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. 2023 Aug 16;76(4):340–350. doi: 10.3138/ptc-2021-0136

Facilitators and Barriers for the Adoption and Use of Telerehabilitation in Outpatient and Community Settings During the COVID-19 Pandemic: A Survey of Ontario Physiotherapists

Bryan Hague *, Leah Taylor *, Chelsey Quarin *, JC Grosso *, Dylan Chau *, Rebecca Kim *, Molly Verrier *,†, Alison Bonnyman *, Sharon Gabison *,†,✉
PMCID: PMC12392811  PMID: 40959473

Abstract

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.

Method:

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.

Conclusions:

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.

Key Words: barriers, COVID-19, facilitators, Ontario, outpatients, surveys and questionnaires, telerehabilitation.

On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic.1,2 There was a worldwide reduction of in-person physiotherapy care in order to contain the virus spread.3,4 In Ontario, Canada, physiotherapists were required to cease or reduce non-essential in-person services between March 19, 2020, and May 26, 2020.5 The immediacy of the COVID-19 response and enforced restrictions changed the options for the delivery of physiotherapy services not only in Ontario, but worldwide.3,4 To continue to deliver physiotherapy services but mitigate the risk of contracting COVID-19, telerehabilitation (TR) was considered.3,6 For example, in Italy, the Spinal Institute pivoted quickly to continue to provide treatment of paediatric clients, delivering 1,200 interactive TR sessions and citing high satisfaction ratings from clients, caregivers, and providing therapists.3 The Canadian Thoracic Society provided guidelines for pulmonary rehabilitation during the pandemic, and suggested hybrid models of care using a combination of in-person and virtual visits to deliver vital pulmonary rehabilitation services while controlling transmission risk.6

Telerehabilitation is a subset of telemedicine encompassing the delivery of clinical rehabilitation services including evaluation, diagnosis, and treatment to various patient populations, synchronously or asynchronously, via telecommunication including video and audioconferencing, remote monitoring, email, and messaging.7, 8, 9, 10–11 TR has been used in a wide range of populations over the last few decades.12 TR efforts delivered to neurological,3,13, 14, 15, 16, 17, 18 cardiorespiratory,13 and musculoskeletal3,13,14,19 populations and those receiving cancer care20 have been well received by patients and resulted in enhanced health outcomes, including reducing pain and analgesic use, and improving function, self-efficacy, and quality of life.18, 19, 20, 21, 22, 23

A recent systematic review of the delivery of TR services to stroke survivors found low to moderate evidence for improving activities of daily living when compared with usual care, with no adverse events reported.15, 16, 17,24, 25, 26 Similar outcomes with respect to reducing pain and improving lower extremity activity scores were found in individuals receiving TR services when compared with conventional physiotherapy following total knee arthroplasty.27 As reported in a recent meta-analysis and systematic review, individuals living with chronic medical conditions who received physiotherapy delivered by telephone experienced improved walking distance when compared with those who did not engage in an exercise programme.23 In patients with low back pain, no significant difference in functional status was found between individuals who had received TR when compared with individuals who did not.28 Patients undergoing an asynchronous home-based TR programme for shoulder pain noted statistically improved scores in the QuickDASH and reduced analgesic consumption and pain ratings scores.21 Previous Canadian studies explored patient perspectives on TR post–total knee arthroplasty, post-stroke, and in the delivery of health services in the rural north.15, 16, 17,24,25 Patients appreciated the reduced time and cost of travel, and the ability to receive physiotherapy care through TR in the comfort of their own home.15, 16, 17,26

As TR requires the use of technology, insufficient Internet connection, cost of training and equipment, and lack of technical support have been described in the literature as barriers to the adoption of TR in remote settings.9,15, 16, 17,29 Maintaining patient privacy and confidentiality has also been shown to be more difficult when using TR.30 Patients with cognitive and physical impairments may not be suitable for TR as maintaining patient safety may be challenging.15,16,29,31 Lack of TR training has been shown to contribute to physiotherapists’ lack of confidence in the use of TR, and has been correlated to poor patient satisfaction, negative patient perspectives, and the discontinuation of TR.15,16,29

