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The ongoing COVID-19 pandemic has required social, health, and rehabilitation organizations to implement remote physiotherapy (RP) as a part of physiotherapists’ daily practice. RP may improve access to physiotherapy as it delivers physiotherapy services to rehabilitees through information and communications technology. Even if RP has already been introduced in this century, physiotherapists’ opinion, amount of use, and form in daily practice have not been studied extensively.
This study aims to investigate physiotherapists’ opinions of the current state of RP in Finland.
A quantitative, cross-sectional, web-based questionnaire was sent to working-aged members of the Finnish Association of Physiotherapists (n=5905) in March 2021 and to physiotherapists in a private physiotherapy organization (n=620) in May 2021. The questionnaire included questions on the suitability of RP in different diseases and the current state and implementation of RP in work among physiotherapists.
Of the 6525 physiotherapists, a total of 9.9% (n=662; n=504, 76.1% female; mean age 46.1, SD 12 years) answered the questionnaire. The mean suitability “score” (0=not suitable at all to 10=fully suitable) of RP in different disease groups varied from 3.3 (neurological diseases) to 6.1 (lung diseases). Between early 2020 (ie, just before the COVID-19 pandemic) and spring 2021, the proportion of physiotherapists who used RP increased from 33.8% (21/62) to 75.4% (46/61;
During the COVID-19 pandemic, physiotherapists increased their use of RP in their everyday practice, although practice time in RP was still low. When planning RP for rehabilitees, it should be considered that the suitability of RP in different diseases seems to vary in the opinion of physiotherapists. Furthermore, our results brought up important new information for developing social, health, and rehabilitation education for information and communications technologies.
Providing easy and equal access to physiotherapy services is a significant challenge due to the aging population; increasing prevalence of chronic diseases; and the concentration of health, rehabilitation, and social services to urban areas [
The COVID-19 pandemic has required health care organizations to implement RP as a part of physiotherapists’ daily practice [
RP may be as effective as conventional physiotherapy in some disease groups, such as musculoskeletal diseases [
Despite the advantages of RP, physiotherapy is still typically practiced in person. There are several barriers that preclude the wider use of RP. These include the physiotherapist’s competence in using technical equipment and resistance to RP; technical investment costs; and the age, degree of education, and computer literacy of the rehabilitee [
There is some evidence that the COVID-19 pandemic has increased the use of RP in Switzerland [
We used a quantitative, cross-sectional, web-based questionnaire study to answer the research questions. Physiotherapists responded to the questionnaire anonymously. This study adhered to the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) [
The term RP was defined as a physiotherapy intervention that includes remote technology such as telephones, smartphones, computers, tablets, activity trackers, computer vision (CV), artificial intelligence (AI), virtual reality (VR), or robotics such that the physiotherapist is physically in a different place than the rehabilitee [
The Finnish health care system consists of two complementary sectors that receive public funding, the public and private sector. There are substantial differences between these systems, such as scope of services provided, user fees, and waiting times. There are also differences in financing mechanisms. The public sector is financed based on taxes and the National Health Insurance (NHI); the private sector is partly (one-third) financed by NHI [
We recruited physiotherapists of working age from the Finnish Association of Physiotherapists (n=5905) and from a private physiotherapy organization (n=620). A questionnaire was mailed to physiotherapists in March (Finnish Association of Physiotherapists) and May 2021 (private physiotherapy organization) via an information letter that included an electronic link to the questionnaire. The questionnaire had a 5-week deadline. Two reminders were sent during this period; the first reminder was sent after 1 week and the second reminder 2 weeks after the first.
A questionnaire was constructed that included items that were based on previous literature in the field [
The questionnaire included 32 questions (31 closed and 1 open question). To study suitability of RP in different diseases and patients with pain, we used an 11-point numeric scale (0=not suitable at all, 10=fully suitable). While most of the patients with chronic pain are patients with musculoskeletal disorder [
Statistical analyses were performed with SPSS (Version 27.0; IBM Corp). Frequency distributions, percentages, and means are given as descriptive statistics. Chi-square statistics and Student
The study was granted ethical approval by the research ethics committee of the Faculty of Medicine at University of Helsinki in February 2021 (registration number 3/2021).
Of the 6525 physiotherapists, a total of 9.9% (n=662) answered the questionnaire. Physiotherapy students and physiotherapists that were retired, lecturers, or researchers were excluded; the final study group included 579 (8.9%) physiotherapists. Of these 579 physiotherapists, 482 (83.2%) were females (mean age 49.3 SD 11.9 years), and 97 (16.8%) were males (mean age 46.2, SD 12.2 years). Of the physiotherapists, 423 (73.1%) worked in the private sector and 152 (26.3%) in the public sector; in addition to these, 3 did not answer this specific question, and 1 could not be classified to either group.
