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The Patient’s Perspective of in-Home Telerehabilitation Physiotherapy Services Following Total Knee Arthroplasty

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This study aimed at exploring patients' perceptions regarding telerehabilitation services received post total knee replacement. In this qualitative embedded single case study, semi-structured interviews were conducted with five patients who had previously received in-home telerehabilitation post total knee arthroplasty. Participants were asked to reflect on their 8-week rehabilitation process and on their experience with the home telerehabilitation program. Interviews were transcribed and a qualitative thematic analysis was conducted. Six overarching themes emerged from the patients' perceptions: (1) improving access to services with reduced need for transportation; (2) developing a strong therapeutic relationship with therapist while maintaining a sense of personal space; (3) complementing telerehabilitation with in-person visits; (4) providing standardized yet tailored and challenging exercise programs using telerehabilitation; (5) perceived ease-of-use of telerehabilitation equipment; and (6) feeling an ongoing sense of support. Gaining a better understating of the patient's experience in telerehabilitation will be essential as programs continue to be developed and implemented.
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Int. J. Environ. Res. Public Health 2013, 10, 3998-4011; doi:10.3390/ijerph10093998
International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
The Patient’s Perspective of in-Home Telerehabilitation
Physiotherapy Services Following Total Knee Arthroplasty
Dahlia Kairy
1,†,
*, Michel Tousignant
2
, Nancy Leclerc
2,†
, Anne-Marie Côté
3,†
,
Mélanie Levasseur
3,†
and the Telage Researchers
1
School of Rehabilitation, Université de Montréal and Centre for Interdisciplinary Research in
Rehabilitation of Greater Montreal—IRGLM site, 6300 Darlington Avenue, Montreal,
Quebec H3S 2J4, Canada
2
Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Faculty of Medicine
and Health Sciences, Université de Sherbrooke, 1036 Belvédère Sud, Sherbrooke,
Quebec J1H 4C4, Canada; E-Mails: michel.tousignant@usherbrooke.ca (M.T.);
nancy.leclerc@usherbrooke.ca (N.L.)
3
School of Rehabilitation, Faculty of Medicine and Health Sciences, Faculty of Medicine and Health
Sciences, Université de Sherbrooke, 1036 Belvédère Sud, Sherbrooke, Quebec J1H 4C4, Canada;
E-Mails: anne-marie.cote3@usherbrooke.ca (A.-M.C.); Melanie.levasseur@usherbrooke.ca (M.L.)
These authors contributed equally to this work.
* Author to whom correspondence should be addressed; E-Mail: dahlia.kairy@umontreal.ca;
Tel.: +1-514-343-6301; Fax: +1-514-343-6929.
Received: 16 July 2013; in revised form: 15 August 2013 / Accepted: 16 August 2013 /
Published: 30 August 2013
Abstract: This study aimed at exploring patients’ perceptions regarding telerehabilitation
services received post total knee replacement. In this qualitative embedded single case
study, semi-structured interviews were conducted with five patients who had previously
received in-home telerehabilitation post total knee arthroplasty. Participants were asked to
reflect on their 8-week rehabilitation process and on their experience with the home
telerehabilitation program. Interviews were transcribed and a qualitative thematic analysis
was conducted. Six overarching themes emerged from the patients’ perceptions:
(1) improving access to services with reduced need for transportation; (2) developing a
strong therapeutic relationship with therapist while maintaining a sense of personal space;
(3) complementing telerehabilitation with in-person visits; (4) providing standardized yet
OPEN ACCESS
Int. J. Environ. Res. Public Health 2013, 10 3999
tailored and challenging exercise programs using telerehabilitation; (5) perceived
ease-of-use of telerehabilitation equipment; and (6) feeling an ongoing sense of support.
Gaining a better understating of the patient’s experience in telerehabilitation will be
essential as programs continue to be developed and implemented.
Keywords: satisfaction; telerehabilitation; patients; semi-structured interview; qualitative
1. Introduction
Important demographic changes, including an aging population, increased life expectancy and a
greater prevalence of chronic conditions are putting increased strain on health care systems worldwide.
Moreover, the reduced length of hospital stays implies that patients return home sicker and with
incapacities [1–3]. To better meet these changing needs, different modes of health service delivery
have been proposed and developed. For example, home care services are well implemented in Canada.
However, it is recognized that home care cannot respond to the increasing demand for services [4,5]
and the lack of human resources [6,7]. Consequently, in-home telehealth, including telerehabilitation
programs, are becoming increasingly common as an alternative mode of service delivery.
Telerehabilitation is defined as the provision of rehabilitation services at a distance using information
and communication technologies [8–10].
Several studies have examined in-home telerehabilitation programs. Initial studies confirmed the
technical feasibility of in-home telerehabilitation [11–13]. More recent studies explored the efficacy of
such services in many patient populations and a number of systematic reviews and reports have
summarized these findings [8,14–17].
The successful implementation and integration of telehealth programs, including home telehealth,
remains slow [18]. It is increasingly recognized that the patient’s perception of the services should be
taken into account when implementing telehealth, including home telerehabilitation [19]. Despite
recognizing the importance of the patient’s perspective, it remains absent from many studies [20],
as was similarly reported by Mair et al. in 2000 [21]. In telehealth, the patient’s perspective is
generally documented through the concept of satisfaction and is reported using questionnaires and
surveys, primarily addressing the technical aspects of using the technology and the communication
between the participants [22].
In telerehabilitation, a similar trend has been noted [17]. For example, a previous study conducted
reported on satisfaction with in-home telerehabilitation for patients and health professionals following
a randomized clinical trial (RCT) post Total Knee Arthroplasty (TKA) [23]. High satisfaction rates
were noted with three predetermined factors: the technology, the health care services and the
relationship with the health care professional using validated questionnaires. The results obtained from
this quantitative study [23] were limited to the participants’ satisfaction concerning exclusively these
three factors (percentage).
Few studies have reported on aspects other than satisfaction when considering the patient’s
point-of-view. Two studies examined chronic pain sufferers’ perspective of in-home telerehabilitation.
The first used semi-structured interviews with participants who were informed about possible
Int. J. Environ. Res. Public Health 2013, 10 4000
telerehabilitation services [24]. The second used a questionnaire based on the Technology Acceptance
Model (TAM) with participants randomly allocated either to an experimental group who got
information about and could try out a web-based program which provided selected instructional videos
or a control group who only got information about the web-based program [25]. In the first study [24],
the authors reported that patients appreciated the flexibility that telerehabilitation could provide,
but were concerned with the lack of therapist in-person contact on their ability to successfully
participate in an exercise program. In the subsequent study [25], participants were more positive about
the usefulness and ease-of-use of the telemedicine program after experiencing it than before. Thus,
brief use of telemedicine has a significant positive effect on participants’ perception of the technology.