Previous literature identifying facilitators of and barriers to the adoption and use of TR were specific to small clinical populations for maintaining continuity of care for patients in rural/remote settings.15, 16, 17,24,25 There is less literature on the adoption of TR in urban settings and for a wider variety of patient populations, including those who access outpatient and community settings. Prior to COVID-19, up to 10% of rehabilitation services were delivered through TR.4,32 The literature related to physiotherapists’ perspectives on the delivery of TR during COVID-19 is limited. The purpose of this study is to describe physiotherapists’ experience with the adoption and use of TR and to identify patient, provider, and system facilitators and barriers for its adoption from the perspectives of physiotherapists working in outpatient and community settings in Ontario, Canada, during COVID-19. Findings from this study could potentially illustrate the facilitators and challenges of TR use during a pandemic and assist physiotherapists in incorporating TR effectively into their future physiotherapy practice beyond the COVID-19 pandemic.

Methods

The study was approved by the University of Toronto's Health Sciences Research Board (Protocol #39569).

Study design

We used a cross-sectional descriptive design administered using a web-based survey with both closed and open-ended questions for the study. The survey was delivered using the Research Electronic Data Capture (REDCap) electronic data capture tool between January and April 2021.

Participants

Physiotherapists registered with the College of Physiotherapists of Ontario who provided in-person patient care in outpatient and community settings were eligible for the study. Exclusion criteria included individuals who did not provide TR.

Survey composition

The 20-minute survey (Online Appendix 1) consisted of eight sections capturing information related to (1) respondents’ demographics, (2) respondents’ TR use, (3) respondents’ in-person and TR caseloads, (4) methods of TR delivery, (5) perceived facilitators of and barriers to TR adoption and use, (6) respondents’ experiences related to the use of TR, (7) perceived patient responses to TR adoption, and (8) experiences of respondents who did not use TR. Questions consisted of forced-choice options, open-ended responses, 5-point bipolar and unipolar Likert rating scales (“strongly disagree” to “strongly agree,” and “not at all” to “a large extent,” respectively) to determine levels of agreement related to presented items. A text box at the end of each of the survey sections and at the end of survey was available for respondents to include open-ended responses and comments.

To identify perceived facilitators of and barriers to TR adoption and use by respondents, the research team identified 29 potential items as either facilitators or barriers from the literature.33, 34, 35, 36, 37, 38, 39, 40 A 7-point Likert bipolar rating scale (−3 = Strong Barrier, −2 = Intermediate Barrier, −1 = Weak Barrier, 0 = Neutral, 1 = Weak Facilitator, 2 = Intermediate Facilitator, 3 = Strong Facilitator)41 was created for respondents to rate each of the 29 items as a facilitator or barrier.

The survey was pilot tested among six physical therapists, four providing direct patient care and two who did not provide direct patient care via TR following COVID-19. Pilot testing was conducted to determine the time required to complete the survey in addition to determining the logic, flow, and clarity of the questions. Additionally, the survey was pilot tested to determine if the questions were relevant to the purpose and objectives of the study. Modifications of the questions were made following pilot testing prior to dissemination.

Recruitment

The Modified Dillman Total Design method42 was used. Advertisements were sent out by the Ontario Physiotherapy Association, directors/owners of outpatient/community physiotherapy clinics, physiotherapy managers of corporations providing physiotherapy services in Ontario, administrators of physiotherapy social media accounts, and members of the research team. Other recruitment approaches included emails sent out by the Physical Therapy and Occupational Therapy Alumni Association of the University of Toronto, eblasts sent out by the Canadian Physiotherapy Association Private Practice Division, and newsletters sent out by the University of Toronto's Department of Physical Therapy between January 2021 and April 2021. Snowball sampling43 was applied by encouraging physiotherapists to share recruitment information with other Ontario physiotherapists.

