Perceptions and Readiness to Use Telerehabilitation Service During the COVID 19 Pandemic Among Physiotherapists: A Review

Multidisciplinary professionals are required to carry out rehabilitation roles which include physiotherapy. Physiotherapy is essential for the acute and post-acute rehabilitation of COVID-19 patients as well as the maintenance of rehabilitation for older and disabled people (Shamsi et al., 2020; World Physiotherapy, 2021). Service delivery must be adjusted as appropriate to ensure safety in light of the pandemic. The importance of physiotherapy services raises several concerns and potential challenges for physiotherapists. To limit the spread of the virus, many national and international orders have been issued, including physical separation and other preventative behaviour modification measures such as hand washing and the use of face masks (Van den Broucke, 2021). The continuity of physiotherapy services still needs to be maintained with some modification as it is one of the essential services. This is done to mitigate the long-term impacts of physiotherapy service disruption, which could result in a considerable increase in the number of disabled people in the future (World Physiotherapy, 2021).

The pandemic outbreak has forced the physiotherapy profession to explore the use of telerehabilitation practice to deliver healthcare services. Telerehabilitation is a modern innovation used in delivering rehabilitation services using the technology platform. These services provide people with disabilities with therapeutic interventions, remote monitoring of progress, education, consultation, training, and a means of networking with others who have similar conditions (Brennan et al., 2010). It was considered a suitable alternative healthcare delivery system during the COVID-19 outbreak, and many studies have promoted its feasibility in treating pain and disability. Telerehabilitation provides advantages over the conventional method of face-to-face rehabilitation sessions in that it is more organized, specialized, and effective service (Aderonmu, 2020; Brennan et al., 2010). It enables medical professionals such as doctors, therapists, and nurses to connect with patients and encourage them to engage in rehabilitation activities in the comfort of their own homes. It gives the patient autonomy and encourages them to manage their condition by becoming an active partner in their care. It allows people in remote areas or with mobility limitations due to physical impairment, transport, or socioeconomic factors to access care (Brennan et al., 2009, 2010). In addition, it reduces healthcare provider and patient travel costs and time.

However, the acceptance and implementation of telerehabilitation are attributed to the attitude and willingness of healthcare personnel, and healthcare organizations who are receptive to new technologies. Hence, it is crucial to study how physiotherapists perceive telerehabilitation and whether they are prepared to use it to provide effective rehabilitation services. This article aims to review the published studies on the perceptions and readiness to use telerehabilitation during the COVID‑19 pandemic among physiotherapists.

The proposed research questions for this review were (1) what are the physiotherapists’ perceptions of telerehabilitation during the COVID 19 pandemic, and (2) are physiotherapists ready or willing to use telerehabilitation during the COVID 19 pandemic?

The authors explored all systematic findings to ensure inclusion criteria were met. After screening all the identified titles and citations, the relevant studies were chosen. All selected studies were restricted to English and published in academic journals. Studies were included for review based on these inclusion criteria: (1) the studies on the physiotherapists’ perception of telerehabilitation, and (2) the studies which investigated the physiotherapists’ readiness or willingness to use telerehabilitation. The exclusion criteria were (1) the study which indicated a case series or report, (2) participants or profession other than a physiotherapist. Based on the inclusion and exclusion criteria, 7 articles published between 2021 and 2022 were selected for review. All the reviewers discussed the articles' relevance to the research question and whether they met the inclusion criteria. The screening process was documented in a flow diagram according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) (Tricco et al., 2018) to depict the flow of the articles from search to its final selection.

The literature search identified 13 published studies that were relevant to the study scope. Reviewers screened the abstract and methodology of all 13 studies. Ten studies were appraised, and 7 studies were selected to be reviewed. The other 3 studies were not selected as 1 had a study population involving another profession and 2 studies did not evaluate the perception or readiness of physiotherapists toward telerehabilitation. Positive perceptions of and readiness to use this telerehabilitation platform were found in the 6 studies (Albahrouh & Buabbas, 2021; Bezuidenhout et al., 2022; Buabbas et al., 2022; D’souza & Rebello, 2021; Meireles et al., 2022; Reynolds et al., 2021). In contrast, one study revealed that most physiotherapists are reluctant to utilize telerehabilitation as a medium to treat patients because they believe that hands-on procedures are necessary, particularly for patients with musculoskeletal diseases (Dierick et al., 2021).

Three themes evolved from the results of the review concerning the perceptions and readiness to use telerehabilitation during the Covid-19 pandemic among physiotherapists: (1) physiotherapists’ perceptions towards telerehabilitation (2) physiotherapists’ readiness or willingness to use telerehabilitation and (3) barriers to the use of telerehabilitation system.

Several positive and negative perceptions of telerehabilitation have been identified in the inclusive articles. A total of six out of seven selected studies have reported on perceptions of telerehabilitation among physiotherapists (Albahrouh & Buabbas, 2021; Bezuidenhout et al., 2022; Buabbas et al., 2022; D’souza & Rebello, 2021; Meireles et al., 2022; Reynolds et al., 2021). Positive perceptions of this platform show great advantages in different aspects such as cost and travel time reduction, flexibility in service delivery, and minimising the risk of COVID-19 infection. Based on these positive perceptions, the telerehabilitation platform is suitable and practical to be utilized especially during the COVID-19 pandemic. However, some points on negative perception should be taken into consideration so that some adjustments can be made to ensure this telerehabilitation is viable to implement. According to Meireles et al. (2022), patients were not satisfied with the telerehabilitation service as the effectiveness was low. The possible reason might be due to the elimination of the physical contact between the physiotherapist and the patient during the treatment sessions (Aderonmu, 2020). Touch is a critical component and essential for physiotherapy practice particularly for assessment and manual intervention purposes (Bjorbækmo & Mengshoel, 2016; Roger et al., 2002). Providing a face-to-face session for an early assessment and intervention before proceeding with telerehabilitation can be an option to improve patients’ satisfaction and effectiveness of care.

