Implementation of telerehabilitation in Austrian outpatient physiotherapy – A qualitative study / Implementierung von Telerehabilitation in der ambulanten Physiotherapie in Österreich – Eine qualitative Studie

In recent years, technological advances have led to new developments that provide possibilities to support physiotherapy treatment. The field of telerehabilitation (TR) in physiotherapy is developing rapidly, offering greater accessibility to therapy and a cost reduction for therapeutic services (Peretti et al., 2017).

Previous studies discussed various technological approaches (Baig et al., 2019; Christensen et al., 2016; van Egmond et al., 2018), ranging from low-level technological solutions, such as telephone calls, video consultations, or emailing (Cottrell et al., 2017; Huang et al., 2015) to more complex technologies, for example, sensor systems and mobile software applications to monitor falls or training sessions (Baig et al., 2019; Toelle et al., 2019). Besides technical aids, TR systems are also used to implement psychological concepts, such as gamification. The aim is to encourage patients to carry out exercises or activities through playful interventions (Christensen et al., 2016; Deacon et al., 2018). In addition to the technologies and concepts applied, TR tools can be divided into different groups depending on their use within the therapy setting. Therefore, a differentiation can be made between synchronous and asynchronous settings (Winters, 2002). While in synchronous TR, the communication and interaction between therapist and patient occur in real time; asynchronous settings, on the other hand, do not require any appointed time for patients and therapists to meet or to participate at the same time (Parmanto & Saptono, 2009). Besides synchronous and asynchronous approaches, so-called blended care can be offered, which is a combination of face-to-face therapy sessions with TR (Kloek et al., 2018; Kloek et al., 2019). The potential and effectiveness of diverse TR technologies has been highlighted in several systematic reviews. Pfeifer et al. (2020) conclude that small, but still significant, improvements in chronic pain patients could be reached with mobile app-based interventions. Cottrell et al. (2017) report, that synchronous telerehabilitation can be as effective as conventional therapy methods for improving musculoskeletal conditions. Furthermore, reviews highlight that the implementation of TR in therapy for orthopaedic and traumatological, neurological, and internal medicine patients show significant improvements in motor function- or exercise-related outcome measures (Agostini et al., 2015; Chen et al., 2020; Coorey et al., 2018). Concerning the costs of TR, recent studies show possible cost reductions due to the implementation of technologies by 20% to up to 75% compared to conventional approaches (Ekman et al., 2020; Pastora-Bernal et al., 2018).

Despite the increasing number of studies, TR interventions do not seem to be fully established yet in physiotherapy. As a result of the coronavirus crisis and the associated lockdowns since spring of 2020, therapists have been facing the question of how to treat their patients appropriately using digital tools. Austrian therapists report a relatively high level of positivity towards TR; however, there is a need to clarify appropriate reimbursement for TR and which software solutions might work best (Rettinger et al., 2021). Comparable findings, such as lack of education and training programs for TR and unclear reimbursement, were highlighted by Rausch et al. (2021) in a study on remote physiotherapy in Switzerland. To address those barriers and following the conclusion by Pfeifer et al. (2020), more research on the use of digital technologies to help patients in the best way is needed. This study aims to investigate how TR can be applied in different clinical fields relevant to physiotherapy. In addition, the experience and expectation of Austrian physiotherapists regarding the use of TR is analysed.

Eight interviews were conducted with experts (4 women, 4 men) in the fields of orthopaedics and traumatology (4), neurology (3) and internal medicine (1). The interviews lasted from 22 to 63 minutes (mean 41 min). Five physiotherapists participated in the focus group discussion, which lasted 120 minutes. Detailed information is documented in Table 1.

Three main categories resulted from the analysis. The categories reflect the perspective of experts regarding implementation of TR technology, and its application as well as the challenges in implementing TR. As the first category can be further divided into subcategories, those are additionally shown in Figure 1.

