Telerehabilitation for physical disabilities and movement impairment: A service evaluation in South West England

Abstract Rationale, Aims and Objectives Telerehabilitation was used to ensure continued provision of care during the COVID‐19 pandemic, but there was a lack of guidance on how to use it safely and effectively for people with physical disabilities and movement impairment. In this service evaluation, we aimed to collate information on practitioner and patient experiences, challenges and facilitators, and examples of best practice to inform the development of an online toolkit and training package. Methods Guided discussions were carried out with 44 practitioners, 7 patients and 2 carers from five health and social care organisations in South West England, and analysed thematically. Results Practitioners and patients had positive experiences of telerehabilitation and were optimistic about its future use. Recognized benefits for people with physical disabilities included greater flexibility, reduced travel and fatigue, having appointments in a familiar environment and ease of involving family members. Challenges encountered were: technological (usability issues, access to technology and digital skills); difficulties seeing or hearing patients; the lack of ‘hands‐on’ care; and safety concerns. Facilitators were supported by colleagues or digital champions, and family members or carers who could assist patients during their appointments. Key themes in best practice were: person‐centred and tailored care; clear and open communication and observation and preparation and planning. Practitioners shared tips for remote physical assessments; for example, making use of patient‐reported outcomes, and asking patients to wear bright and contrasting coloured clothing to make it easier to see movement. Conclusion Telerehabilitation holds promise in health and social care, but it is necessary to share good practice to ensure it is safe, effective and accessible. We collated information and recommendations that informed the content of the Telerehab Toolkit (https://www.plymouth.ac.uk/research/telerehab), a practical resource for practitioners, patients and carers, with a focus on remote assessment and management of physical disabilities and movement impairment.

tions increased from being rarely used to being employed for 90% of general practitioner appointments in April 2021. 3 This speed of implementation has resulted in a dearth of guidance and training for practitioners. Although learning needs for healthcare professionals in using video consultations have been previously identified, 4 there was little specific published guidance, training and support on how to undertake assessments and deliver rehabilitation remotely for people with physical disabilities. 5 Professional bodies and clinical networks have highlighted the marked variations in approaches to telerehabilitation between and even within organisations, expressing concerns about potential inequity and inefficiency. [6][7][8] The findings of our national survey of UK health and social care practitioners confirm these issues, with few practitioners receiving formal training and many reporting perceived low competence and confidence in carrying out remote physical assessments. 9 Practitioners need to improve their knowledge and understanding of telerehabilitation for people with physical disabilities and movement impairment. In the Telerehabilitation Project, 10 we aimed to collate information on practitioner and patient experiences, challenges and facilitators, and best practice in telerehabilitation. The overarching aim of the project was to inform an online toolkit and training package (the Telerehab Toolkit) to assist the current and future health and social care workforce in conducting safe and effective remote physical assessments and consultations.
This service evaluation had three objectives: 1. Examine the context of telerehabilitation including its use and impacts, and patient and practitioner experiences and satisfaction with the remote consultation process.
2. Explore challenges and facilitators in undertaking remote physical assessments, including how challenges have been overcome. 3. Identify examples of feasible and effective practice in telerehabilitation for people with physical disabilities and movement impairment.

| Governance approvals
This service evaluation was undertaken in line with Good Clinical Practice guidelines and the guidance and regulation set out by the General Data Protection Regulation. 11 Governance approvals were obtained from each of the four participating NHS Trusts and one independent social enterprise in South West England in October 2020.

| Overview of study design and theoretical basis
Implementation science is key to understanding change and implementing new resources, interventions or services in healthcare. 12 The Knowledge to Action (KTA) framework, 13 which seeks to identify and synthesise current knowledge about a particular issue and refine and implement this knowledge in an iterative process, 13 provided the conceptual framework. The two main phases of KTA are knowledge creation and action. 13 The service evaluation described in this paper was one source of knowledge creation (i.e., gathering information to inform the content of the toolkit).
This was a pragmatic service evaluation rather than an in-depth qualitative study, but to ensure transparency and rigour in reporting our data collection and analysis, the Consolidated Criteria for Reporting Qualitative Research (COREQ) 14 were followed. Sampling took place through contact with lead practitioners at the five participating organisations; these practitioners were informed of the sampling criteria and they provided the names of relevant practitioners. These individuals were then contacted by the researchers (Sarah A. Buckingham or Kim Sein) via telephone or e-mail to explain the purpose of the service evaluation and gain verbal consent to participate. For patients and carers, practitioners made initial contacts on our behalf, minimising the amount of personal data handled by the project team. If they subsequently agreed to take part, the researchers followed up via telephone or e-mail to answer any remaining queries and schedule the discussion.

