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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
The Patient’s Perspective of in-Home Telerehabilitation
Physiotherapy Services Following Total Knee Arthroplasty
Dahlia Kairy
*, Michel Tousignant
, Nancy Leclerc
, Anne-Marie Côté
Mélanie Levasseur
and the Telage Researchers
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
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: (M.T.); (N.L.)
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: (A.-M.C.); (M.L.)
These authors contributed equally to this work.
* Author to whom correspondence should be addressed; E-Mail:;
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
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
Living alone Yes No, with wife Yes Yes No, with husband
Type of housing Apartment building Single family dwelling Single family
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,
disorder, visual
hypertension, prostate
in remission
Arthritis, asthma,
acute respiratory
distress syndrome
(ARDS), angina,
disorder, depression,
Arthritis, asthma, diabetes,
depression, anxiety, sleep
apnea, hypertension
double pulmonary
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.
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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... For instance, approximately 50% of patients undergoing hip arthroplasty in China did not participate in facility-based face-to-face rehabilitation because they lived far from the hospital or there was a lack of available rehabilitation resources [5]. Domiciliary care is implemented in some countries, such as Canada, to deliver face-to-face rehabilitation services to patients dwelling in the community, but it cannot respond to the rapidly growing demand for services [6]. Unsupervised home-based rehabilitation has become an option in some countries such as the United States of America, Australia, and China [7,8]. ...
... Qualitative interviews are a suitable method to obtain rich information regarding patients' experiences [21], whereby researchers acquire an in-depth understanding of patients' perspectives on telerehabilitation. Some studies have interviewed patients after arthroplasty regarding their experiences with telerehabilitation and found that patients were satisfied with the accessibility of services [6] and experienced "closeness at a distance" with therapists as well as competence in exercises under the therapists' remote guidance [22]. Telerehabilitation programmes improved patients' engagement, self-management, and motivation in arthroplasty rehabilitation [23]. ...
... Telerehabilitation programmes improved patients' engagement, self-management, and motivation in arthroplasty rehabilitation [23]. However, these experiences were derived from patients using telerehabilitation based on videoconferencing [6,22] or web-based access [23]. Patients' experiences using a mobile app-based rehabilitation programme remain unknown. ...
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Background: An increasing number of patients are discharged from a total hip or knee arthroplasty with a short length of hospital stay. Technologies, such as mobile applications, are used to provide remote support to patients' postoperative rehabilitation. Patients' experiences of receiving mobile application-based rehabilitation after total hip or knee arthroplasty have not been investigated extensively. Methods: This was a qualitative descriptive study. Twenty-five participants who had completed a mobile application-based rehabilitation programme for total hip or knee arthroplasty were recruited. Semi-structured interviews were conducted via telephone between July 2021 and January 2022 regarding the participants' experiences using the programme. All interviews were audio-recorded and verbatim transcribed. Data were analysed using inductive content analysis. The reporting of this study followed the Consolidated Criteria for Reporting Qualitative Research. Results: Data analysis revealed five categories: (a) improved access to health care, (b) encouraged postoperative recovery, (c) established supportive relationships, (d) facilitated learning, and (e) future directions. Conclusion: The theory-underpinned mobile application-based rehabilitation programme demonstrated potential value in supporting patients' rehabilitation after arthroplasty. Nurses can consider using mobile technologies to expand their role in arthroplasty rehabilitation and improve the quality of rehabilitation care.
... To our knowledge, many studies are available to examine the perspectives of patients regarding telemedicine versus in-person visits. Most of the studies conducted so far have focused solely on patients with specific diseases (such as COVID-19, Parkinson's disease, heart diseases, multiple sclerosis) [17][18][19][20] or disabilities (like knee arthroplasty) [19][20][21][22] or disabilities (like knee arthroplasty) [23] in relation to their preference for telemedicine or in-person visits. Moreover, in many of these studies, the factors influencing the choice between telemedicine and in-person visits have not been thoroughly identified. ...
