This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Rehabilitation and Assistive Technology, is properly cited. The complete bibliographic information, a link to the original publication on https://rehab.jmir.org/, as well as this copyright and license information must be included.
A tele-rehabilitation platform was developed to improve access to ambulatory rehabilitation services in Hong Kong. The development was completed in October 2019 and rolled out for use to occupational therapists, physiotherapists, and speech therapists. During the COVID-19 pandemic, rehabilitation services were severely interrupted. Tele-rehabilitation was used extensively to meet the demand for rehabilitation service delivery.
The aims of this study were to (1) describe the design and development process of a tele-rehabilitation service, and (2) study how the tele-rehabilitation platform was used to overcome the disruption of rehabilitation service during the COVID-19 pandemic.
Tele-rehabilitation was developed utilizing 4 core determinants of Unified Theory of Acceptance and Use of Technology as guiding principles. A generic prescription platform, called the activity-based prescription system, and a mobile app, called the Rehabilitation App, were built. Five outcomes were used to examine the utilization of tele-rehabilitation both before and during the pandemic: throughput, patient demographic, patient conditions, workforce, and satisfaction from patients and staff.
There was a tremendous increase in the use of tele-rehabilitation during pandemic. The total number of patients (up until July 2020) was 9101, and the main age range was between 51 to 70 years old. Tele-rehabilitation was used for a much wider scope of patient conditions than originally planned. More than 1112 therapists, which constituted 50.6% of the total workforce (1112/2196), prescribed tele-rehabilitation to their patients. Moreover, there was a high satisfaction rate from patients, with a mean rating of 4.2 out of 5, and a high adherence rate to prescribed rehabilitation activities (107840/131995, 81.7%).
The findings of our study suggested that tele-rehabilitation in the form of a generic prescription platform and mobile app can be an effective means to provide rehabilitation to patient. During the COVID-19 pandemic, tele-rehabilitation has been used extensively and effectively to mitigate service disruption. Our findings also provide support that there is a high level of satisfaction with tele-rehabilitation; however, a longer duration study is required to demonstrate the sustained use of tele-rehabilitation, especially after the pandemic.
The Hospital Authority is the statutory body responsible for managing public health services in Hong Kong. The Hospital Authority provides over 90% of inpatient care and 30% of outpatient care and is the major provider of rehabilitation service to Hong Kong citizens [
To overcome service bottlenecks, especially those for patients after stroke, patients after hip fracture, and older adult patients with frailty, the report [
Tele-rehabilitation refers to the provision of rehabilitation service at a distance using telecommunication technology as the service delivery medium. It is an alternative means of providing all aspects of care including interviews, physical assessments, diagnoses, interventions, maintenance activities, consultations, education, and training to patients in a remote location [
The tele-rehabilitation platform’s development was completed in October 2019. The aim of its development was to provide therapists with a new form of service delivery. Since mid-January 2020, COVID-19 has affected Hong Kong and in late January 2020 rehabilitation services delivery became seriously disrupted, with a 50% drop in attendance. To combat the disruption of service, occupational therapists, physiotherapists, and speech therapists extensively utilized the tele-rehabilitation platform from mid-February 2020 onward, and its content expanded rapidly from early March 2020 onward, gathering momentum during the COVID-19 outbreak.
The aims of this study were to describe the design and development process of the tele-rehabilitation platform and investigate how the tele-rehabilitation platform was used to overcome the disruption of rehabilitation services during the COVID-19 pandemic.
A technology or innovation can only be considered useful if it is accepted and used in daily clinical practice. There are several criteria to consider in predicting whether target users will actually use the technology. The Unified Theory of Acceptance and Use of Technology [
Focus groups were formed to work in close collaboration with physiotherapists, occupational therapists, and speech therapists. An agile approach was used; therapists could test the prototypes during regular focus group meetings and provide feedback. Moreover, patients were invited to try the mobile app and provide comments on a regular basis for continuous user interface improvements.
Tele-rehabilitation has been used for patients after stroke [
After thorough discussions, it was decided that a new prescription platform and a mobile app would be developed. The utilization of a mobile app in tele-rehabilitation has been supported in many studies [
System design. ABPS: Activity Based Prescribing System; Clinical Management System; DB: database; OT: occupational therapist; PT: physiotherapist; ST: speech therapist.