Physiotherapists in the public and private sector typically had extensive work experience. Almost four-fifths (440/579, 76%) had over 10 years of experience; there was no difference in work experience between the physiotherapists in these two sectors. However, the proportion of physiotherapists who reported that they do not have work experience in RP was higher in the public sector than in the private sector. Detailed characteristics of the physiotherapists are shown in
There were minimal differences when the mean suitability “score” (0=not suitable at all to 10=fully suitable) of RP in different connected disease groups between public and private sectors were compared. However, the mean suitability “score” of lung diseases (
Three-quarters of all physiotherapists reported that they did not spend any of their practice time in RP before the COVID-19 pandemic in early 2020. The proportion of such physiotherapists was higher in the private sector than in the public sector (171/213, 80.3%; vs 41/62, 66.1%;
Between early 2020 and spring 2021, the proportion of physiotherapists who used RP increased from 33.8% (21/62) to 75.4% (46/61;
When studying the methods and equipment used in individual RP, the real-time method was the most common method in the public (46/66, 69.7%) and the private (157/219, 71.7%) sector. In contrast, only a few physiotherapists used the method not tied to time (
Characteristics of the study physiotherapists.
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Total group (n=579) | Public sector (n= 152) | Private sector (n=423) | |||
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Total | 48.8 (11.9) | 48.6 (11.9) | 49.0 (11.9) | .73a | |
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Female | 49.3 (11.9) | 49.3 (11.9) | 49.3 (11.7) | .93a | |
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Male | 46.2 (12.2) | 42.3 (10.3) | 47.3 (12.3) | .15a | |
Time from physiotherapy degree (years), mean (SD) | 22.3 (12.6) | 21.4 (12.5) | 22.7 (12.5) | .27a | ||
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.47b | |||||
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<1 year | 18 (3.1) | 7 (4.6) | 10 (2.4) |
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≥1 year and <5 years | 65 (11.2) | 17 (11.2) | 47 (11.1) |
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≥5 years and <10 years | 56 (9.7) | 12 (7.9) | 43 (10.2) |
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≥10 years | 440 (76.0) | 116 (76.3) | 323 (76.4) |
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<.001b | |||||
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No experience | 210 (36.3) | 77 (50.7) | 130 (30.7) |
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<1 year | 209 (36.1) | 26 (30.3) | 162 (38.3) |
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1 year to 2 years | 135 (23.3) | 26 (17.1) | 109 (25.8) |
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>2 to 4 years | 13 (2.2) | 1 (0.7) | 12 (2.8) |
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>4 years | 12 (2.1) | 2 (1.3) | 10 (2.4) |
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a
b
Suitability score of remote physiotherapy in different disease groupsa.
Connected disease groups and subgroups | Total group, mean (SD) | Public sector, mean (SD) | Private sector, mean (SD) | Mean difference (95% CI) | |||||||
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6.1 (2.4) | 6.5 (2.1) | 5.9 (2.5) | 0.6 (0.1 to 1.1) | .02 | ||||||
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Asthma | 6.6 (2.5) | 6.8 (2.3) | 6.5 (2.5) | 0.3 (–0.3 to 0.8) | .31 | |||||
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COPDc | 5.6 (2.6) | 6.2 (2.2) | 5.4 (2.7) | 0.8 (0.3 to 1.3) | .003 | |||||
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5.7 (2.2) | 6.1 (1.9) | 5.6 (2.3) | 0.6 (0.1 to 1.0) | .01 | ||||||
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Knee and hip osteoarthritis | 6.6 (2.5) | 7.2 (2.1) | 6.4 (2.6) | 0.8 (0.3 to 1.2) | .001 | |||||
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Low back pain | 5.9 (2.6) | 5.9 (2.5) | 5.9 (2.6) | 0.0 (–0.5 to 0.5) | .98 | |||||
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Repetitive strain injury of the hand and forearm | 5.9 (2.8) | 6.5 (2.7) | 5.6 (2.8) | 0.9 (0.3 to 1.5) | .002 | |||||
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Tendon disorder of the shoulder | 5.8 (2.7) | 6.0 (2.6) | 5.7 (2.7) | 0.4 (–0.2 to 0.9) | .19 | |||||
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Rheumatoid arthritis | 5.7 (2.5) | 6.1 (2.3) | 5.5 (2.6) | 0.6 (0.1 to 1.2) | .02 | |||||