Figure 1

All interview partners, no matter which clinical field they work in, were in favour of working with asynchronous tools, which are intended to be used throughout the entire therapeutic process. The participants agreed that these tools can be used from the very beginning in addition to conventional therapy. Therefore, asynchronous TR is generally considered to be useful in blended care because it continuously supports the execution of exercises and helps with self-monitoring. Studies also show positive results for asynchronous TR for ACL rehabilitation (Dunphy et al., 2017). For chronic neurological patients in general and for acute or subacute neurological patients in later stages of the rehabilitation process, regular independent training is a central component of the therapy, which can be usefully supplemented by asynchronous tools (Ellis et al., 2019; Grau-Pellicer et al., 2020; Wu et al., 2020). In terms of internal medicine, studies show that outcome parameters such as physical activity or weight loss can be additionally improved by therapy accompanied by asynchronous TR (Recio-Rodriguez et al., 2018). It could also be shown that asynchronous TR has the potential to encourage and motivate patients to complete their home-based training (Grau-Pellicer et al., 2020; Wu et al., 2020). Besides exercise monitoring and providing health-related content, asynchronous TR could support patients with self-assessments, exercise programmes, or with a pain diary (Shebib et al., 2019; Toelle et al., 2019).

Otherwise, synchronous TR was discussed as a controversial issue in different clinical fields. There was agreement that synchronous TR sessions cannot completely replace face-to-face sessions. Therefore, TR should serve as a supplemental therapy option. This finding coincides with those of Dunphy and Gardner (2020). In general, the interview partners can imagine using synchronous TR tools for orthopaedic and traumatological patients. They reported, however, that they would be more hesitant to use synchronous tools than asynchronous TR. An initial face-to-face phase appears to be essential for most patients. In the second half of the therapy process, face-to-face sessions alternating with synchronous TR could be used. Studies highlight comparable outcomes for both traditional as well as blended-care therapy approaches (Kloek et al., 2018; Lambert et al., 2017). Synchronous TR sessions for ACL rehabilitation are considered inadvisable because hands-on techniques cannot be used in TR therapy. Therefore, interviewees recommended starting with face-to-face sessions and adding a synchronous TR setting only at a later stage of therapy. The situation was discussed in a similar manner for pain patients. For those patients, TR is considered beneficial at a later stage of therapy. An exception was the statement that a social history could be taken first in a synchronous setting. This initial TR anamnesis can help to gather important psychosocial information as a basis for the treatment of chronic pain patients (Turk, 1999). A predominant role for hands-on techniques are also considered appropriate in the early phase of therapy, which contradicts the use of synchronous TR at this point. In later stages, the use of synchronous TR sessions would be quite conceivable, as therapists also impersonate a coaching role for this patient group. Studies underline the importance of coaching chronic pain patients, whereas manual therapy should also be used, but not be the sole focus (Moffett & McLean, 2006; Semmons, 2016).

Similar to working with orthopaedic and traumatological injury patients, therapists interviewed could also imagine synchronous therapy sessions for supervising already learned exercises for scoliosis patients. In addition to hands-on techniques, the therapeutic treatment consists mainly of training therapy exercises. However, it was noted that there is an urgent need for face-to-face therapy sessions at regular intervals, as this disorder may progress during adolescence, and exercises need to be adjusted accordingly (Negrini et al., 2018). The interview partners stated that performing these exercise adjustments using TR tools does not seem to be feasible with the currently available technical possibilities. Thus, a treatment plan with initial face-to-face sessions followed by alternating synchronous sessions for exercise repetition and face-to-face sessions for adapting the exercises or implementing hands-on techniques is advised.

In neurological patients, neuropsychological disorders are identified as a hurdle for the applicability of both asynchronous and synchronous TR. These include, for example, impairments of speech or speed of processing, which may impact the overall outcome of the rehabilitation (Barker-Collo & Feigin, 2006). For this reason, the use of TR is only considered useful for patients not affected by neuropsychologic disorders. Moreover, the interview partners were sceptical about synchronous TR for neurologic patients. They stated that neurological physiotherapy often uses hands-on techniques, that cannot be replaced by TR. Nevertheless, studies promoting therapy in neurological patients, which is supported by exercise-focused TR, show that these applications can help to improve adherence as well as recovery in this patient group (Grau-Pellicer et al., 2020; Wu et al., 2020).