The Clinical Management System is the electronic medical record that all therapists in Hospital Authority use daily for clinical practice to disseminate health care information or clinical data and enhance patient care [
A therapist could complete a prescription with a few clicks. Altogether, 144 videos were incorporated into the ABPS. The ABPS was designed as a generic prescription platform to allow the future addition of training videos and reminders and future inclusion of more allied health professions.
Patients using tele-rehabilitation could be older adults who may have cognitive impairment or poor memory. Thus, the mobile app was designed to be simple and barrier-free. If a therapist prescribed a training video to a patient, a notification would be pushed to the app at the prescribed time. A swipe on the notification message could trigger the training video without having to log in to the app (
Push notification to trigger training video.
Occupational therapist, physiotherapist, and speech therapist staff committees were engaged to encourage therapists to participate in design, testing, and use. Senior management also expressed that tele-rehabilitation was a corporate direction, and therapists were encouraged to use this new technology. During the rollout of tele-rehabilitation, onsite support was provided to all hospitals. In addition, user guides and support hotline were provided to therapists and training videos were made available to patients to ensure adequate support to both therapists and patients.
Privacy and data security were essential concerns in the development of tele-rehabilitation [
We compared tele-rehabilitation use before and during the COVID-19 outbreak. Analysis before the outbreak analysis pertained to the period from October 2019 to January 2020, and analysis during outbreak period analysis pertained to the period from February 2020 to July 2020.
We collected 5 outcomes: throughput, the prescription rate of tele-rehabilitation; patient demographics; patient conditions for which tele-rehabilitation was prescribed; utilization rates by occupational therapists, physiotherapists, and speech therapist; and staff and patient satisfaction.
Satisfaction surveys were prepared and forwarded to both therapists and patients for collecting their opinion on the Rehabilitation App. The format of the surveys was discussed in the focus group. Therapists suggested that the surveys should be simple and require only a short time to complete. The survey for the therapists consisted of 8 questions while the survey for patients consisted of 4 questions. A 5-point scale was use in the survey (1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree). A prompt was shown on ABPS 30 days after the therapist started prescribing with the platform. The prompt contained a reminder to complete the survey. For patients, 7 days before their prescribed rehabilitation activity ended, a prompt was shown in Rehabilitation App to invite the patient to complete the survey.
Patient demographic, workforce, and patient condition variables were nonparametric categorical data; therefore, chi-square analysis was used.
Physiotherapy added 41 musculoskeletal training videos in early March and 15 additional musculoskeletal training videos in April. Speech therapy added 8 swallowing training videos in mid-March. Occupational therapy added 8 pulmonary training videos in early April. A total of 72 videos were added from February to April.
The number of prescriptions per month showed a slightly decrease from October 2019 to January 2020. The number of new patients per month increased to 462 in February 2020 and spiked to 2024 in March 2020. The total number of patients prescribed accumulated to 9101 (
Patients prescribed tele-rehabilitation by month.
Tele-rehabilitation prescriptions per month by professions.
The Rehabilitation App was designed for adult patients, and the age of prescribed patients ranged from 18 to 106 years old. Age group analysis of patients revealed that before the outbreak, the age group with the highest prescription rate was 61 to 70 years (
Before and during outbreak age distributions of patients prescribed tele-rehabilitation.
Tele-rehabilitation patient demographics before and during the COVID-19 outbreak.
Characteristic | Beforea (n=1246) | Duringb (n=7845) | |||
|
|
|
|||
|
Female | 648 (52.0) | 4158 (53.0) | ||
|
Male | 598 (48.0) | 3687 (47.0) | ||
|
|
|
|||
|
Below 60 | 610 (49) | 4001 (55) | ||
|
Above 60 | 636 (51) | 3884 (45) | ||
Age (years), mean (SD) | 60 (15.5) | 59 (16.2) | |||
Age (years), median | 61 | 60 |
aOctober 2019 to January 2020.
bFebruary 2020 to July 2020.
Speech therapy had a relatively simple patient condition distribution; the main conditions were head and neck diseases, stroke, neurological conditions, neurosurgery, and cancer. Stroke and head and neck disease remained the largest case group for speech therapy throughout (
Percentage distribution of patient conditions for speech therapy before and during the outbreak.