Similarly, in a chronic pain population [26], participant satisfaction (perceived usefulness, ease of
use and intent to use) was documented using a questionnaire based on the TAM, following a
myofeedback-based teletreatment which recorded data that was transmitted to the therapist for a
weekly teleconsultation. The authors reported that for a majority of participants, perceived ease of use
and usefulness increased after using the technology, although this study did not show a relationship
between satisfaction, compliance with treatment and clinical outcome.
Eriksson et al. [27] reported on the experience of patients in Sweden who had recently experienced
in-home telerehabilitation following a shoulder joint replacement using interviews with the patients.
Participants reported “feeling close at a distance” with their therapist who was able to guide them in a
home exercise program, overcoming their fear of pain.
Hence, few studies have explored the patient’s perspective of regarding telerehabilitation, even
though patients’ perceptions can have a significant impact on rehabilitation outcome [28]. This study
aimed at better understanding the patient’s experience of home telerehabilitation. More specifically,
this study explored the perception of patients who have undergone a total knee replacement (TKA)
concerning in-home telerehabilitation services.
2. Methods
2.1. Study Design
An embedded single case study design [29] was used in order to obtain an in-depth understanding
of the patients’ perception of the actual telerehabilitation services received. This type of study
design facilitates the understanding of the phenomenon of in-home telerehabilitation post TKA that
is at the same time context-dependent and influenced by the individual patient’s experience and
characteristics [29,30]. The case analysed was an in-home telerehabilitation program for patients who
had undergone total knee arthroplasty (see Section 2.3).
2.2. Participant Recruitment
In order to recruit participants who had experienced telerehabilitation and given the lack of
actual home telerehabilitation programs, patients were selected from a pool of participants from
the experimental arm of a RCT for in-home telerehabilitation post-TKA. In this context, we used
non-probability sampling. Participants were recruited once they had fully completed their participation
in the study, so as not to impact on the RCT. This study was not designed as part of the RCT TKA
Int. J. Environ. Res. Public Health 2013, 10 4001
(RCT recently concluded and findings not yet published). In order to obtain an in-depth understanding
of the phenomena, a purposive sample was selected, as suggested by Groenewald [31]. In order for
participants to be able to comment on their telerehabilitation experience, and compare it to in-person
types of physiotherapy services, only participants who previously received physiotherapy services in
the community, including but not limited to a previous TKA, were recruited. Eligible patients were
invited to take part in an in-person interview concerning their experience with the in-home
telerehabilitation service. This study was approved separately from the RCT by the appropriate ethics
review boards, with informed consent obtained from all participants.
2.3. Description of the in-Home Telerehabilitation Program
The in-home telerehabilitation program consisted of twice-a-week physiotherapy sessions for
eight weeks (total 16 sessions), each session lasting 45 to 60 min. The content of the intervention was
an adaptation of the Intensive Functional Rehabilitation (IFR) protocol [32]. Clinical equipment
(step, exercise pedal, 3- and 5-pounds weights and elastics) was lent out to each participant for the
entire duration of the intervention. The intervention was aimed at improving walking and functional
autonomy in daily activities as well as mobility and strength of lower limbs. A videoconferencing
system located in the participant’s home was connected remotely through high speed internet to the
health center’s system where the physiotherapist was located. The telerehabilitation platform used was
developed with a user-friendly system to ensure that interaction between clinician and patient during
the session was similar to that of the in-person intervention (Figure 1). The platform is the same as the
one used for previous studies [11,33]. Prior to starting the telerehabilitation services, participants had
never met their therapist in person.
Figure 1. Set-up for in-home telerehabilitation: (A) Videoconferencing system; (B)
Screen; (C) on/off switch.
Int. J. Environ. Res. Public Health 2013, 10 4002
2.4. Data Collection and Analysis
A semi-structured individual interview was conducted with each patient in their home by a research
agent who is a member of our research team and had not been involved in providing the patients’
telerehabilitation services. An interview guide was developed based on the literature in the area of
technology adoption which suggests that concepts such as perceived usefulness, perceived ease of use,
attitude, intent to use, actual use and other external variables will affect how technology is used [34].
Participants were asked to reflect on their entire rehabilitation experience, with a particular emphasis
on key events such as finding out they would receive services at home by videoconference, having the
internet and videoconferencing equipment installed at home and receiving services by videoconference
including dealing with technical issues and completing the 8-week rehabilitation process.
Interviews were audiorecorded and transcribed word for word. Each transcript was read and coded
line by line by one member of the research team using Text Analysis Markup System (TAMS)
Analyzer. We used investigators triangulation such that the interviews were initially analysed by one
researcher and then reread and confirmed by another researcher. When they had differences in the
codification, the researchers arrived at a consensus. The findings were then discussed in group with the
research team thus increasing the validity of the findings. Similarities and differences between the
cases were noted throughout the coding process and overarching themes were identified by the
research team [35].
In order to analyse each unit of analysis or each patient’s perception, we used thematic analysis
by Miles and Huberman [35] as mentioned by Yin [29]. This method provides an exhaustive
description of each unit of analysis (own patient perception of the telerehabilitation).
We then used matrices to explain the whole case and compare between patients to obtain a broader
perception of in-home telerehabilitation.
3. Results
Participant characteristics that could impact on the patient’s experience of telerehabilitation
(e.g., gender, age, work status, type of housing, living alone or not, internet access that was previously
installed or not, functional status prior to surgery) are presented in Table 1. Interviews lasted on
average 55 min, ranging from 37 to 67 min.
Overall, all participants agreed that the telerehabilitation treatment was a good alternative to
in-person physiotherapy sessions. Upon analysis, the patients’ perceptions of in-home telerehabilitation
services post-TKA were regrouped into six main themes as reported in the following section. Verbatim
quotes illustrate the results. Following the analysis in the original French Canadian version, quotes
were translated into English for publication, while retaining the style and meaning of the quote.
3.1. Improving Access to Services
The predominant benefit mentioned by all participants, was the elimination of all transportation
time for both the patient and therapist. More specifically, this was viewed as particularly useful
the first few weeks post-surgery when participants had more pain, as compared to travelling for
out-patient services.
Int. J. Environ. Res. Public Health 2013, 10 4003
Table 1. Patients’characteristics.