Statistical analysis

IBM SPSS Statistics, version 24.0 (IBM Corporation, Armonk, NY) was used to analyze survey responses. Descriptive statistics were used to present the results, with nominal data displayed using frequencies and percentages; ordinal data displayed using frequencies, percentages, and medians; and ratio data presented using means and one standard deviation.

Responses to items related to perceived facilitators and barriers (section 5 of the survey) were assigned as facilitators or barriers according to the following criteria: if the median score was greater than zero, the item was assigned as a facilitator, and if the median score was less than zero, the item was assigned as a barrier. Neutral responses were determined by having a median score of zero and more than 50% of respondents choosing “neutral” for a given item.

Given the objectives of the study, sections 1 to 6 of the survey were the focus.

Results

Of the 383 individuals who opened the survey, 274 completed the demographic section of the survey and indicated whether or not they had previously provided TR. Of those, 243 individuals indicated “yes” to providing TR while 29 individuals indicated “no.” Individuals could skip questions and exit the survey prior to its completion. Therefore, the number of total responses collected for each item ranged from 191 to 243 for those who provided TR (Online Appendix 1).

Table 1 depicts the demographics of the respondents who provided TR. One-third (n = 82, 33.7%) of respondents worked in more than one area of practice (e.g., cardiorespiratory and orthopaedics). Approximately two-thirds of respondents (n = 151, 62.1%) provided services for multiple age groups. Less than one-third of respondents (n = 66, 27.2%) worked in multiple practice settings (e.g., private practice and hospital).

Table 1.

Demographics and Characteristics of Survey Respondents

Mean (+/− 1 SD) Median Min-Max
Years in Practice 17.6 (12.1) 16 1–56
n (%)
Patient Population (Years of Age)
 Adults (18–64) 209 (86.0)
 Geriatrics (65+) 162 (66.7)
 Paediatrics (0–17)  93 (38.3)
Area of Practice
 Musculoskeletal 216 (88.9)
 Neurological  82 (33.7)
 Cardiorespiratory  26 (10.7)
 Other*  33 (13.6)
Practice Setting
 Private Practice Clinic 161 (66.3)
 Hospital Outpatient Clinic  38 (15.6)
 Home Care Public (e.g., LHINs**) 20 (8.2)
 Public Practice Clinic 19 (7.8)
 Community Physiotherapy Clinic 18 (7.4)
 Home Care Private 18 (7.4)
 Retirement Residence  9 (3.7)
 Long-term Care Facility  6 (2.5)
 Therapist's Private Home Office  5 (2.1)
 Primary Care Community Health Clinic  5 (2.1)
 Other***  31 (12.8)
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Note: Respondents indicated multiple responses throughout the demographic portion of the survey; therefore the total percentages do not equal 100.

*

Included setting area such as pelvic health, vestibular rehab, chronic pain, and cancer rehab.

**

Local Health Integration Networks.

***

Included practice settings such as administration, paediatric treatment centres, and acute care.

Figure 1 highlights the main practice setting locations of respondents who provided TR mapped to the geography of the 14 health regions of the province of Ontario used to deliver local home and community care support services, including physiotherapy. Almost half of the respondents (n = 115, 47.3%) worked in the Toronto Central, Central, and Champlain regions of the province.

Figure 1. Respondents’ primary practice location throughout Ontario. Regions are represented according to the former 14 health regions (Local Health Integration Networks [LHINs]) in Ontario.

Figure 1

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Caseload changes during COVID-19 and methods of TR delivery

Prior to the lockdown period, respondents who indicated that they provided TR reported treating an average of 40 patients per week through in-person visits and 1 patient per week using TR. During the lockdown, respondents reported their caseload averaged 3 patients per week through in-person visits and 10 patients per week using TR. Following the lockdown, respondents reported treating an average of 28 patients per week through in-person visits and 5 patients per week through TR.