Patient conditions for which speech therapy was prescribed before and during the COVID-19 outbreak.
Patient conditions | Beforea | Duringb | |||
|
Mean per month (SD) | % | Mean per month (SD) | % | |
Head and neck conditions | 11.2 (3.4) | 31.5 | 21.3 (5.9) | 18.2 | |
Stroke | 10.2 (1.3) | 28.7 | 36.0 (6.6) | 30.7 | |
Neurological | 7.3 (1.2) | 20.6 | 20.3 (6.1) | 17.4 | |
Neurosurgery | 2.5 (0.8) | 7.0 | 4.0 (2.4) | 3.3 | |
Cancer | 1.0 (1.8) | 2.8 | 25.3 (7.1) | 21.6 | |
Other conditions | 3.3 (0.7) | 9.3 | 10.3 (3.8) | 8.8 | |
Total | 35.5 | 100 | 117.0 | 100 |
aOctober 2019 to January 2020.
bFebruary 2020 to July 2020.
Occupational therapy had several major patient condition groups including stroke, neurological conditions, weakness and deconditioning, pain and injury, cancer, and fractures (
Percentage distribution of patient conditions before and during outbreak for occupational therapy.
Patient conditions for which occupational therapy was prescribed before and during the COVID-19 outbreak.
Patient conditions | Beforea | Duringb | |||
|
Mean per month (SD) | % | Mean per month (SD) | % | |
Stroke | 68.0 (13.0) | 57.7 | 105.3 (32.1) | 49.1 | |
Neurological | 12.0 (1.9) | 10.2 | 16.3 (6.6) | 7.6 | |
Pain and injury | 6.0 (0.5) | 5.1 | 14.2 (4.7) | 6.6 | |
Weakness and deconditioning | 7.5 (0.8) | 6.4 | 8.7 (3.9) | 4.1 | |
Fracture hip | 2.5 (0.5) | 2.1 | 11.0 (3.9) | 5.1 | |
Neurosurgery | 1.5 (1.9) | 1.3 | 1.8 (1.8) | 0.8 | |
Pulmonary | 1.3 (0.5) | 1.1 | 10.3 (6.8) | 4.8 | |
Cancer | 1.8 (1.9) | 1.5 | 13.8 (4.9) | 6.4 | |
Other fracture | 1.5 (0.6) | 1.3 | 4.5 (2.3) | 2.1 | |
Other conditions | 15.8 (2.3) | 13.4 | 28.3 (8.1) | 13.2 | |
Total | 117.9 | 100 | 214.3 | 100 |
aOctober 2019 to January 2020.
bFebruary 2020 to July 2020.
Physiotherapy had a diverse patient conditions distribution. There were several conditions including stroke, weakness and deconditioning, fracture hip, pain and injury, neurological conditions, and low back pain (
Percentage distribution of patient conditions before and during outbreak for physiotherapy.
Patient conditions for which physiotherapy was prescribed before and during the COVID-19 outbreak.
Patient conditions | Beforea | Duringb | Adjusted residual valuec | ||||
|
Mean per month (SD) | % | Mean per month (SD) | % |
|
||
Stroke | 20.3 (6.0) | 11.7 | 93.3 (13.4) | 9.2 | –0.9, 0.9 | ||
Weakness and deconditioning | 15.8 (2.7) | 9.1 | 46.8 (4.6) | 4.6 | –2.5, 2.5c | ||
Neurological | 14.0 (2.9) | 8.0 | 29.2 (9.9) | 2.9 | –3.4, 3.4c | ||
Knee pain | 12.3 (2.7) | 7.1 | 67.0 (39.3) | 6.6 | –0.1, 0.1 | ||
Lower back pain | 10.0 (5.5) | 5.7 | 138.5 (62.8) | 13.7 | –2.9, 2.9c | ||
Other fracture | 9.8 (4.2) | 5.6 | 34.2 (16.6) | 3.4 | –1.5, 1.5 | ||
Pain and injury | 6.8 (3.9) | 4.0 | 90.3 (45.1) | 8.9 | –2.2, 2.2c | ||
Cancer | 5.8 (2.7) | 3.3 | 37.7 (10.4) | 3.7 | –0.2, 0.2 | ||
Fall | 3.0 (1.2) | 1.7 | 24.2 (6.5) | 2.4 | –0.5, 0.5 | ||
Neurosurgical | 2.5 (2.1) | 1.4 | 13.3 (8.3) | 1.3 | –0.5, 0.5 | ||
Pulmonary | 4.0 (0.5) | 2.3 | 14.3 (5.9) | 1.4 | –0.9, 0.9 | ||
Neck pain | 2.0 (1.1) | 1.1 | 46.0 (27.0) | 4.5 | –2.1, 2.1c | ||
Fracture hip | 5.0 (1.9) | 2.9 | 53.2 (13.5) | 5.2 | –1.3, 1.3 | ||
Shoulder pain | 1.5 (0.7) | 0.9 | 20.3 (5.5) | 2.0 | –0.8, 0.8 | ||
Cardiac | 1.8 (1.1) | 1.0 | 19.5 (6.0) | 1.9 | –0.8, 0.8 | ||
Other conditions | 59.3 (20.4) | 34.1 | 287.3 (63.3) | 28.3 | –1.5, 1.5 | ||
Total count | 173.9 | 100 | 1015.2 | 100 | N/Ad |
aOctober 2019 to January 2020.