Characteristics Participant 1 Participant 2 Participant 3 Participant 4 Participant 5
Gender Woman Man Man Woman Woman
Age (years) 44 72 62 59 70
Years of schooling (years) 15 18.5 15 16 11
Work status Not working Retired On disability Specialized educator (on
leave for recovery from
TKA)
Retired
Living alone Yes No, with wife Yes Yes No, with husband
Type of housing Apartment building Single family dwelling Single family
dwelling
Apartment building Duplex
Stairs at home Yes Yes No Yes Yes
Prior internet service No Yes No Yes No
Years of knee pain (years) 1–5 More than 10 1–5 More than 10 More than 10
Other medical condition Arthritis,
diabetes, anxiety,
disc degeneration
Arthritis, diabetes,
gastro-intestinal
disorder, visual
problem,
hypertension, prostate
cancer
in remission
Arthritis, asthma,
acute respiratory
distress syndrome
(ARDS), angina,
gastro-intestinal
disorder, depression,
anxiety
Arthritis, asthma, diabetes,
depression, anxiety, sleep
apnea, hypertension
Arthritis,
gastro-intestinal
disorder,
hyperthyroidism,
double pulmonary
embolism
Int. J. Environ. Res. Public Health 2013, 10 4004
“I really like it (telerehabilitation). I found it fantastic…you know, just the fact of not
having to travel when we are in pain (…) I adored it…” (participant 2)
Decreased preparation time was reported as a benefit, in particular not having to get ready to attend
an appointment in an out-patient setting. However, two of the participants did not feel that they needed
to save time at that particular point in their rehabilitation, when they are not working or participating in
many activities. Nevertheless, they do consider that telerehabilitation would be of benefit to others as,
according to them, it allows patients to access health services more easily and therapists to see
more patients.
3.2. Developing a Bond with Their Therapist While Maintaining a Sense of Personal Space
Although services were not provided face-to-face, all patients appreciated the contact they have
with their physiotherapist and their availability. All participants felt they developed a relationship with
the physiotherapist who made them at ease to express their needs. Overall, they felt listened to and
felt that they could express their concerns regarding their condition or other more personal issues.
They perceived the physiotherapist as supportive and well informed about their physical condition.
For example, participants reported that they felt as if the therapist was there in person. Moreover,
participants appreciated having informal conversations with their therapist. Four of the participants
mentioned that the therapist became like a family member.
“Well look, she (the physiotherapist), was roughly my nieces’ age. So it was the same as if
I was an aunt with her” (participant 1)
“…we talked about fishing, we talked about hunting, (…) we talked about skiing, hum, of
all sorts of things, while I was doing my exercises, we talked about anything and we
always had something to say. I think that she knew my whole life (laughter) (…)”
(participant 4)
One of these participants even preferred the use of telerehabilitation as compared to having the
therapist come to her home in person, such as was the case for participants who were assigned to the
usual-care arm of the RCT:
“I was satisfied. (...) the fact that she (the physiotherapist) was not with me in the house, I
was less stressed.” (participant 4)
As compared to out-patient services, participants reported that they appreciated the increased sense
of privacy and the bond they developed with their therapist with the use of telerehabilitation, as
compared to being in a physiotherapy department among other patients and therapists. Four of the
participants also felt the use of telerehabilitation provided their therapist with insight into their
home environment.
3.3. Complementing Telerehabilitation with in-Person Visits
A benefit mentioned by all the participants was the perception that the physiotherapist was able to
adequately evaluate via telerehabilitation the amplitude of the knee as well as the scar and their fatigue
and pain. They found the intensity of the exercises and length of the sessions to be appropriate for their
Int. J. Environ. Res. Public Health 2013, 10 4005
condition. Despite participants reporting that the use of telerehabilitation was appropriate for their
condition, three of the participants felt that their rehabilitation should have included some in-person
visits with their therapist. They felt that complementing telerehabilitation with the occasional in-person
visit would improve the physiotherapist’s evaluation of the knee as well as facilitate clinical follow-up.
For example, two participants mentioned that they would have liked more physical contact with a
therapist in order to ensure that they were progressing adequately and to deal with issues that arose,
such as poor patellar mobility, in a timelier manner.
“… she would have seen if she had touched me that my patella was not in the right place.”
(participant 1)
“I’m fairly certain that at least twice, on two occasions certainly if he would have come, it
would have been a plus. Well, maybe psychologically, I think, thinking that he could have
manipulated your knee, to see in a tangible manner and be able to manipulate it, but hum
it’s the suggestion that I would give, to at least meet, I don’t know how often … (…).”
(participant 2)
In addition, two participants compared the assessment findings recorded by their therapist to those
reported by their orthopedist or another therapist. The participant who felt it was important to have
in-person visits with the therapist (participant 1) reported that an orthopedist’s assessment of the range
of motion differed from that of their therapist. On the other hand, the participant who did not feel it
was necessary to have an in-person visit with the therapist reported that their therapist’s findings were
identical to those of another therapist.
3.4. Providing Standardized yet Tailored and Challenging Exercise Programs Using Telerehabilitation
Although participants followed a standardized exercise program, they all felt their therapist tailored
the exercises appropriately thus respecting their fatigue, pain and abilities. They were confident that
the therapists provided appropriate supervision from a distance.
Participants appreciated being able to perform some of their exercise program outside of the
scheduled therapy time, thus increasing their exercise time with their therapist during the sessions.
“I installed the things I needed. Like that, all my bicycle, and hum... my step. I installed
that and it went well. Look, it took 2 min.” (participant 3)
“I got on the bike (stationary bicycle). I was hooked up (by videoconference), and I got on
the bike. Instead of him (the physiotherapist) watching me for 10–15 min, I had already
done a few minutes. So that after that, well, we did the rest.” (participant 4)
3.5. Perceived Ease-of-Use of Telerehabilitation Equipment
The use of new technology was not viewed as a limitation by any of the participants and did
not hinder their appreciation for telerehabilitation. All found it easy to use (“the touch of an on/off
button”) and found the equipment of little inconvenience in the space it occupied or the change it
produced to their home environment. The human aspect surrounding the new technology were
positively viewed including the process of setting up the internet connection, installing the technology
in the home and the trouble-shooting provided by the telerehabilitation team. Participants reported that
Int. J. Environ. Res. Public Health 2013, 10 4006
they did not feel additional stress when receiving services by telerehabilitation even for the few times
when there were communication difficulties. Four participants appreciated the clarity of the sound and
the concordance of the voice and the image, although in two of the five cases there were sessions with
a delay. All participants reported that the image of the physiotherapist was clear. Despite the freezing
of the image reported by one patient, the transmission of the image did not impact on the perception of
the quality of the treatment received for that person.
