Exploring remote models of physiotherapy service delivery for people with osteoarthritis

© 2018 Dr Belinda LawfordKnee and hip osteoarthritis (OA) is highly prevalent and has a significant burden on both the individual sufferer and society. All current clinical guidelines recommend education and exercise for management of OA, however exercise participation amongst people with OA is sub-optimal. Barriers to exercise uptake and adherence include inequitable access to appropriate healthcare, and difficulties changing behaviour and incorporating exercise into daily life. This thesis explores remote models of service delivery (telerehabilitation) as a potential method of improving exercise participation in people with OA. Specifically, this thesis aimed to explore the perceived acceptability of telerehabilitation services amongst people with OA and physiotherapists, and also investigate physiotherapist training in behaviour change techniques and person-centred care for telephone-delivery. Study 1 involved a survey that investigated the perceptions people with knee and/or hip OA (n=330) have towards the delivery of exercise therapy by a physiotherapist via internet-mediated video and telephone consultations. Participants had overall positive perceptions, acknowledging ease of use and time saving advantages. However, most (>50%) did not agree that they would like the lack of physical contact, that they would be willing to pay for telerehabilitation services, that telephone-delivery would be effective, or that a physiotherapist would be able to adequately monitor their condition via telephone. Study 2 involved a survey that investigated the perceptions of physiotherapists (n=217) towards the delivery of exercise therapy via internet-mediated video and telephone consultations for people with OA. Most physiotherapists agreed such services would save patient’s time and maintain their privacy, but most did not believe they would like the lack of physical contact with patients. In addition, physiotherapists favoured the use of video technologies over telephone, with most feeling uncertain about the safety, effectiveness, usefulness, or acceptability of telephone-delivered care. Study 3 qualitatively explored physiotherapists’ (n=8) perceptions before and after a training program in behaviour change techniques and person-centred principles that was done in preparation for a clinical trial involving the delivery of exercise therapy via telephone. After training, physiotherapists’ perceptions about their role managing patients with OA had changed, increasing their feelings of responsibility to assist their patient with exercise adherence, and they felt confident and prepared to deliver the intervention remotely via telephone. Study 4 evaluated the fidelity of physiotherapists from Study 3 (n=8) to the behaviour change techniques and person-centred principles taught during training, and involved both self- and expert audits of practice telephone consultations. Physiotherapists performed moderately well, but had room for improvement from further practice and/or training. Physiotherapists’ self-ratings of performance generally agreed with expert ratings, however they tended to underestimate their ability to implement some principles and techniques. Study 5 explored the perceptions of people with knee OA (n=20) who participated in a clinical trial involving telephone-delivered exercise therapy by a physiotherapist. Although participants were initially sceptical about receiving care via telephone, they described mostly positive experiences, valuing the sense of undivided focus and attention and feeling confident performing their exercise program without supervision. Study 6 explored how experience delivering exercise therapy via telephone as part of a clinical trial changed physiotherapists’ (n=8) perceptions about such services. Physiotherapists were initially sceptical about the effectiveness of telephone-delivered service models, expressing concern about the lack of physical and visual contact. However, after experience, physiotherapists were pleasantly surprised by the effectiveness of the intervention and by the positive outcomes that they were able to achieve with their participants. Collectively, findings from this thesis suggest that, overall, telerehabilitation is perceived to be an acceptable model of service delivery by people with OA and physiotherapists. Although there was evidence of scepticism about the effectiveness of telephone-delivered care amongst those who are inexperienced, particularly physiotherapists, these perceptions appeared to change with experience. Physiotherapists believed that training in behaviour change techniques and person-centred care helped them communicate effectively via telephone and also changed their perceptions about their role managing patients with OA. Findings from this thesis can be used to inform the future design and implementation of telerehabilitation services and clinician training programs