The methods of TR delivery used prior to, during, and following the lockdown are shown in Figure 2. The most common videoconferencing platforms used through the COVID-19 pandemic included Zoom Health (n = 36, 22.2%), Microsoft Teams (n = 25, 13.4%), Jane App (n = 23, 11.9%), Embodia (n = 23, 11.9%), and the Ontario Telemedicine Network (n = 17, 8.8%).

Figure 2. Methods of delivery of telerehabilitation used by survey respondents (lockdown period representing the time between March 19 and May 26, 2020).

Figure 2

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Reasons for initiating and increasing TR

Respondents who provided TR agreed or strongly agreed that they initiated and increased the use of TR to maintain continuity of care (n = 200, 94.8%) and to enhance patient outcomes (n = 142, 67.3%). Respondents agreed that they used TR in order to limit their patients’ exposure to COVID-19 (n = 161, 76.3%).

Identified facilitators of and barriers to the adoption and use of TR by physiotherapists who provided it

Median scores of identified facilitators and barriers are found in Online Appendix 2. Of the 29 items which respondents were asked to rate as a facilitator, a barrier, or neutral relating to the adoption and use of TR, there were six items that were identified as facilitators, five items identified as barriers, and three items identified as neutral (Figure 3). Fifteen items did not satisfy the cut-off criteria for being a facilitator, barrier, or neutral response.

Figure 3. Frequency of responses for identified facilitators, barriers, and neutral responses. Please refer to Online Appendix 1 for a full list of items that participants were asked to identify as facilitators and barriers and Online Appendix 2 for median scores.

Figure 3

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Physiotherapists’ experiences with adoption and use of TR

Survey items related to respondents’ experience in the delivery of TR (section 6) are reported in Table 2. Respondents who provided TR agreed or strongly agreed that TR was the only way to provide continuity of care (n = 147, 76.6%) and the technology used allowed them to meet the Ontario physiotherapy standards of practice (n = 155, 81.2%). Respondents agreed or strongly agreed that being resourceful and creative was important to provide successful TR (n = 179, 93.7%) and that all physiotherapists working in outpatient and community settings should know how to provide TR (n = 142, 74.3%).

Table 2.

Respondents’ Experience with the Use of Telerehabilitation

Response item Disagree/strongly disagree Count (%) Neutral Count (%) Agree/strongly agree Count (%) Not applicable Count (%)
Telerehabilitation was the only way to provide continuity of care 23 (12.0) 22 (11.5) 147 (76.6) 0 (0)
Collaboration with colleagues and other health care professionals influenced my use of telerehabilitation 24 (12.5) 47 (24.5) 117 (60.9) 4 (2.1)
Telerehabilitation was easy to implement 40 (20.8) 44 (22.9) 107 (55.7) 1 (0.5)
I was able to build/maintain the same degree of rapport with patients when using telerehabilitation when compared with in-person care 75 (39.1) 21 (10.9) 96 (50) 0 (0)
The same quality of care was provided when using telerehabilitation compared with in-person care 96 (50.0) 36 (18.8) 57 (29.7) 3 (1.6)
Patients were satisfied with the use of telerehabilitation 33 (17.2) 40 (20.8) 118 (61.5) 1 (0.5)
Pro bono sessions were offered to determine the efficacy of telerehabilitation 58 (30.2) 36 (18.8) 47 (24.5) 51 (26.6)
The technology used allowed me to meet the physiotherapy standards of practice 13 (6.8) 23 (12.0) 155 (81.2) 0 (0)
The use of formal guidelines (e.g., College of Physiotherapists of Ontario, Ontario Public Health) helped me to provide telerehabilitation 25 (13.1) 50 (26.2) 113 (59.2) 3 (1.6)
The use of post-graduate education (e.g., Webinars, resources) helped me to provide telerehabilitation 43 (22.5) 35 (18.3) 105 (54.4) 9 (4.7)
Being resourceful and creative was important to successfully provide telerehabilitation 2 (1.0) 10 (5.2) 179 (93.7) 0 (0)
My catchment area of practice increased as a result of the COVID-19 pandemic 70 (36.6) 42 (22) 72 (37.7) 7 (3.7)
Learning about telerehabilitation during my physiotherapy program would have better prepared me for its implementation into my practice during the COVID-19 pandemic 35 (18.3) 35 (18.3) 109 (57.1) 12 (6.3)
All physiotherapists working in outpatient and community settings should know how to provide telerehabilitation 17 (8.9) 32 (16.8) 142 (74.3) 0 (0)
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Note: Values reflect the total number of respondents (count), with corresponding percentage (%), who rated a response item in the respective category. Total counts are pooled for “disagree strongly” and “disagree,” and for “agree strongly” and “agree.”