3.6. Achieving an Ongoing Sense of Support
At the time of discharge from the hospital, none of the participants were worried about receiving
telerehabilitation treatments. They were confident in the telerehabilitation team and considered that the
information provided throughout was clear regarding upcoming steps and appointments.
“They had told me that it would be this way (…). So being advised, you know, you’re ok.
(…) This way, being advised of the date, that the beginning of the treatments will be on
such and such a date. And having the little handouts that said which exercises to do, well
then ultimately, it was positive regardless. We say well we’re heading in, in the right
direction… to recuperate.” (participant 2)
Participants considered the telerehabilitation technical support team as part of team providing
therapy and they all expressed that they felt well supported by the entire team at all times.
4. Discussion
In this study, participants were interviewed regarding their telerehabilitation experience
post-surgery for a TKA as compared to their previous experience with rehabilitation services. Contrary
to the previous quantitative study conducted by our research team about satisfaction of patients
concerning telerehabilitation [23], the analyzed themes of the present qualitative research were
identified after the interviews and covered a larger spectrum of the patient’s experience. Although
participants never met their therapist face-to-face, they felt that their therapist was able to provide a
tailored exercise program, adjusting it to according to their ability, pain and fatigue. Participants also
felt that they developed a bond with their therapist and felt supported throughout their rehabilitation.
None of the participants regarded the videoconferencing technology or the space that it occupied as a
barrier to receiving quality rehabilitation services. Three participants did however express a preference
for combining telerehabilitation with more traditional in-person services.
All the participants in this study were confident that they participated in an exercise program that
was tailored to their needs. These findings differed from that of Cranen et al. [24], where patients
reported their perception of telerehabilitation after receiving an introduction to in-home
telerehabilitation through examples of potential exercise-based telerehabilitation services, without
actually experiencing it. They found that participants were concerned with the quality of the feedback
they would obtain from their therapist when interviewed regarding potential in-home telerehabilitation
services for chronic pain. In a subsequent study [25], patients who were randomly allocated to trying
out a web-based exercise program for a few minutes were more positive about ease-of-use and
Int. J. Environ. Res. Public Health 2013, 10 4007
usefulness as compared to those who did not actually experience it. Hence, actually experiencing the
technology may be important when assessing the patient’s perception of the service.
Eriksson et al. [27] also reported on participants’ perception of telerehabilitation, after experiencing
it following a shoulder joint replacement. In their study, participants felt they received appropriate
feedback and support through actual telerehabilitation following a shoulder joint replacement. Thus,
the actual experience of telerehabilitation may impact on participants’ perceptions of the ability of a
therapist to provide adequate guidance and appropriate exercises from a distance.
An important component of the rehabilitation process is the relationship and trust that develops
between the patient and therapist. Crepeau and Garren [36] describe that the therapeutic relationship
that emerges between a therapist and a patient who meet in-person develops through the use of humor
to establish reciprocity, ordinary conversation to build the rapport and providing attention which
is viewed as caring. In our study, all the patients reported discussing elements of ordinary life
with their therapist, feeling that their therapist was attentive to their needs throughout, and that
a close relationship did in fact develop with their therapist, similar to the findings reported by
Eriksson et al. [27]. In contrast, in Cranen et al.’s study of potential telerehabilitation services, patients
felt that an emotional bond would not develop with their therapist, and that this could have a negative
impact on their rehabilitation outcome [24]. In fact, they expressed that telerehabilitation would make
them feel alienated and would be impersonal. Hence, actually experiencing telerehabilitation seems to
therefore alter the perception of the patient-therapist relationship that can develop [36].
Some participants in our study felt that telerehabilitation should be complemented by hands-on
therapy. Participants expressed that it would be beneficial in order to improve the physical assessment
of their knee, namely palpation and range of motion, and in particular when there is contradictory
information from different health professionals. The desire for some in-person contact with the
therapist was also reported in Cranen’s study [24]. However, in that study, participants considered
in-person contact to be important to ensure emotional support, whereas in our study it was viewed as
important to improve the physical assessment. The differences between these studies may be the result
of changes in perception when participants actually experience telerehabilitation, as mentioned
previously. It may also depend on the medical condition or on what patients are comparing the
telerehabilitation services to, as rehabilitation services can be provided in a variety of modes, including
in and out-patient settings and in-home services. Future studies could assess patients’ perceptions both
prior to and after undergoing therapy at a distance as well as assess whether there is indeed a benefit to
combining in-person and distance services. Combining in-person and distance services could be done
by having one scheduled visit with the therapist or other health professional at the clinical site or
patient’s home, such as midway through therapy, although the impact of this remains to be shown.
In general, patients consistently report more positive views of telehealth, including home telecare,
than do service providers [22]. Although most studies that examine patient satisfaction with telehealth,
including telerehabilitation, report high satisfaction rates, the main area of dissatisfaction reported is
generally with technical difficulties [23]. In this study, patients reported that if technical difficulties
arose, namely difficulties with establishing a connection between the home and clinical site, this did
not impact on their perception of the services received. Indeed, the communication was easily
reestablished or the appointment rescheduled. For these participants, this was not problematic as they
had limited mobility and were generally available at home. In the first few weeks following a TKA,
Int. J. Environ. Res. Public Health 2013, 10 4008
patients have limited mobility and are greatly limiting their activities, mostly because of the pain [37,38].
This may vary for medical conditions where limited mobility is not a primary concern and/or where
the goal is to increase patients’ social participation including returning to work as soon as possible.
Study Limitations and Future Directions
This study provides a first portrait of telerehabilitation as experienced and perceived by patients
who have undergone a TKA. In order to obtain an in-depth understanding of the phenomenon
and ensure that different perspectives would be included in the study, the sample included patients
with different characteristics that could impact their experiences and perceptions of telerehabilitation
(e.g., gender, age, work status, type of housing, living alone or not, internet access that was previously
installed or not, functional status prior to surgery). All the patients however received the same
telerehabilitation services for the same medical condition, had previously had in-person physiotherapy
services, and were recruited from the telerehabilitation arm of an RCT. A sample size of five patients
was used since data saturation was achieved regarding their experience with telerehabilitation, with no
new themes identified after the third interview; the latter two interviews provided additional examples
for themes which had previously been identified. This may in part be due to the similar intervention
received by the participants given the nature of their condition and the rigour of the RCT. While results
from a case study are not generalizable to all contexts, the extent to which findings from this study are
transferable to other settings is increased through a detailed description of the case and context,
allowing readers to extract the pertinent information to their setting [39]. This study provided insight
into patients’ perceptions based on their experiences. Future studies comparing perceptions of
patients receiving different modes of therapy, such as from a distance and in-person would help
better understand the role that prior experience plays in the way patients perceive the services they
receive. In addition, future studies should explore the relationship between clinical outcome and
patient perceptions.