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Abstract Introduction Despite the fact that telemedicine can eliminate geographical and time limitations and offer the possibility of diagnosing, treating, and preventing diseases by sharing reliable information, many individuals still prefer to visit medical centers for in-person consultations. The aim of this study was to determine the level of acceptance of telemedicine compared to in-person visits, identify the perceived advantages of telemedicine over in-person visits, and to explore the reasons why patients choose either of these two types of visits. Methods We developed a questionnaire using the rational method. The questionnaire consisted of multiple-choice questions and one open-ended question. A total of 2059 patients were invited to participate in the study. Chi-square tests and descriptive statistics were employed for data analysis. To analyze the data from the open-ended question, we conducted qualitative content analysis using MAXQDA 18. Results Out of the 1226 participants who completed the questionnaire, 865 (71%) preferred in-person visits, while 361 (29%) preferred telemedicine. Factors such as education level, specific health conditions, and prior experience with telemedicine influenced the preference for telemedicine. The participants provided a total of 183 different reasons for choosing either telemedicine (108 reasons) or in-person visits (75 reasons). Avoiding infectious diseases, saving cost, and eliminating and overcoming geographical distance barriers were three primary telemedicine benefits. The primary reasons for selecting an in-person visit were: more accurate diagnosis of the disease, more accurate and better examination of the patient by the physician, and more accurate and better treatment of the disease. Conclusion The results demonstrate that despite the numerous benefits offered by telemedicine, the majority of patients still exhibit a preference for in-person visits. In order to promote broader acceptance of telemedicine, it becomes crucial for telemedicine services to address patient preferences and concerns effectively. Employing effective change management strategies can aid in overcoming resistance and facilitating the widespread adoption of telemedicine within the population.
... The suitability of TR for all types of patients and conditions, particularly the limitations in assessment and treatment options, has been previously reported. 13,24,[28][29][30] In the review of Rettinger & Kuhn, 24 practice related issues (Limited examinations, demonstrations, interventions, and assistance.) were the most commonly identified barriers which were reported in about 59% of the reviewed studies. ...
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Objective To assess the readiness of healthcare institutions that serve as clinical platforms for Stellenbosch University’ rehabilitation students, and to explore the opinions of rehabilitation professionals regarding the integration of telerehabilitation (TR) into service delivery and students clinical training. Methods This study employed a qualitative research design and involved the participation of fourteen rehabilitation managers. Semi-structured interviews were conducted using both face-to-face and online platforms. Thematic analysis was employed to analyse the collected data. Results The readiness for implementing TR services varies across different dimensions. Facilities faced challenges related to funding for TR equipment and the absence of policies and guidelines, indicating a lack of financial and governance readiness. Rehabilitation professionals demonstrated high attitudinal readiness but low technical readiness due to a lack of knowledge and skills. Rehabilitation students particularly lacked practical experience, confidence, clinical reasoning and decision-making skills further contributing to low technical readiness. Conclusion Health care institutions are generally not ready for a successful implementation of TR. To improve the readiness, senior management should actively participate and provide financial support, develop policies, guidelines and training programs for rehabilitation professionals. Educational institutions should incorporate TR program into curricula to prepare students to gain practical experience and familiarity with the use of TR technology for their future clinical practice.
... Overall, participants reported good acceptance, usability, and satisfaction of telerehabilitation. This is consistent with previous findings in other populations that suggest telerehabilitation is acceptable, including in older rehabilitation patients [32], chronic pain [33], total knee arthroplasty [34], and shoulder joint replacement patients [35]. The telerehabilitation technology was generally considered acceptable and easy to use. ...