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Pain patient | 5.2 (2.7) | 5.3 (2.6) | 5.1 (2.7) | 0.2 (–0.4 to 0.8) | .50 | |||||
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Neck pain | 4.8 (2.7) | 4.7 (2.6) | 4.8 (2.7) | –0.1 (–0.7 to 0.5) | .75 | |||||
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4.9 (2.7) | 5.3 (2.6) | 4.7 (2.7) | 0.6 (0.0 to 1.2) | .06 | ||||||
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Anxiety disorder | 5.2 (3.0) | 5.6 (3.1) | 5.0 (3.0) | 0.6 (0.0 to 1.3) | .045 | |||||
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Depression | 5.0 (2.9) | 5.3 (2.8) | 4.8 (2.9) | 0.5 (–0.2 to 1.1) | .15 | |||||
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Personality disorder | 4.7 (2.9) | 4.9 (2.9) | 4.6 (2.9) | 0.4 (–0.2 to 1.0) | .23 | |||||
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3.3 (2.1) | 3.3 (1.9) | 3.3 (2.2) | 0.1 (–0.5 to 0.4) | .81 | ||||||
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Multiple sclerosis | 4.4 (2.6) | 4.3 (2.4) | 4.4 (2.7) | –0.1 (–0.6 to 0.5) | .85 | |||||
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Parkinson disease | 4.0 (2.6) | 4.1 (2.5) | 4.0 (2.6) | 0.1 (–0.5 to 0.7) | .69 | |||||
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Cerebral infarction (eg, stroke) | 3.3 (2.6) | 3.1 (2.4) | 3.4 (2.6) | –0.2 (–0.8 to 0.3) | .45 | |||||
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Spinal cord injury | 3.2 (2.7) | 2.9 (2.3) | 3.3 (2.8) | –0.5 (–1.1 to 0.1) | .09 | |||||
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Brain injury | 3.2 (2.5) | 2.9 (2.4) | 3.2 (2.6) | –0.3 (–0.8 to 0.2) | .25 | |||||
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Memory disorder | 2.1 (2.2) | 2.3 (2.3) | 2.0 (2.2) | 0.3 (–0.2 to 0.8) | .21 | |||||
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Heart disease/failure | 5.8 (2.7) | 6.1 (2.5) | 5.7 (2.8) | 0.4 (–0.1 to 1.0) | .14 | |||||
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Cancer | 5.2 (2.8) | 5.3 (2.7) | 5.2 (2.8) | 0.1 (–0.5 to 0.7) | .75 | |||||
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Multimorbid patient | 3.6 (2.6) | 3.7 (2.6) | 3.5 (2.7) | 0.2 (–0.4 to 0.8) | .46 |
aSuitability score (0=not suitable at all to 10=fully suitable).
b
cCOPD: chronic obstructive pulmonary disease.
Proportion of physiotherapists who used remote physiotherapy before (early 2020) and during the COVID-19 pandemic (spring 2021).
Proportion of practice time (%) | Total group, n (%) | Public sector, n (%) | Private sector, n (%) | |||
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.03 | |||||
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0 | 212 (76.8) | 41 (66.1) | 171 (80.3) |
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1-20 | 60 (21.7) | 19 (30.6) | 40 (18.8) |
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>20 | 4 (1.4) | 2 (3.2) | 2 (0.9) |
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.20 | |||||
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0 | 65 (23.7) | 15 (24.6) | 50 (23.5) |
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1-20 | 177 (64.6) | 35 (57.4) | 142 (66.7) |
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>20 | 32 (11.7) | 11 (18.0) | 21 (9.9) |
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a
Methods and equipment used in remote physiotherapy on a weekly basis.
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Total group, n (%) | Public sector, n (%) | Private sector, n (%) | |||||||
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.47 | |||||||||
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Real-time method | 203 (71.0) | 46 (69.7) | 157 (71.7) |
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Method not tied to time | 11 (3.8) | 1 (1.5) | 10 (4.6) |
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Real-time method and method not tied to time | 25 (8.7) | 5 (7.6) | 20 (9.1) |
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Computer/tablet | 229 (79.0) | 46 (67.6) | 183 (82.8) | .01 | |||||
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Smartphone | 149 (51.4) | 33 (48.5) | 116 (52.5) | .58 | |||||
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Phone | 51 (17.6) | 18 (26.5) | 33 (14.9) | .04 | |||||
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Activity trackerb | 18 (6.2) | 3 (4.4) | 15 (6.8) | .58 | |||||
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Othersc | 10 (1.7) | 1 (1.5) | 9 (4.1) | .76 |
a
bFor example, pedometer and accelerometer.
cExergame, television application, virtual reality, computer vision, artificial intelligence, robotics, smart textile, or augmented reality.