Discussion

This is one of the first Canadian studies that investigated facilitators and barriers related to the adoption and use of TR through the continuing COVID-19 pandemic by Ontario physiotherapists working in outpatient and community settings. Canadian physiotherapists delivering TR to individuals living with multiple sclerosis reported challenges related to usability of the exercise platforms used and the suitability of the client for TR. However, they valued the fact that they could monitor the client's participation and engagement in the programme and provide services to underserviced areas.44 Another Canadian study explored health care professionals’ perspectives on TR for cancer rehabilitation and found TR to be a viable alternative to in-person care and helped with self-management.20 However, the study was comprised of a heterogeneous group of health care professionals.20

The physiotherapists in this study worked in a wide variety of practice areas, patient populations, and geographical areas. The survey response rate was only 5.3% of eligible physiotherapists working in community settings in Ontario, based on 2020 data that reported 5,191 Ontario physiotherapist practising in community settings including community health care, visiting agency/business, group practice/clinic, solo professional practice/business, and school or school board.45 Almost half of the respondents in this study were located within 5 of the 14 health regions throughout Ontario with the majority of respondents practising in the area of musculoskeletal physiotherapy

Adoption and use of TR

Findings from this study are consistent with those in Italy and Australia3,4 showing a decrease of in-person physiotherapy services and a recovery of some services with TR during the lockdown. Public health mandates that discontinued non-essential in-person care worldwide created a barrier for the continuation of in-person physiotherapy services.5,46 This study identified that Ontario physiotherapists continued to use TR during and following the lockdown period, which may reflect the degree of COVID-19 exposure concern despite adherence to government-mandated COVID-19 operational requirements for in-person care. Protecting people from COVID-19 by avoiding travel and in-person contact was prioritized worldwide.3,14 Our study suggests that limiting patient COVID-19 exposure was an important driving factor for the use of TR, and this may have been due in part to the lack of understanding of the mechanism of transmission of the virus and its mortality rate, thus heightening the concern of putting patients’ health at risk, especially vulnerable populations. Respondents from this study agreed that TR was used during the lockdown in order to maintain continuity of care and to enhance patient outcomes, which is consistent with other studies.13,14,47,48 The majority of respondents also agreed that TR was the only way to maintain continuity of care during the lockdown when physiotherapy was deemed non-essential and in-person care was prohibited.

Facilitators of and barriers to the adoption of TR

Environmental factors

Respondents indicated that facilitators for adopting TR included their access to technology and the ability of the technology to meet the Ontario physiotherapy standards of safety, confidentiality, and privacy. This aligns with recent technological advancements whereby health care providers are able to virtually communicate health-related information safely.3,13,14 A study by Prvu Bettger and colleagues46 noted that videoconferencing was preferred over audioconferencing for TR. This is consistent with our findings as respondents increased their use of videoconferencing during and after the lockdown more than their use of audioconferencing. Participants were provided the option of reporting which types of platforms were used in the delivery of TR. The most frequently reported videoconferencing platforms used by respondents included Zoom for Healthcare, Microsoft Teams, Jane App, Embodia, and the Ontario Telemedicine Network. It is important to ensure that the videoconferencing platforms used are compliant with the data protection regulations, including the national Personal Information Protection and Electronic Documents Act (PIPEDA) and the provincial Personal Health Information Protection Act (PHIPA), ensuring that the standards for patient privacy and confidentiality are maintained.