In terms of physiotherapists' perception of security and privacy of telerehabilitation technology, specific policies, and guidelines to address this issue are essential for telerehabilitation use. This is to prevent breaches of confidential data when utilizing telerehabilitation (Albahrouh & Buabbas, 2021; Meireles et al., 2022). The finding by Meireles et al. (2022) and Albahrouh and Buabbas (2021) indicated that it is very important to provide legal clarification to patients treated through telerehabilitation and store the data in the cloud or backup. Additionally, the ability of physiotherapists to use existing ICT systems will influence the tendency to use telerehabilitation (Albahrouh & Buabbas, 2021; Bezuidenhout et al., 2022; D’souza & Rebello, 2021). These studies revealed that increased comfort and familiarization with ICT will improve the probability to use telerehabilitation. This finding was supported by Tousignant et al. (2011) that revealed healthcare providers who became more familiar with technology will be more comfortable with providing healthcare services over time.

The discovery of this review revealed majority of respondents in these studies were willing to use telerehabilitation particularly during the COVID-19 pandemic. Most physiotherapists believed that using telerehabilitation at work was the appropriate approach to deliver the service (Albahrouh & Buabbas, 2021; Bezuidenhout et al., 2022; Buabbas et al., 2022; D’souza & Rebello, 2021). Moreover, telerehabilitation can be used without restrictions both during and after the COVID-19 pandemic. Another finding from the study in this review shows that the more physiotherapists utilized the internet and email in their job and felt more comfortable with technology, the more ready they were to adopt telerehabilitation technologies (Albahrouh & Buabbas, 2021). This indicated that exposure to ICT for physiotherapists is important to encourage use of telerehabilitation.

However, Dierick et al. (2021) showed opposite findings, where physiotherapists were reluctant to use telerehabilitation as they emphasized proper management which includes touch and hands-on techniques for musculoskeletal disorders. Touch and hands-on techniques are essential for conventional face-to-face treatment session as it is more engaging for both patients and physiotherapists (Bjorbækmo & Mengshoel, 2016; Roger et al., 2002). The alternative suggested by Buabbas et al. (2022) to overcome this situation is to examine the patient in person first, then continue treatment via telerehabilitation. Besides, physiotherapists also highlight the importance of education about neurofunctional telerehabilitation to facilitate the monitoring of patients with neurological problems (Bezuidenhout et al., 2022; D’souza & Rebello, 2021; Meireles et al., 2022). In short, physiotherapists' readiness regarding the benefits of telerehabilitation can reduce patient waiting lists and increase access to physical therapy care (Buabbas et al., 2022; D’souza & Rebello, 2021).

Based on the review conducted, several barriers have been identified in the selected studies. Inadequate training, lack of connections between ICT experts and clinicians, patient privacy and confidentiality, patient ability to use ICT, caregivers’ lack of understanding about handling during sessions and internet connection issues are some of the common barriers that may prevent physiotherapists from using telerehabilitation (Albahrouh & Buabbas, 2021; D’souza & Rebello, 2021; Meireles et al., 2022). However, Reynolds et al. (2021) reported that no significant barriers to telehealth implementation were discovered in their study, as telehealth was just getting started. Some factors that were considered included service user suitability, adequate technical and organizational resources, physiotherapist's professional conduct, physiotherapist's skills, and COVID19 restrictions.

Good connections between ICT experts and physiotherapists and proper training are necessary for successful telerehabilitation delivery. Thus, communication between these multidisciplinary experts regarding the needs and suitability of appropriate telerehabilitation implementation is required to reach a consensus (Leochico, 2020). Furthermore, exposure to massive open online courses, as well as other accessible educational materials must be established for physiotherapists to address inadequate training issues (Fioratti et al., 2021). Next, before using telerehabilitation, patients' privacy and confidentiality must be prioritized to avoid data breaches. This could be overcome by developing particular policies and regulations for telerehabilitation practice to ensure the safety of both partiespatients and physiotherapists (Albahrouh & Buabbas, 2021).

Patients’ ability to use ICT and understanding during the telerehabilitation session are some barriers that must be considered. A comprehensive training program and user-friendly software for both patients and physiotherapists can be introduced to increase the clinical efficacy of telerehabilitation (Mukaino et al., 2020). This must be a priority to ensure telerehabilitation is more accessible to a larger population. Besides, good infrastructure such as strong internet coverage will influence the viability of telerehabilitation practice. Collaboration between the healthcare and telecommunication sectors is an option to resolve the internet connection problem for telerehabilitation implementation.

This review's findings indicated that telerehabilitation is a promising alternative method of delivering physiotherapy services, particularly during the COVID-19 pandemic. However, the identified potential barriers must be addressed in order to implement effective telerehabilitation. Despite the reported barriers, telerehabilitation has the potential to provide a more comprehensive and improved service during or after the COVID-19 pandemic. The development of a user-friendly application as a medium for telerehabilitation delivery through collaboration between physiotherapists, ICT experts, and stakeholders would improve telerehabilitation adoption. Therefore, proper guidelines and policies should be designed to manage the telerehabilitation practices.