This study sought to investigate physiotherapists’ opinion on the current state of RP in Finland. While the ongoing COVID-19 pandemic has increased the use of RP in everyday practice, practice time for RP was still minimal, as just 1 in 10 used >20% of practice time to conduct RP. The suitability of RP varied across different disease groups. According to the physiotherapists, RP is better suited for rehabilitees with lung, heart, or musculoskeletal diseases than for rehabilitees with neurological diseases. RP was most commonly performed with a computer/tablet or a smartphone and with real-time methods. Less than 2% of physiotherapists used other technological equipment (eg, VR, AI, or CV).
The COVID-19 pandemic has led to the rapid adoption of RP by hospitals and clinics. RP has enabled physiotherapists to continue to provide therapy to rehabilitees during the pandemic, prevent further transmission of the virus, and decrease the burden of the health system during this period [
In the private sector, 4 in 5 physiotherapists did not use RP at all prior to the COVID-19 pandemic, in contrast to 2 in 3 in the public sector. During the study period, the proportion of physiotherapists who reported that they do not use RP has decreased to slightly over 20% in both sectors. This increased use of RP observed in our study is consistent with the findings of Rausch et al [
Previous studies indicate that RP is comparable to conventional physiotherapy for rehabilitees with stroke [
Physiotherapy has traditionally been a hands-on profession, and thereby physiotherapist may find it challenging to reach the standard of conventional physiotherapy with RP. RP may require changes in work routines and skills, as well as a greater workload and changes in interaction with rehabilitees [
A computer or tablet was the most chosen communication medium. This is comparable with previous findings that reported that physiotherapists preferred real-time methods with video technologies over other mediums [
In this study, almost three-quarters of the physiotherapists had no experience or had <1 year experience of RP, which can affect the use of RP. A previous study revealed that work experience is associated with the perception of how convenient RP is in clinical practice [
A strength of this study is the number of physiotherapists (n=662) who answered the survey, even if only a total of 9.9% (662/6525) answered. The physiotherapists were recruited from all municipalities in Finland and included physiotherapists with short and long clinical experience. Our physiotherapists could somehow be generalizable to the broader Finnish physiotherapy workforce, where 82% of employed physiotherapists are female with a mean age of 44.8 years, and the physiotherapists have relatively long clinical experience.
Our study also had some limitations. Our survey data were collected in Finland, and our findings may not be generalizable to other countries where physiotherapists may have more experience in RP and with a different health care system. The proportion of physiotherapists in the private sector who answered the questionnaire was higher than the corresponding proportion in the overall Finnish physiotherapy workforce in the private sector. Some of the physiotherapists in the private physiotherapy organization are also members of the Finnish Association of Physiotherapists and had the possibility to respond twice to the questionnaire. To avoid such an overlap, we recommended in the information letter not to respond twice. Furthermore, we do not know the reasons for overrepresentation of physiotherapists from the private sector in our study, but we analyzed the private and public sector separately.
Further, one limitation of our study may be nonparticipation bias. We recruited the study physiotherapists from the Finnish Association of Physiotherapists and from a private physiotherapy organization, but we had to collect the data anonymously. Therefore, it was not possible to analyze whether responders were significantly different from nonresponders and how these possible differences influenced the results of the study. Lastly, the use of a scientifically unvalidated questionnaire can be seen as a limitation. However, the questionnaire was based on consensus in a broad expert group, essential literature in the field, and was pilot-tested.
Based on our results, the suitability of RP for different diseases varies. During the COVID-19 pandemic, physiotherapists increased use of RP in their clinical practice, but use is still rare. To conduct RP, physiotherapists use a computer/tablet or a smartphone and use a real-time method. Other technological equipment and methods are used infrequently. These results may help physiotherapists and organizations in planning and implementing RP in everyday work and in the development of physiotherapy education of ICT.
artificial intelligence
Checklist for Reporting Results of Internet E-Surveys
computer vision
information and communications technology
National Health Insurance
remote physiotherapy
Strengthening the Reporting of Observational Studies in Epidemiology
virtual reality
This work was supported by “Fonden för teknisk undervisning & forskning,” a fund for supporting education and technical research at Arcada University of Applied Sciences.
The authors wish to thank Derek Ho for the language editing of this article.
TH, JA, and JK contributed to designing the research. All authors were involved in constructing the questionnaire and edited, reviewed, and approved the final manuscript.
None declared.