In the clinical field of internal medicine, experts view the use of TR as beneficial and advocate its use primarily for patient education and monitoring of training or vital parameters. The duration of COPD patient hospitalization, in case of acute exacerbation, is often short, thus limited time for physiotherapy treatment is available. Extending the duration of treatment with TR could be particularly beneficial for this group. Studies yielded positive results when TR was applied in this clinical field, especially through telephone consultations (Huang et al., 2015). In addition to therapeutic interventions, a high-quality TR program should include elements of telemonitoring, e-learning, telecoaching, and social networking (Frederix et al., 2015). Therapists may act as coaches who repeatedly provide input and support the patient to become more autonomous. According to the therapists interviewed, it would be useful to have a conclusive face-to-face session after a TR phase to conduct a final examination and clarify any open questions. In addition, interdisciplinary therapy approaches could also be facilitated with the help of TR, as those are stated as impact goals by the Austrian diabetes report (Schmutterer et al., 2017).

Respondents also believe that adding content, such as telemonitoring or assessments (e.g. pain scales), to TR programs would be helpful. Within the framework of this study, it was not possible to analyse these topics in further detail. Nevertheless, studies lead to the conclusion that TR has a beneficial impact if education and intensive telemonitoring are combined (McLean et al., 2013). Monitoring data can further be used for tailormade therapy interventions. Besides these positive aspects of TR, it is necessary to always evaluate benefits in contrast to privacy and data protection. These aspects should be addressed in further studies.

Besides telemonitoring, gamification was frequently discussed in the interviews. Gamification uses game-related content, for example, feedback, rewards, or social connections to enhance motivation (Pereira et al., 2014). These incentives may be used in supporting patients to complete home exercise programs. During interviews, some participants questioned whether gamification primarily enhances extrinsic motivation and therefore does not increase intrinsic motivation. Although it is true that gamification primarily uses extrinsic motivation, there are approaches that can also raise internal motivation (Chan et al., 2018). In the development of TR tools, all aspects of gamification and motivation should be considered, as motivation-enhancing content and direct feedback seem to improve outcomes (Wibmer et al., 2016).

Participants were also interested in how to appropriately select patients for TR. One approach to assessing patients’ suitability for TR could be to develop standardised checklists. However, careful consideration of administrative, clinical, technical, and ethical issues as well as the types of motivation mentioned above is needed (Brennan et al., 2010; Kloek et al., 2020). Even therapists who have little experience with TR could use checklists to determine whether their patients are suitable for TR. Furthermore, TR should not be limited to a small group of patients but be accessible to people of all ages and social groups. Therefore, it is important to develop TR tools and products that are, on the one hand, easy to use and accepted by the users and, on the other hand, cost-effective in order to facilitate access.

Especially for the clinical field of neurology, interview partners stated that patients are facing high costs for physiotherapy and TR may ease this burden. Studies show tendencies that TR could lead to a reduction in costs, but the evidence has not yet been fully established (Petersen et al., 2021; Tchero et al., 2018). In order to establish TR, it is necessary that probable costs are known and cost-effectiveness investigated thoroughly. It would be a questionable approach to posit that the primary benefit of TR will be cost reduction.

One possible benefit mentioned was a potential collaboration among health professions using TR. During the first national coronavirus-related lockdown in spring 2020, other professions, such as occupational or speech therapists, gathered positive experience with TR (Rettinger et al., 2021). For example, research was conducted using an app-based approach to prevent type 2 diabetes mellitus. By combining exercise and dietary recommendations, weight loss was significantly increased among the patients in the study (Muralidharan et al., 2019). Patient care can often be improved by considering interdisciplinary approaches for developing TR tools.

One barrier for TR is the limitation in therapeutic strategies that can be applied. Currently, TR is mainly focused on exercise, monitoring, information, and education (Huang et al., 2015; van Egmond et al., 2018). Moreover, TR is particularly applicable when more exercises and fewer hands-on techniques are used. To enable hands-on assessments and techniques, blended care scenarios could be a solution. Therefore, different roles and competencies of physiotherapists need to be considered (Eckler et al., 2017). Regarding TR, physiotherapists act as managers, communicators, and innovators, which could also lead to changes in the way the profession of physiotherapy is perceived.