5. Conclusions
While it is essential to ensure the efficacy of telerehabilitation interventions, such as through
clinical trials, a better understanding of patients’ perceptions with its use is crucial as they are the
end-users. This study showed that participants were satisfied with most of the aspects of their
experience, including the access to services, the relationship with therapist, the exercises program,
the technology and the support provide by the technical team. Given that there are few successfully
implemented home telerehabilitation programs, an analysis of patients’ perceptions, as reported here,
can be included as part of larger scale studies. Such analyses would provide essential information to
support the implementation and sustainability of in-home telerehabilitation programs.
Acknowledgements
We thank the participants in this study, the Telage researchers (Hélène Moffet, Sylvie Nadeau,
Chantale Mérette, Patrick Boissy, Hélène Corriveau, François Marquis, François Cabana, Pierre
Ranger, Étienne Belzile, Pascale Larochelle, Ronald Dimentberg) and the research staff at the
Int. J. Environ. Res. Public Health 2013, 10 4009
Research Center on Aging involved in this study. This research was supported by the Research Center
on Aging of Sherbrooke as well as post-doctoral grants (D.K.) from Réseau de formation
interdisciplinaire en recherche sur la santé et le vieillissement (FORMSAV) and the Quebec
Rehabilitation Research Network (REPAR).
Conflicts of Interest
This research was supported by the Research Center on Aging of Sherbrooke. All the authors report
no conflicts of interest.
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© 2013 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article
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... Furthermore, Piraux et al. 19 identified that the application interface may not be suitable for patients with lower technological literacy. Nevertheless, patients reported a high overall level of satisfaction with the teleprehabilitation program, and the authors discussed the added value of reducing transportation burden on patients' schedules 15,16,20 . ...
... Patient's experience. The high satisfaction reported in the current study aligns with many telehealthbased interventions in the perioperative field 16,[18][19][20] . Notably, a telerehabilitation by Kairy et al. 16 aimed to document the patient's perspective of a telerehabilitation program after hip arthroplasty through interviews. ...
... The high satisfaction reported in the current study aligns with many telehealthbased interventions in the perioperative field 16,[18][19][20] . Notably, a telerehabilitation by Kairy et al. 16 aimed to document the patient's perspective of a telerehabilitation program after hip arthroplasty through interviews. In both studies, patients emphasized their appreciation for the technology's ease of use and the reduced need for hospital commutes. ...
Article
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This study documents the implementation of a multimodal teleprehabilitation program (e.g., completion rate, exercise metrics, and program successes and challenges) for cancer patients undergoing surgery. It also documents the patients’ experience of the program. This pilot-cohort study included adults scheduled for elective thoracic and abdominal cancer resection surgery, referred to the prehabilitation clinic to engage in physical activity, and received a teleprehabilitation program between August 1st, 2020, and February 28th, 2021. The technology platform provided to the patients included a tablet and a wearable device to facilitate communication and data collection. Data collected for this article were acquired through virtual physical activity monitoring in addition to patient charts. Qualitative data collected comprised of successes and challenges of implanting a teleprehabilitation program, in addition to patients’ perspectives of the program. Quantitative data collected comprised of the exercise metrics, perioperative functional outcomes, in addition to the surgical and postoperative outcomes. Ten patients (8 males and 2 females; mean age: 68.3 years, SD 11.96) diagnosed with various thoracoabdominal malignancies were included in the current descriptive study. The successes identified were related to recruitment and assessment, improvement in functional capacity, clinic scheduling and interventions, and optimal medical follow-up. The challenges identified were related to the adoption of the technologies by patients and the multidisciplinary team, the accurate acquisition of patient physical activity data, and the initial costs to acquire the new technologies. Patients were satisfied with the teleprehabilitation program (i.e., services delivered; average appreciation: 96%), and they perceived the technologies provided to be 90% user-friendly. The findings of the current study highlight important concepts in view of the current international health paradigm changes prioritizing remote interventions facilitated through digital communication technologies. It provides important insight into the clinical application of telehealth in elderly populations, notably in the context of acute preoperative cancer care. This article may provide guidance for other cancer care facilities aiming to implement teleprehabilitation programs.
... The seven papers included two from New Zealand, two from Australia and one each from Canada, United States of America and Denmark. They were from a spread of clinical specialties including palliative care (Funderskov et al., 2019), primary care (Bazzano et al., 2018;Imlach et al., 2020;Wright & Honey, 2016) and three from musculoskeletal care (Hinman et al., 2017;Kairy et al., 2013;Lawford et al., 2018). The approach to non-face to face consultations included video consultations alone (x3), telephone alone (x1) or conducted pre-SARS-CoV-2 pandemic and one (Imlach et al., 2020) was conducted during the SARS-CoV-2 pandemic. ...
... To overcome some of the technical issues an 'easy-to-use' kit was provided and evaluated by Kairy et al. (2013) The quality of internet connections was discussed in the studies, with particular reference to variable or poor internet quality (Hinman et al., 2017;Imlach et al., 2020), poor sound quality (Wright & Honey, 2016) ...
... The building of therapeutic relationships is noted in six of the studies as the foundation for providing a positive experience for both patients and clinicians (Bazzano et al., 2018;Funderskov et al., 2019;Hinman et al., 2017;Imlach et al., 2020;Kairy et al., 2013;Lawford et al., 2018). A pre-existing relationship between patient and clinician was seen to facilitate the building of a rapport in a remote setting with the physiotherapists in Lawford et al. (2018) study of the use of Skype, reporting that physiotherapists found video consultation somehow more personal than face to face and Imlach et al. (2020) primary care study reported patient participants responding similarly about a more 'human' interaction than in the busy GP surgery. ...