The majority of respondents perceived patients’ Internet connectivity to be a weak barrier to the adoption of TR. These findings suggest that while Internet connectivity problems may impact the success of TR, respondents still offered their services virtually. Hasani and colleagues49 in Australia found that Internet issues resulted in patient dissatisfaction when using TR, but did not inhibit the overall provision of TR. Comparably, other TR implementation studies identify Internet connectivity and limited bandwidth as challenges in the delivery of TR.15, 16, 17 It is important to note that respondents from this study were predominantly from urban areas where Internet connectivity was likely less of a problem, although bandwidth may have been limited due to an increase in remote working demand. Findings from this study suggest that generally physiotherapists did not perceive connectivity issues to be a barrier in the delivery of TR. Cottrell and Russell30 recommended testing Internet connectivity on a given TR platform prior to the scheduled session in order to ensure TR success. It is important to consider that IT support is required when delivering TR and may not exist for all physiotherapists. In order to ensure continuity of care through TR, IT support should be provided for physiotherapists who deliver TR during a pandemic and thereafter.

Patient factors

From the respondents’ perspectives, patient facilitators of TR adoption were related to the patients’ satisfaction, convenience, ease of scheduling sessions, and the comfort of remaining in their own homes. Consistent with our findings, results from a study in Italy14 reported increased acceptance of TR by patients accessing musculoskeletal services as they appreciated the increased scheduling flexibility and had high levels of satisfaction. A recent Australian qualitative study explored clinicians’ experiences and perceptions as well as barriers and enablers in the adoption of TR for cardiac rehabilitation services using a non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework. These researchers found challenges for ongoing delivery related to patients (e.g., digital inequity), staff (e.g., capacity), carers (e.g., availability), and organizations (e.g., resources).50 Findings from this study suggest that physiotherapists can encourage patients to adopt TR by highlighting its convenience, in-home comfort, and positive patient satisfaction.

In contrast, from the respondents’ perspectives, patients’ ease of adoption of TR and attitudes regarding the ability of TR to address their needs were indicated as barriers. It is likely that increased TR adoption is related to the ease of technology set-up and TR platform functionality. Patients’ lack of knowledge and discomfort with the use of technology are barriers to TR adoption.15,51 It has been suggested that TR technology should be user-friendly and practical in order to aid its adoption and adherence.52 Suso-Marti and colleagues53 also suggest that providing education and technology training prior to initiating TR can improve the attitudes of patients and can potentially ease the challenges of adoption by instilling better understanding of TR. It has also been reported that patients have negative attitudes regarding the ability of TR to address their needs as they see the value of TR only when hands-on therapy is not required.14,51 TR may enable the provision of functional exercises and self-management techniques that can be done at home effectively while adapting treatment to the patient's home environment. Thus, it is suggested that physiotherapists educate patients on the advantages and value of TR to ensure they make informed health decisions about the delivery approach to be used.

Physiotherapist factors

Respondents indicated that their attitude regarding TR, such as having a positive attitude, facilitated its adoption. These findings complement a study in Kuwait that found that positive perceptions by physiotherapists on the use of TR were facilitators for the use of TR during the pandemic.54 Respondents reported it necessary to adapt their care when using TR, and that being resourceful and creative were key factors. Creative adaptations and solutions have been identified in the literature as necessary to develop effective assessment and treatment approaches when using TR,52 such as teaching self-mobilizations and use of home furniture to maintain stability during exercises. Respondents also agreed that physiotherapists working in outpatient and community settings should have access to resources on how to provide TR effectively. This study supports the inclusion of TR education in physiotherapy programmes to ensure competency. Post-graduate TR courses, webinars, and the dissemination of shared lessons learned should be designed to improve confidence, creativity, and competency and support a positive attitude to TR use so as to ensure appropriate future use.