bFebruary 2020 to July 2020.
cStatistically significant 95% confidence interval (<–1.96 and >1.96).
dN/A: not applicable.
In February 2020, there were a total of 907 occupational therapists, 1177 physiotherapists, and 112 speech therapists employed in Hospital Authority, and 1112 therapists (372 occupational therapists, 635 physiotherapists, and 105 speech therapists) prescribed tele-rehabilitation to patients, which constituted 50.6% (1112/2196) of the total workforce. Physiotherapy and occupational therapy had a 3-tier rank structure (rank I, rank II, and senior). Rank II was the entry rank, and rank I was the middle rank. Speech therapy had a 2-tier rank structure (basic and senior). Speech therapists had the highest overall prescription rate (speech therapists: 105/112, 93.8%; physiotherapists: 635/1177, 54.0%; occupational therapists: 372/907, 41.0%). There were statistically significant differences in prescriptions by rank for occupational therapists (
Analysis of prescription according to therapist rank.
Rank | Total workforce | Prescribed tele-rehabilitation | Percentage of workforce | Adjusted residual value | |||||||
|
|
|
|
|
.001 | ||||||
|
Occupational therapist II | 442 | 201 | 45.5 | –2.7, 2.7 |
|
|||||
|
Occupational therapist I | 389 | 154 | 39.6 | –0.8, 0.8 |
|
|||||
|
Senior occupational therapist | 76 | 17 | 22.4 | –3.5, 3.5 |
|
|||||
|
|
|
|
|
<.001 | ||||||
|
Physiotherapist II | 554 | 350 | 63.2 | –6.0, 6.0 |
|
|||||
|
Physiotherapist I | 524 | 266 | 50.8 | –2.0, 2.0 |
|
|||||
|
Senior physiotherapist | 99 | 19 | 19.2 | –7.3, 7.3 |
|
|||||
|
|
|
|
|
.45 | ||||||
|
Speech therapist | 104 | 97 | 93.3 | –0.8, 0.8 |
|
|||||
|
Senior speech therapist | 8 | 8 | 100 | –0.8, 0.8 |
|
Of 2196 therapists, 111 therapists completed the survey; the response rate was 5.2%. Overall satisfaction toward the Rehabilitation App was rated as 3.7 (
Therapist survey scores.
Therapist questions | Score (n=111), mean |
The installation procedures are easy to administer | 3.5 |
The training app is well organized. | 3.8 |
The training app is user-friendly | 3.6 |
The content of the app meets the patient’s training need | 3.7 |
The app can enhance patient’s treatment frequency apart from regular treatment | 3.8 |
The app could facilitate you to prescribe the home program | 4.2 |
The app could assist you in treatment planning | 3.8 |
Overall, you satisfy with the training app. | 3.7 |
The response from the patient’s side was very positive. The response rate was 28.8%, with 2623 of 9101 patients completing the survey. Overall satisfaction rate was rated as 4.2 (
Patient survey scores.