Article
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Aims: To identify, evaluate and summarize evidence of patient and clinician experiences of being involved in video or telephone consultations as a replacement for in-person consultations. Design: Narrative synthesis. Data sources: Medline; EMBASE; EMCARE; CINAHL and BNI. Searching took place from January 2021 to April 2021. Papers included were published between 2013 and 2020. Review methods: Papers were appraised by two independent reviewers for methodological quality. Data extraction was conducted according to the standardized tool from Joanna Briggs Institute. Results: Seven qualitative studies were included, from five countries and from the perspective of patients, relatives, administrators, nurses, physiotherapists and physicians. We developed two main themes: Pragmatic Concerns and Therapeutic Concerns. Each theme contained two categories: Pragmatic Concerns: (a) the convenience of non-face to face consultations; (b) using technology and equipment in a consultation; Therapeutic Concerns (c) building therapeutic relationships; and (d) embracing benefits and addressing challenges. Conclusion: This narrative synthesis presents the existing evidence on clinician and patient experience of participating in non-face to face consultations. Experiences are varied but largely focus on communication and forming relationships, using the technology successfully and the ability for patients to self-manage with support from clinicians who are not in-person. More high-quality studies are required to explore the experiences of patients and clinicians accessing remote consultations as a result of global implementation post-SARS-CoV-2 pandemic to identify any learning and education opportunities. Impact: Health care staff can provide high-quality care through video or telephone appointments as well as face to face appointments. This review has, however, identified that the evidence is limited and weak in this area and recommends there is research further to inform practice and influence future care.
... Home-based rehabilitation methods have been developed to accommodate recent trends relating to available PTs and the number of patients requiring therapy. Compared to inpatient or outpatient rehabilitation, home-based interventions are less expensive [9][10][11][12] and more accessible [12,13]. One critique of at-home rehabilitation, however, is decreased regimen adherence that is usually seen in unguided or unsupervised rehabilitation [14]. ...
... One critique of at-home rehabilitation, however, is decreased regimen adherence that is usually seen in unguided or unsupervised rehabilitation [14]. However, important advantages of at-home rehabilitation, as described by patients, include ease of use of many currently available systems, decreased stress, and "not having to travel when we are in pain" [13]. ...
Article
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In this work, a knee sleeve is presented for application in physical therapy applications relating to knee rehabilitation. The device is instrumented with sixteen piezoresistive sensors to measure knee angles during exercise, and can support at-home rehabilitation methods. The development of the device is presented. Testing was performed on eighteen subjects, and knee angles were predicted using a machine learning regressor. Subject-specific and device-specific models are analyzed and presented. Subject-specific models average root mean square errors of 7.6 and 1.8 degrees for flexion/extension and internal/external rotation, respectively. Device-specific models average root mean square errors of 12.6 and 3.5 degrees for flexion/extension and internal/external rotation, respectively. The device presented in this work proved to be a repeatable, reusable, low-cost device that can adequately model the knee’s flexion/extension and internal/external rotation angles for rehabilitation purposes.
... The hasty implementation in clinical practice meant there was limited preparation or education and training of either clinicians or patients although previous evidence identified the need to prepare both clinicians and patients for this type of consultation. [5][6][7][8][9] Pre-pandemic, the patients' perspective appears to have been less evident in the literature than that of the health professional. 10 Of the studies which explored patient perspectives prior to the pandemic, the care setting remained primary care. ...
Article
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Objectives During the SARS-CoV-2 pandemic, clinicians were instructed to move all but emergency consultations to remote means to reduce the spread of the virus. The aim of this study was to evaluate patients’ and clinicians’ experiences of moving to remote means of consultation with their health care professionals during the SARS-CoV-2 pandemic. Methods The study design was a qualitative service evaluation. Twenty-six clinicians and forty-eight patients who met the inclusion criteria consented to be interviewed. Clinician participants were from either medical, nursing, or allied health professional backgrounds. Patients were recruited from diabetes, acute care, and haematology and cancer areas. Data analysis was conducted using a thematic analysis framework. Results Following coding and thematic analysis of the data collected from clinicians, five themes were identified: personal and professional well-being; providing a safe and high-quality experience; adapting to a new way of working; making remote consultations fit for purpose and an awareness of altered dynamics during consultation. Patient data was coded into 3 themes: remote consultation adds value; remote consultation brings challenges and concerns about remote consultation. Conclusions Clinician and patient experiences reported here are reflected in the literature. The study indicates that remote consultation is not suitable for all patients and in all contexts. Whilst maintaining the benefits to patients, remote means of consultation needs organisational support and preparation. A way forward that maintains the benefits whilst addressing concerns seems urgent.
... Braun and Clarke (31) state that thematic analysis provides "a way of identifying what is common to the way a topic is talked or written about and of making sense of those commonalities." Thematic analysis has been used in studies of OA and rehabilitation (32)(33)(34) and was appropriately selected here to support the identification of patterns of shared meaning and significance for people involved in the provision and receipt of the intervention. ...
Article
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Objective: To identify how patients with osteoarthritis waiting for and recovering from total knee arthroplasty (TKA) conceptualized and participated in physical activity behaviors in their rural setting and to gather perceptions of health care professionals and rehabilitation decision-makers on the feasibility of a remotely led physical activity coaching intervention. Methods: Using a qualitative descriptive study, we collected data from three stakeholder groups: patients waiting for or recovering from TKA (interviews), health professionals delivering a physical activity intervention to patients in the recovering cohort (focus group), and rehabilitation leaders involved in decision-making at the local or provincial level (interviews). Results: A total of 38 individuals provided their perspectives (25 patients, five health professionals, eight decision-makers). Patients waiting for and recovering from surgery described the attributes of their rural environment that supported and restricted their ability to participate in physical activities. Patients recovering from TKA appreciated support for goal-setting and problem-solving during their rehabilitation. Health care professionals and decision-makers commented on the benefits of the program's innovative use of relatively simple technology to support remotely delivered, personalized rehabilitation in rural settings. Conclusion: This study adds to the limited voice of and about patients living with osteoarthritis who reside in rural settings and identifies facilitators and barriers to TKA rehabilitation in this population. Our findings highlight that it is important to consider the local context and the resources available to patients as they navigate living well with osteoarthritis.
... The rapidly growing demand for rehabilitation also challenges the sustainability of face-to-face rehabilitation services [14]. With the advancement in technology, telerehabilitation, which refers to the remote delivery of rehabilitation services via information and communication technologies, such as telephones and computers, has emerged to complement or offer an alternative to face-to-face rehabilitation [15,16]. Among all these telerehabilitation services, mobile applications (apps) are increasingly being used because they are easy to access [17] and allow health care professionals to provide support whenever and wherever patients need it [18,19]. ...