Another challenge mentioned was infrastructure availability to therapists and patients. In addition, the therapists interviewed do not feel sufficiently trained in using TR yet. Recent TR developments require different types of equipment. This can range from telephones to complex sensor systems (Baig et al., 2019; van Egmond et al., 2018). More extensive training of therapists leads to better knowledge about available systems, which would prevent unnecessary investments and finally provide patients with appropriate tools. If patients have to use internet-capable tools for TR, the question of how these devices are provided and who should bear the costs is still unclear. An approach enabling the use of existing equipment would be reasonable and would also avoid purchasing new infrastructure for all involved parties. Those barriers and challenges should be clarified in further studies and/or be defined in legal regulations.

Probably the largest barrier for applying TR currently is the therapists’ subjective feeling of insecurity in the context of various related factors, such as having technical questions, clarifying legal parameters, and how to ensure patient safety. Recent studies assessed these issues and, for example, Grau-Pellicer et al. (2020) report in their study that no adverse events occurred during their intervention. Hasenöhrl et al. (2020) conducted semi-structured interviews with patients using TR tools, and among the patient group, home-based exercise training was perceived as safe. Questions regarding the legal situation, reimbursement, and documentation of TR are not completely clarified. In addition, a broader range of training courses may give therapists the confidence they require for practical application. These courses should provide information about liability and the legal framework, but also about data protection and correct use of TR tools.

We were able to gather initial experience and attitudes towards the use of TR in Austria from the experts interviewed. The legal situation, which was still unclear at the time of data collection, renders applying TR difficult. Currently, the Federal Ministry for Social Affairs, Health, Care and Consumer Protection has issued a clear statement on the use of synchronous TR (Bundesministerium für Soziales, Gesundheit, Pflege und Konsumentenschutz, 2020). For the use of asynchronous TR, details are not yet known.

In summary, open questions still remain regarding liability, regulatory guidelines, and billing for both forms of application—synchronous and asynchronous—that need to be clarified before widespread use of TR can be adopted.

While considering the results and findings discussed, a variety of limitations have to be taken into account. As described in the methods section, therapists were recruited from the fields of orthopaedics and traumatology, neurology, and internal medicine. Since the focus of the qualitative survey was on these areas, experiences and attitudes of experts in other clinical fields could not be gathered.

Another limiting factor of this study is that the clinical fields investigated could only be discussed on the basis of a limited number of pathologies. Therefore, the results cannot be generalized across the entire range of clinical fields, even though literature does show potential for the use of TR beyond the conditions discussed in this study (Agostini et al., 2015; Grau-Pellicer et al., 2020; Wu et al., 2020).

Interviews were conducted separately for each clinical field. During focus group discussion, the division in clinical fields was maintained. Breaking up this structure during the focus group discussion might have led to different content and thus a different inductive category formation.

In addition to these limitations, the focus of this study was on outpatient one-on-one therapy settings. For this reason, other relevant settings, such as group therapy or preventive physiotherapy, were not investigated. Additionally, scenarios with patient transfer, like for instance changing from outpatient to inpatient physiotherapy, or vice versa, were not examined.

The aim of this study was not to analyse and discuss the relevant issues concerning cost structures, remuneration, regulatory issues, liability claims, and data protection. These were perceived as important topics but could not be investigated in further detail.

Within the framework of this qualitative study, information on TR was gathered in different clinical fields relevant to physiotherapy. The attitude of experts towards blended care approaches and asynchronous TR was consistently positive. The therapists interviewed highlighted the necessity for initial face-to-face therapy sessions to establish patient–therapist rapport, conduct assessments, and apply manual techniques. From the information derived from the interview surveys and the focus group, it appears that TR approaches are currently seen to be more suitable for orthopaedic and traumatology patients and internal medicine patients than for patients suffering from neurological diseases. This should be considered when using TR in physiotherapy. Reported barriers for TR are insecurities concerning the legal situation, billing, or perceived security, which should be resolved for widespread implementation of TR in Austria. Within the framework of this study, it was not possible to analyse these opportunities and obstacles in more detail. Further research should provide a more detailed investigation of opportunities and barriers, as well as a detailed investigation of blended care TR scenarios.