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Introduction: Telerehabilitation has been explored as a solution to several of the barriers to stroke rehabilitation access, and as a necessary alternative to in-person rehabilitation in response to the COVID-19 pandemic. This review aims to explore stroke survivors' acceptance and satisfaction of telerehabilitation delivery of physiotherapy services. Methods: A systematic search using key terms relating to stroke and telerehabilitation was completed of the following electronic databases in July 2021: CINAHL complete (EBSCOhost), Embase (Ovid), Informit, ProQuest, PubMed, ScienceDirect, SCOPUS and SpringerLink. Studies of stroke survivors participating in physiotherapy via telerehabilitation were evaluated for acceptance, usability, and satisfaction outcomes. Duplicates were removed and inclusion criteria applied. Studies were included if they were published between 2010 and July 2021 with an intervention that included a technology element, a component of weightbearing/standing/lower limb exercises, and monitoring from a therapist throughout the intervention period. The included articles were then appraised and categor-ised into four subgroups. Results: There were 980 studies initially identified, with eight studies involving 209 participants meeting the criteria for inclusion in this review. There was significant heterogeneity in the included studies across eligibility criteria, intervention parameters, telerehabilitation systems and outcome measures. Overall, stroke survivors had high levels of satisfaction and found physiotherapy delivered via telerehabilitation generally acceptable and easy to use. Conclusions: Findings of this review indicate stroke survivors are accepting and satisfied with telerehabilitation as a delivery method for physiotherapy. Telerehabilitation in this population may be an effective and acceptable alternative to in-person rehabilitation and ameliorate access barriers associated with COVID-19 restrictions.
... Previous studies have already shown that patients had similar satisfaction levels when using digital rehabilitation [32][33][34]. The reduced need for transportation, the remote relationship, the personalized treatment and the ease of use are some of the advantages of digital rehabilitation [35]. ...
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The COVID-19 pandemic highlighted the need for efficient use of hospital infrastructure. The hypothesis was that a rapid shift to outpatient surgery after hip or knee arthroplasty could be implemented without compromising quality of care. The aim of this study was to assess the safety, pain management and patient-reported outcomes before and after the implementation of an accelerated discharge program using a digital follow-up tool. A retrospective cohort design was used to compare 97 patients who received primary total hip or knee arthroplasty during the pandemic (early discharge) to comparable 194 pre-pandemic patients (normal discharge). Both cohorts had the same inclusion criteria and were closely monitored using the digital follow-up tool. The accelerated discharge program reduced length of stay from a median of 3 days (before the pandemic) to a median of 1 day (during the pandemic) (p < 0.001). The complication rate of 2% was the same for both groups (p > 0.05). Patient-reported outcomes for matched samples of hip (n = 100) and knee (n = 82) arthroplasty patients were similar before, at 6 weeks and 3 months after surgery for both groups (p > 0.05). There were no differences in pain and medication consumption for the first 6 weeks (p > 0.05). This study demonstrates that reducing length of stay from three to one night after total knee or hip arthroplasty, with the help of a digital follow-up tool, results in a stable rate of complications, readmission, and comparable clinical outcomes, while reducing the socio-economic burden on the health system.
... Some patients may be denied access due to the high cost of robotic devices [65]. To operate and troubleshoot the devices, patients, and clinicians may require additional training [67]. Ensuring patient safety in a home-based setting can be challenging, especially when clinicians are not physically present [68]. ...
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Upper limb dysfunction (ULD) is common following a stroke, spinal cord injury, trauma, and occupational accidents. Post-stroke patients with ULD need long-term assistance from therapists for their rehabilitation, which generally occurs at the hospital or outpatient clinic. Physical therapists are unavailable because of geographical, financial, and scheduling concerns, and continuity of care needs to be improved due to the need to travel to multiple locations for therapy. As a result, providing specific, tailored therapy programs is challenging due to the absence of feedback and real-time monitoring. An effective telerehabilitation system can address this issue and is more cost-effective for healthcare providers and patients than traditional inpatient or person-to-person rehabilitation. Remotely operating robotic devices and using advanced technology improves patient and healthcare provider safety and reduces injuries. In this study, we developed a novel telerehabilitation framework for rehabilitation robots utilizing PTC’s Industrial Internet of Things (IIoT) platform to remotely provide robot-aided therapies for individuals with ULD. With the developed telerehabilitation framework, an operator can teleoperate the rehab robots to deliver Upper-limb (UL) exercises via an Augmented Reality (AR) based graphical user interface (GUI). This AR platform communicates bidirectionally using ThingWorx IIOT. It leverages the digital twin (DT) structure facilitated by Vuforia studio to visualize the physical robot motions happening in remote places. The telerehabilitation framework was validated through a commercially available robot (xArm 5), an exoskeleton (SREx), and an end-effector type rehabilitation robot (DMRbot) developed at Biorobotics Lab, UWM. The experiment results show that the telerehabilitation system can successfully provide UL rehab exercises in 2D and 3D planes via AR. The proposed framework is developed to facilitate robust and more promising robot-aided rehabilitation sessions remotely, and it can also be applied in other medical applications.