Article
Full-text available
Background The global increase in total hip or knee arthroplasty has led to concern about the provision of postoperative rehabilitation. Telerehabilitation may be a strategy to meet the patients’ requirements for rehabilitation after arthroplasty. This study aims to investigate the effectiveness of a telerehabilitation programme delivered via the mobile application WeChat in patients after total hip or knee arthroplasty on the following outcomes: self-efficacy, physical function, pain, depression, anxiety and health-related quality of life. Methods This is a single-centre, single-blinded, parallel-group, superiority randomised controlled trial conducted in Shanghai, China. Eighty-four eligible participants who undergo primary total hip or knee arthroplasty will be recruited preoperatively in a university teaching hospital and randomly assigned to the experimental or control group with their informed consent. Once discharged, the control group ( n = 42) will receive the usual care provided by the hospital. The experimental group ( n = 42) will receive usual care and a 6-week mobile application rehabilitation programme that consists of physical exercises and techniques for enhancing participants’ self-efficacy for rehabilitation. Baseline assessments will be conducted on the day before hospital discharge, and outcome assessments will be conducted 6 and 10 weeks postoperatively. The primary outcomes are changes in self-efficacy and physical function 6 weeks postoperatively, and the secondary outcomes include pain, depression, anxiety and health-related quality of life. The approach of a generalised estimating equation will be used to analyse the effect of the intervention on outcomes at a significance level of 0.05. Discussion This study is the first of its kind conducted in China to incorporate self-efficacy and learning theories as a framework to guide the development of a mobile application rehabilitation programme after arthroplasty. This study will contribute to the knowledge about the effectiveness of mobile application-based rehabilitation among patients after total hip or knee arthroplasty. If the findings are positive, they will support the implementation of mobile application-based rehabilitation in practice, which may potentially increase the accessibility of rehabilitation services as well as patient adherence to rehabilitation. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12621000867897 . Retrospectively registered on July 6, 2021
... Sin embargo, la mayoría refirió que no los/las motivaba. En la literatura, se reportó que algunas personas prefieren combinar la atención virtual con la presencial 25 . Dicha combinación de tratamiento podría ser una estrategia a plantearse a futuro, para contrarrestar la falta de motivación. ...
Article
Resumen Antecedentes y objetivo. La Organización Mundial de la Salud declaró a la infección por COrona VIrus Disease 19 (COVID-19) como pandemia y recomendó como medida preventiva, el distanciamiento social. Esto afectó todos los tratamientos médico-clínicos incluidos los relacionados con el proceso de rehabilitación física. El objetivo fue describir las percepciones sobre el proceso de rehabilitación debido a las modificaciones experimentadas por las personas con discapacidad motora de un hospital de rehabilitación durante la pandemia COVID-19. Pacientes y métodos. Diseño cualitativo. La muestra elegida fue por conveniencia y el análisis de datos fue por análisis temático, el cual permite identificar, analizar y reportar temas relevantes. Las entrevistas se realizaron a pacientes atendidos en la División de Kinesiología. Criterios de inclusión: adultos >18 años, diagnóstico de discapacidad motora, en tratamiento kinésico ≥1 mes de forma ambulatoria, con alta temprana de internación o internados al momento de la realización del estudio y firma del consentimiento informado. Criterios de exclusión: alta kinésica por motivos diferentes a la COVID-19 y diagnóstico de enfermedad psiquiátrica. Resultados. La muestra se compuso de 16 participantes. El 31,2% era de sexo femenino. Doce presentaron diversas alteraciones neurológicas y 4, secuelas de amputación. Se identificaron 4 temas principales: importancia de la rehabilitación, modificaciones/interrupción del tratamiento, actividades de la vida diaria y telerrehabilitación. Conclusiones. Se describieron las percepciones sobre el proceso de rehabilitación y el impacto en las modificaciones experimentadas en las personas con discapacidad motora. Destacamos la importancia de la telerrehabilitación como un recurso alternativo.
... Relatedness (ie, feeling positive relationships with others) is fostered by the clinician through active listening, expressing empathy, and encouraging perspectives and questions from the participant. Studies from a variety of rehabilitation disciplines, including physiotherapy [95], occupational therapy [96], and psychology [97], demonstrate that therapeutic alliance can be developed effectively through videoconferencing. Weekly appointments foster a strong therapeutic relationship, which has been shown to influence adherence to home exercise programs [98]. ...
Article
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Background: Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions. Objective: This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery. Methods: The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes. Results: Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion. Conclusions: The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.
Article
Background: Rural injured workers requiring multidisciplinary assessments for musculoskeletal disorders face health access disparities, which include travel to urban centers. Virtual care can enhance access to multidisciplinary team care for musculoskeletal conditions in rural areas. Materials and Methods: A retrospective chart audit of 136 multidisciplinary assessment reports of injured workers was conducted. Comprehensive management recommendations from the health care assessment team were extracted for analysis. The health care team used virtual technologies to join with patients and at least one local rural health practitioner in one of three locations. Remote presence robotics (RPR; Xpress Technology™) or laptop-based telehealth was used to complete the assessments. Results: RPR were used in 46% of assessments over two sites, with 54% using laptop-based telehealth at a third site. Frequencies of team members' assessment using technologies were as follows: physical therapist (100%), psychologist (78%), plastic surgeon (8%), and physician (43%). Spine (42%) and shoulder (32%) disorders were the most common problems. Most workers (79%) were 3 or more months postinjury. The most common management recommendation was the need for daily comprehensive rehabilitation care (76%). Travel time was saved by 89% of participants. Conclusions: Virtual care was used to unite multidisciplinary assessment teams for the evaluation of injured rural workers with complex musculoskeletal injuries. Future research recommendations include comparing between virtual and fully in-person multidisciplinary assessment and recommendation findings, and evaluation of patient and practitioner experiences with comprehensive virtual team assessments.
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Purpose: Multiple Canadian jurisdictions have curtailed public funding for outpatient physiotherapy services, impacting access and potentially creating or worsening inequities in access. We sought to identify evaluated organizational strategies that aimed to improve access to physiotherapy services for community-dwelling persons. Method: We used Arksey and O’Malley’s scoping review methods, including a systematic search of CINAHL, MEDLINE, and Embase for relevant peer-reviewed texts published in English, French, or German, and we performed a qualitative content analysis of included articles. Results: Fifty-one peer-reviewed articles met inclusion criteria. Most studies of interventions or system changes to improve access took place in the United Kingdom (17), the United States (12), Australia (9), and Canada (8). Twenty-nine studies aimed to improve access for patients with musculoskeletal conditions; only five studies examined interventions to improve equitable access for underserved populations. The most common interventions and system changes studied were expanded physiotherapy roles, direct access, rapid access systems, telerehabilitation, and new community settings. Conclusions: Studies evaluating interventions and health system changes to improve access to physiotherapy services have been limited in focus, and most have neglected to address inequities in access. To improve equitable access to physiotherapy services in Canada, physiotherapy providers in local settings can implement and evaluate transferable patient-centred access strategies, particularly telerehabilitation and primary care integration.
