implemented similar working methods online despite considerable differences in their offline ways of working.For example, art-therapists, dance artists, integrative oncologists, and allied health clinicians all incorporated self-treatments.Further, art-therapists, fitness instructors, dance artists, psychologists, and physiotherapists all used materials or objects from participants' homes to creatively involve people over distance.
Other methods were more field-specific, such as creating a virtual 'foyer' after an online multisensory performance.However, these methods might still be transferable to other fields in the future.An online session of a group pain management program might, for example, equally benefit from a virtual foyer (or 'waiting room') prior or after sessions aiming at re-creating the informal waiting room experience remotely to facilitate the informal meeting of patients with similar symptoms, the exchange of personal experiences regarding the therapy program, and to find peer support.Further, creating a digital patchwork of art in response to personal experiences, hopes or fears might not only lend itself to art-therapy sessions but also to integrative oncology patients who often must deal with their feelings alone. 47ing pre-recorded voice recordings that include sensory imagery can help remember touch and awaken sensorial experiences.This method could benefit not only dance artists and their audiences but also patients who feel disconnected from their senses and seek support from manual therapists or psychotherapists.Describing any of the five human senses is categorised as sensory imagery, a commonly used stylistic device in all forms of literature where it helps to create mood and enables the reader to picture the story's setting. 48Sensory imagery instructions such as "This might feel like cold water washing over you" or "My cold hand is resting on your warm shoulder, it will feel heavy" can allow participants to recall sensorial experiences by accessing their haptic memory, especially relevant during a time when actual physical contact is limited. 49ing beyond the scope of this review, other innovative in-person methods which were developed long before the COVID-19 pandemic could equally lend themselves to the new online format.][52] Notably, the stroking of pets can reduce anxiety levels in patients even if patients are not considered animal lovers. 53Further, a study found that any odor that for a given individual evokes a happy autobiographical memory can have a beneficial effect on their health. 51Lastly, the use of objects can enhance the treatment during speech and language therapy sessions for children. 54hile these methods do not inherently hinge on face-to-face interactions, their successful adaptation for online sessions and other eHealth approaches should be undertaken with due consideration for the specific therapy and context, mindful of practical constraints that may arise.These innovative ways of working could be especially impactful for practitioners who experienced the lack of physical contact as a barrier or who struggle to connect to their participants on a personal level during online sessions.The potential for borrowing innovative working methods from diverse fields warrants further exploration.If found to be practicable, this approach may underscore the value of transcending professional boundaries, particularly within the digital realm.
Innovative working methods mentioned in this review incorporate a lot of 'humanness' and emotion into one's work, which has often been considered lacking when working online. 55The physical risk of such methods is relatively low.However expectations of participants may have to be set accordingly.p.2) 58 The fact that art-therapists were so creative may be due to their training, but non-existent expectations or an open-mindedness of their participants might have also influenced their risk-taking when implementing new creative methods. 59herefore, it seems important to set accurate expectations and to explain possible new, creative working methods to patients prior to an online telehealth session.
Apart from setting accurate expectations, it is important to acknowledge the different contexts of healthcare settings as practitioners working in public healthcare systems often do not have enough time to implement creative, sometimes time consuming methods.The main application for above named methods will therefore likely be for private practitioners, longer public healthcare sessions or digital therapeutics.For instance, digital therapeutics can leverage pre-recorded audio files accessible through an app to enhance treatment plans.These audio files could provide patients with guided ways to imagine and visualize touch.By incorporating this feature, digital therapeutics can offer a more immersive and effective experience for patients, contributing to improved therapeutic outcomes.
The significance of touch in hands-on fields such as manual therapy, art therapy, psychology, fitness coaching, dance, integrative oncology, and physiotherapy justifies a collective effort to develop practical methods that transcend physical barriers and promote accessibility, including online touchbased practices.Online interventions are especially relevant for individuals seeking touch-based benefits while also desiring greater agency over their experiences.The online format empowers participants to engage in touch-based interventions from the comfort and privacy of their own homes.Interestingly, some individuals may find that the physical distance in online sessions paradoxically fosters a stronger sense of connectedness.Online touch-based practices hold particular promise for individuals facing barriers to in-person interventions, such as geographical constraints, physical disabilities, or other circumstances limiting face-to-face sessions.Therefore, this review invites practitioners from diverse fields to draw inspiration from the innovative methods discussed and explore their applicability to their own online practices.
Further, when finding it difficult to imagine how field-specific working methods could be adapted to suit someone's own practice, we recommend reaching out to experts in the field in order to find creative ways of adapting or incorporating cross-field methods.Health practitioners, for example, could work closely with Yoga practitioners when wanting to implement breathing exercises during their online sessions to ensure their techniques are correctly applied and beneficial.Involving fieldspecific experts during the development phase of new working methods will arguably be key in ensuring successful implementation.
As seen in the past, collaborations across fields have often been seminal in developing innovative ways of working and ensured a more tailored support for participants.1][62] For example, arts engagement in childhood can support child development, enhancing mother-infant bonding, speech and language acquisition, and educational attainment. 63,64Regarding online ways of working, we similarly believe that collaboration and exchange between fields is key in the future to learn from each other's success or challenges.Only by stepping out of their comfort zones, practitioners from different fields will be able to develop original and seminal working methods for the digital realm.