Patient questions | Score (n=2623), mean |
The training app is easy to use. | 4.2 |
The training app improves my participation in the home program. | 4.2 |
The training app is helpful for my rehabilitation. | 4.1 |
Overall, I am satisfied with the training app. | 4.2 |
Use of tele-rehabilitation increased remarkably during the COVID-19 pandemic. Physiotherapy had the highest number of prescriptions. Tele-rehabilitation was mostly prescribed to patients between 51 and 70 years of age. Patients reported a high level of satisfaction. Over 50% of the total workforce prescribed tele-rehabilitation to patients (1112/2196, 50.6%). Originally, tele-rehabilitation was designed to treat patients with stroke, patients with hip fracture, and older adults with frailty. Our study showed that tele-rehabilitation can be used for a much wider spectrum of patient conditions. The generic design of the tele-rehabilitation was able to expand training content and cope with the service demand for rehabilitation during the outbreak period.
Tele-rehabilitation utilization reached a peak in March 2020 during the first wave of outbreak in Hong Kong. Tele-rehabilitation use dropped from 2024 new patients in March to approximately 1300 per month from April to July. The stable trend indicated that tele-rehabilitation was used irrespective of number of confirmed COVID-19 cases. Continuous monitoring is needed to study the sustainability of utilization and especially during the postpandemic phase.
Our study showed that there was no difference in distribution between patients above or below 60 years old. This finding echos those of Crotty et al [
Analysis of workforce data demonstrated that 50.6% of the total workforce (1112/2196) prescribed tele-rehabilitation. There was significant difference in prescription rate between basic and senior ranks in occupational therapy (
Analysis of clinical conditions revealed that there was an increase in prescriptions for patients after stroke during the outbreak period (1.55-fold increase in occupational therapy, 4.60-fold increase in physiotherapy, and 3.53-fold increase in speech therapy). These findings aligned well with the initial goals of the tele-rehabilitation platform. However, we noticed that hip fracture ranked rather low in the prescription rate for both physiotherapists and occupational therapists which was surprisingly not aligned with the objectives of the platform’s development. On the other hand, both physiotherapists and occupational therapists prescribed tele-rehabilitation for a broad spectrum of clinical conditions. There was a significant increase in prescriptions to musculoskeletal conditions of lower back pain (adjusted residual –2.9, 2.9), neck pain (adjusted residual –2.1, 2.1), and pain and injury (adjusted residual –2.2, 2.2). The results demonstrate that tele-rehabilitation is indicated for a broad spectrum of patient conditions.
A generic design was adopted for both the ABPS and mobile app. This facilitated rapid expansion of training content. Previous studies [
The COVID-19 pandemic has altered health care delivery globally. Severe restrictions such as social distancing and the suspension of rehabilitation services were enacted to prevent spread of disease. The World Health Organization recommended postponing treatments that were not considered urgent in order to ensure safety, while still guaranteeing the essential rehabilitation services [
Through the advent of technology, faster internet connection, cheaper smart devices (smartphones and tablets), and new software being available, tele-rehabilitation is able to offer many benefits. However, there are challenges ahead if tele-rehabilitation is to be used extensively in the future. For example, the use of tele-rehabilitation is a paradigm shift for therapists from conventional face-to-face interventions. During the outbreak, there was a rapid increase in the number of therapists who needed to prescribe tele-rehabilitation. Consequently, training and accrediting staff to use tele-rehabilitation became essential. A
The COVID-19 pandemic will not affect the acute outbreak period alone but may also create a serious backlog for rehabilitation in the postpandemic recovery period, which is referred to as “care debt [
This observational study has a number of limitations. This study only reports outcomes of tele-rehabilitation utilization before and during outbreak periods. It does not cover the clinical effectiveness of tele-rehabilitation to patients; this requires additional well-powered clinical studies. The Unified Theory of Acceptance and Use of Technology [
The COVID-19 pandemic has seriously affected rehabilitation service delivery. Our study has shown that a tele-rehabilitation platform was used extensively and effectively during the outbreak period to mitigate service disruption. In addition to the original targeted conditions (stroke and hip fracture), tele-rehabilitation was prescribed for a large variety of clinical conditions. The tele-rehabilitation platform, though it cannot replace all face-to-face rehabilitation services, has demonstrated its potential during the COVID-19 crisis and has promising potential to become a sustainable service delivery model.
Supplementary material.
activity-based prescribing system
None declared.