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This article distills the core principles of a phenomenological research design and, by means of a specific study, illustrates the phenomenological methodology. After a brief overview of the developments of phenomenology, the research paradigm of the specific study follows. Thereafter the location of the data, the data-gathering the data-storage methods are explained. Unstructured in-depth phenomenological interviews supplemented by memoing, essays by participants, a focus group discussion and field notes were used. The data explicitation, by means of a simplified version of Hycner's (1999) process, is further explained. The article finally contains commentary about the validity and truthfulness measures, as well as a synopsis of the findings of the study.
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Objectives To explore patients’ perceptions regarding prospective telerehabilitation services and the factors that facilitate or impede patients’ intentions to use these services. Design Using semi-structured interviews, patients reflected on the pros and cons of various scenarios of prospective telerehabilitation services. Patients’ arguments were first arranged according to the Unified Theory of Acceptance and Use of Technology (UTAUT). Next, using inductive analysis, the data for each UTAUT component were analysed and arranged into subthemes. Setting and participants Twenty-five chronic pain patients were selected from a rehabilitation centre in the Netherlands. Results Overall, participants considered telerehabilitation helpful as a complementary or follow-up treatment, rather than an autonomous treatment. Arguments mainly related to the UTAUT constructs of ‘performance expectancy’ and ‘facilitating conditions’. Patients valued the benefits such as reduced transportation barriers, flexible exercise hours and the possibility to better integrate skills into daily life. However, many patients feared a loss of treatment motivation and expressed concerns about both reduced fellow sufferer contact and reduced face-to-face therapist contact. Few arguments related to ‘social norms’ and ‘effort expectancy’. Conclusions The effect of telerehabilitation on healthcare strongly depends on patients’ willingness to use. Our study showed that chronic pain patients valued the benefits of telerehabilitation but hesitate to use it as an autonomous treatment. Therefore, future initiatives should maintain traditional care to some degree and focus on patients’ attitudes as well. Either by giving information to increase patients’ confidence in telerehabilitation or by addressing reported drawbacks into the future design of these services. Further quantitative studies are needed to explore patients’ intentions to use telerehabilitation.
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Information technology (IT) acceptance research has yielded many competing models, each with different sets of acceptance determinants. In this paper, we (1) review user acceptance literature and discuss eight prominent models, (2) empiri- cally compare the eight models and their exten- sions, (3) formulate a unified model that integrates elements across the eight models, and (4) empiri- cally validate the unified model. The eight models reviewed are the theory of reasoned action, the technology acceptance model, the motivational model, the theory of planned behavior, a model combining the technology acceptance model and the theory of planned behavior, the model of PC utilization, the innovation diffusion theory, and the social cognitive theory. Using data from four organizations over a six-month period with three points of measurement, the eight models ex- plained between 17 percent and 53 percent of the variance in user intentions to use information technology. Next, a unified model, called the Unified Theory of Acceptance and Use of Tech- nology (UTAUT), was formulated, with four core determinants of intention and usage, and up to four moderators of key relationships. UTAUT was then tested using the original data and found to outperform the eight individual models (adjusted
Adequate understanding of change management is essential for successful implementation of any programme. The four components of organisational change are strategy, structure, people, and processes, all of which need to be addressed for a balanced approach to change. We use this framework to discuss the implementation and sustenance of a telerehabilitation programme at a large not-for-profit healthcare organisation in Oklahoma. The article describes the process from need assessment and identification of stakeholders to the development of programme strategy, and involvement of human factors. The structure provides the building blocks for the programme, and includes the business model, economic model, and the infrastructure. The processes complement the programme structure, and include protocols, training, documentation, and outcomes measures. The article concludes with the results in terms of number of interventions, cost saved, and lessons learned.
This innovative analysis aims to quantify the use of evaluation criteria in telemedicine and to identify current trends in metric adoption. The focus is to determine the frequency of actual performance metric reporting in telemedicine evaluation, in contrast to systematic reviews where assessment of study quality is the goal. Automated literature search identified telemedicine studies reporting quantitative performance metrics. Studies were classified by telemedicine class; store-and-forward (SAF), real-time consultation (RTC) and telecare (TC), and study stage. Studies were scanned for evaluation metric reporting, i.e. clinical outcomes, satisfaction, patient quality and cost measures. Evaluation metric use was compared among telemedicine classes, and between pilot and routine use stages. Diagnostic accuracy was reported significantly more frequently in pilots for RTC and TC. Cost measures were more frequently reported in routine use for TC. Clinical effectiveness and hospital attendance were better reported in routine use for SAF. Comparison also revealed different evaluation strategies. In pilots, SAF favoured diagnostic accuracy, compared to RTC and TC. TC preferred clinical effectiveness evaluations and TC more frequently assessed patient satisfaction. Cost was only reported in less than 20 per cent of studies, but most frequently in RTC. Routine use led to increased reporting of all metrics, except diagnostic accuracy. Clinical effectiveness reporting increased significantly with routine use for RTC and SAF, but declined for TC. Clinical outcomes and patient satisfaction were reported frequently in telemedicine studies, but reporting of other performance metrics was rare. Understanding current trends in metric reporting will facilitate better design of future telemedicine evaluations.
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Providing a complete portal to the world of case study research, the Fourth Edition of Robert K. Yin's bestselling text Case Study Research offers comprehensive coverage of the design and use of the case study method as a valid research tool. This thoroughly revised text now covers more than 50 case studies (approximately 25% new), gives fresh attention to quantitative analyses, discusses more fully the use of mixed methods research designs, and includes new methodological insights. The book's coverage of case study research and how it is applied in practice gives readers access to exemplary case studies drawn from a wide variety of academic and applied fields.Key Features of the Fourth Edition Highlights each specific research feature through 44 boxed vignettes that feature previously published case studies Provides methodological insights to show the similarities between case studies and other social science methods Suggests a three-stage approach to help readers define the initial questions they will consider in their own case study research Covers new material on human subjects protection, the role of Institutional Review Boards, and the interplay between obtaining IRB approval and the final development of the case study protocol and conduct of a pilot case Includes an overall graphic of the entire case study research process at the beginning of the book, then highlights the steps in the process through graphics that appear at the outset of all the chapters that follow Offers in-text learning aids including 'tips' that pose key questions and answers at the beginning of each chapter, practical exercises, endnotes, and a new cross-referencing tableCase Study Research, Fourth Edition is ideal for courses in departments of Education, Business and Management, Nursing and Public Health, Public Administration, Anthropology, Sociology, and Political Science.