Respondents indicated that the ability of TR to address the perceived needs of their patients was a barrier to its adoption. Previous studies have described inappropriate patient populations for TR as those requiring hands-on care15,16,29,31 and/or the monitoring of physiological responses.13 Additionally, TR has been found to be challenging when patients’ clinical needs change.44 Possible solutions to facilitate TR use with these patients could include the presence of family members and/or other caregivers to provide assistance and monitor safety during the sessions.15, 16, 17,29 The use of guidelines or checklists such as the Dutch Blended Physiotherapist Checklist55 may facilitate the delivery of TR by determining patient appropriateness prior to implementation, and assist in developing a hybrid-model treatment plan. A hybrid approach to treatment may involve comprehensive in-person teaching of safe self-mobilization/range-of-motion techniques to then enable safe and effective implementation during TR.

Financial factors

Our survey included items pertaining to cost and reimbursement, which were considered barriers in TR adoption prior to the COVID-19 pandemic.56 In this study, respondents indicated that the cost of the TR platform, Internet, and reimbursement for TR did not strongly influence their adoption of TR during the pandemic, which might suggest that financial considerations had less impact on the use and adoption of TR by Ontario physiotherapists. The majority of our respondents worked in a private practice setting, suggesting that private clinics may have been able to absorb the costs of adopting TR platforms, implementing TR, and obtaining reimbursement, thereby making TR financially viable. Further exploration within the other types of health care organizations is warranted.

Limitations

Physiotherapists reported patient factors in the adoption and use of TR; therefore, our findings may be biased toward physiotherapists’ perceptions of their patients. The recruitment advertisement was worded to attract physiotherapists who had adopted TR versus those who had not. Therefore, physiotherapists who did not adopt TR were not represented in this study. Our respondents’ locations of practice spanned all health regions of the province of Ontario. However, the respondent data did not proportionally represent the number of physiotherapists working in each health region as the majority of the respondents worked in urban settings. Although not the intent of our study, we did not capture the physiotherapy human resources and infrastructure required, nor the magnitude of the patient population in need of TR. An in-depth understanding of such data would provide further insights into the facilitators of and barriers to physiotherapy service delivery. Additionally, specific workplace demographics were not collected. Although respondents were asked to rate each of the 29 items as a facilitator or barrier, only 14 of the items were ranked by participants as a facilitator, barrier, or neutral response based on our criteria, excluding potential items which might require further investigation.

Conclusion

Ontario physiotherapists in outpatient and community practice settings have adopted and increased their use of TR because of the COVID-19 pandemic. This study highlights key facilitators of and barriers to the adoption and use of TR during the pandemic, and supports the thesis that TR has applicability to a broad spectrum of community-based patients. Facilitators for adopting TR perceived by respondents were physiotherapists’ attitudes and access to technology, convenience and ease of scheduling sessions, and perceived patient satisfaction and comfort in their home. Barriers to adopting TR perceived by respondents were patient factors including attitudes, suitability, ability to address their needs, ease of adoption, and Internet connectivity. Interestingly, financial factors had no impact on the adoption and use of TR during the pandemic. To optimize the delivery of TR and address the barriers identified, continuing education regarding use of TR should be developed for both patients and physiotherapists to foster positive patient attitudes regarding the value of TR, and ensure the competency of physiotherapists when providing TR.

Key Messages

What is already known on this topic?

Previous literature highlighted that the use of TR guidelines, patient and PT education on TR use, and the benefits of TR facilitate adoption. In addition, technological difficulties, patient appropriateness, and protection of privacy can present as barriers. These identified facilitators and barriers in prior studies were not studied in a pandemic and were specific to small clinical populations to maintain continuity of care for patients living in rural/remote settings.

What this study adds

This study provides important insights on specific facilitators of and barriers to the adoption of TR within outpatient and community practice settings across Ontario during the COVID-19 pandemic. Our results suggest new areas of focus for effective adoption and use of TR beyond the pandemic. Given that patient and provider attitudes present as both facilitators of and barriers to the adoption and use of TR, further understanding of what shapes attitudes should be explored. Additionally, education in entry-level physiotherapy programmes and postgraduate training, as well as patient education, might enhance the continued effectiveness of TR use.

Supplemental Material

References

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