Strengths and limitations
The strengths of the present study include the fact that it is the first comprehensive qualitative synthesis to focus on creatively adapted working methods by touch-based fields to suit the new online format, offering some ideas about how to adapt in-person working methods across fields.As a multidisciplinary team, we conducted a comprehensive literature search and thematic synthesis to identify repeated themes across studies in regard to creative working methods and to participant's and practitioner's experiences when working online.Our concurrent presentation of creatively adapted working methods as well as challenges and advantages of participant's and practitioner's experiences permitted a comprehensive understanding.
This systematic review has several limitations that should be considered when interpreting the results.Firstly, the results were reliant on how primary data were interpreted and reported, thus potentially carrying over primary studies' biases and limitations.All only examined qualitative literature and did not include quantitative studies, as none were relevant to our review.Additionally, the reporting of touch-based activities in many screened and potentially eligible articles was often lacking, preventing us from including these studies in the review.Another potential limitation of this review is the lack of analysis on sociodemographic/protected characteristics, which may limit the generalizability of findings for marginalized groups and their experiences with online/web-based methods of healthcare.Further, data extraction and quality appraisal were performed by one author, while the second author cross-checked the data against the original articles.Compared to duplicate extraction, this approach may have introduced discrepancies in the process.This was, however, considered acceptable given the qualitative nature of the information (as opposed to numerical extractions which may be more prone to extraction errors).However, the main analysis employed only qualitative data for which text passages were extracted with, arguably, little potential for error.Finally, the review focused on the impact of the COVID-19 pandemic on the practice of touch-based activities online and did not include studies conducted prior to the pandemic.Future research could consider incorporating these studies to provide a more comprehensive understanding of the subject.

Conclusion
In conclusion, our systematic review provides evidence of the crucial role of innovation and adaptability in touch-based fields, specifically in terms of increasing accessibility and inclusivity.The results highlight the potential of new methods to enhance the participant experience and emphasize the need for further research to fully understand the long-term effects and sustainability of these adaptations.These modifications could potentially improve traditional methods and automated care, such as digital therapeutics.These findings have far-reaching implications for practitioners and researchers in touch-based fields, as well as individuals who draw on these practices for their wellbeing.As such, we hope that this review will serve as a catalyst for continued exploration and innovation in this area and contribute to the development of accessible and inclusive touch-based practices for all.
Practitioners used imagination and visualization to replicate the sense of touch.Creative methods using materials or additional tools Methods involving physical objects, materials, or digital tools to enhance online sessions and overcome the felt distance via screens.Using a foam roller during a couple therapy session for a trust-based exercise.Creative use of Online Platforms tools/ Additional Technologies Digital methods implemented to enhance the online experience for participants.Using the gallery feature of WhatsApp as a virtual gallery.

Figure 2
Figure2Illustration of a method to create the sensation of shared space online.From Corona Chicken (Part Two).44 Figures

Table 2
Description of Studies

Table 3
Quality assessment of qualitative research using the CASP tool for qualitative studies Appraisal

Table 4
Demographics: Study Population

Table 5
Overview of Themes