Purpose To describe the impact of COVID-19 on the adoption and use of telerehabilitation (TR), and to identify facilitators and barriers of the provision in Ontario physiotherapy outpatient/community settings. Methods A cross-sectional design, web-based survey was disseminated to Ontario physiotherapists working in outpatient/community settings. Descriptive statistics were used for data analysis. Results Responses from 243 physiotherapists were included in the analysis. Respondents reported increasing and initiating TR to maintain continuity of care and limit patient COVID-19 exposure. Facilitators for adopting TR were physiotherapists’ attitudes and access to technology, convenience and ease of scheduling sessions, and perceived patient satisfaction and comfort in their home environment compared with in-person care. Patient related barriers for adopting TR perceived by respondents included patients’ attitude, suitability and ability to address their needs, ease of adoption, and internet connectivity. More than 50% of respondents perceived that financial factors did not influence TR adoption. Conclusion Physiotherapists increased their use of TR through the COVID-19 pandemic. Effective implementation of TR should include both patient and physiotherapist education, and best practice guidelines on implementation of TR in order to create a hybrid model of care that would better address the patient’s needs.
Introduction In 2020, the COVID-19 pandemic caused a rapid uptake of virtual consultations (VCs) to minimise disease transmission and for this reason, research into telerehabilitation has been expanding. This review aimed to map and synthesize evidence on the use of VCs in upper limb musculoskeletal rehabilitation, describe key characteristics, and identify gaps in the research. Methods This scoping review investigated synchronous rehabilitation consultations performed over VC. All asynchronous, wearable or pre-recorded technology was excluded. CINAHL Complete, Medline, PEDro, Google Scholar and grey literature sources were searched. Screening and data extraction were done by a single researcher. Frequency counts were used to analyse the data. Results Nineteen studies were identified, with patients with shoulder injury/pain most frequently studied. Most sources (n = 9) used bespoke video programmes. Range of motion (ROM) was the most common assessment (n = 10) and exercise prescription (n = 7) was the most common treatment. Benefits included time and cost savings, maintaining therapeutic relationships and increasing patient independence. Most diagnostic assessments, except joint and nerve tension tests, were found to be reliable and valid. Studies noted increased function in activities, decreased pain and increased ROM after VCs. Limitations included restricted ‘hands-on’ treatment, resource and training concerns and limiting patient factors. Conclusions This review mapped available evidence and identified several gaps in the literature. Further robust research into VCs for hand/wrist disorders, ROM assessment and cost-effectiveness is needed.
Purpose: To synthesize common or differing perceptions of patients' and clinicians' that influence uptake of online-delivered exercise programmes (ODEPs) for chronic musculoskeletal (MSK) conditions. Methods: Eight databases were searched from inception to April 2023 for studies including (1) patients with and/or clinicians delivering ODEPs for chronic MSK conditions, and (2) synchronous ODEPs, where information is exchanged simultaneously (mode A); asynchronous ODEPs, with at least one synchronous feature (mode B); or no ODEPs, documenting past experiences and/or likelihood of participating in an ODEP (mode C). Critical Appraisal Skills Programme checklists were used to assess study quality. Perceptions of patients' and clinicians' influencing uptake of ODEPs were extracted. Quantitative and qualitative data were synthesised and integrated. Results: Twenty-one studies were included (twelve quantitative, seven qualitative, and two mixed-methods) investigating the perceptions of 1275 patients and 534 clinicians on ODEP mode A (n = 7), mode B (n = 8), and mode C (n = 6). Sixteen of the 23 identified perceptions related to satisfaction, acceptability, usability, and effectiveness were common, with 70% of perceptions facilitating uptake and 30% hindering uptake. Conclusions: Findings highlight the need to promote targeted education for patients and clinicians addressing interconnected perceptions, and to develop evidence-based perception-centred strategies encouraging integrated care and guideline-based management of chronic MSK conditions.
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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.
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.