| Participants and recruitment
With the exception of the lead practitioners, all participating practitioners, patients and carers were unknown to the researchers before recruitment commences.

| Data collection
Data collection took place between October 2020 and April 2021. The discussions began with introductions, with researchers reminding participants of the project aims and context of the work.
The researchers took care to ensure that they retained a neutral stance regarding telerehabilitation and did not express their own views. Although the discussion points were used as a guide, discussions were flexible and open-ended rather than structured or exhaustive, and followed the points that participants wished to discuss.
In light of COVID-19 pandemic restrictions, all discussions were carried out remotely; either online (e.g., Zoom 15 ) or via telephone.
Discussions took place in private locations including the researchers' home offices, patients' homes, and practitioners' homes or a private workplace setting. Having telephone as an option avoided potential digital exclusion and maximized reach and representativeness of the participants.
Detailed field notes were made during the discussions. To ensure a reliable understanding of the discussed content, verbal summaries were given by researchers during and at the end of the discussion, and confirmed with participants. With explicit approval from each participant, discussions were temporarily recorded to ensure completeness and accuracy of the field notes, and to enable the capture of illustrative quotes. The audio and video recordings were deleted within 2 h of the discussion. Field notes were added after the discussions to include reflections on context and any potential preconceptions or biases of the researchers.
Data collection continued until the maximal variation sampling criteria had been met and saturation had been reached in discussions with practitioners (i.e., no new themes had been identified). For patients and carers, data collection continued until the broad sampling criteria were met. Note: This is not an exhaustive list and discussions covered a range of aspects of telerehabilitation.

| Data analysis
Three researchers (Sarah A. Buckingham, Kim Sein and Krithika Anil) carried out a qualitative thematic analysis based on the guidance of Braun et al. 16 Following familiarisation with the discussion field notes, the researchers independently 17 coded and organized the field note data into key themes using NVivo. 17    (Person with stroke)

iii) Video versus telephone consultations
Video consultations were generally seen by practitioners and patients as better than telephone appointments for building rapport and carrying out physical assessments. However, telephone was useful in cases where the patient had struggled with the technology or where the practitioner wanted to quickly review progress or offer reassurance. The utility of being able to offer support and reassurance remotely, particularly in the early days of the pandemic, was often viewed by practitioners and patients as the most positive aspect of the remote consultation.
'It was the reassurance of being able to speak to the physio when face-to-face contact was not possible, that's what kept me going'.
(Person with stroke) Practitioners and patients shared the perception that telephone or video consultations might be more effective after an initial face-to-face assessment. For example: 'An initial face-to-face appointment might be better to build rapport'.
(Patient with Multiple Sclerosis) iv) The future of telerehabilitation 'Although telerehabilitation is a useful tool, it can never replace face-to-face consultations'.
(Physiotherapist, Neurology) Overall, there was optimism about remote consultations; practitioners and patients thought that they should and would be used more in the future: 'Having seen how much we can do remotely, I think remote consultations will be used a lot more now. It's here to stay I think'.
(Physician, General Practice) 'Remote appointments could be used more and should be used more'.

| Challenges and facilitators
There were four categories of challenges in telerehabilitation: technological; difficulties seeing or hearing patients; the lack of 'hands-on' care; and safety concerns. These challenges (and how they were overcome) are described below.

i) Technological challenges
Technology was a commonly encountered challenge for practitioners, and even those who were confident technology users initially struggled with learning new software. Hardware problems were also common, for example, microphones not working, cameras being low quality, and unstable internet connections. Some practitioners were unable to access the technology they needed from their workplace or home, which delayed or prevented the use of video consultations. These issues tended to improve over time as iii) Lack of 'hands-on' care The lack of 'hands-on' care and ability to handle a limb was a concern for some practitioners. This was more of an issue for certain types of consultations. For example, practitioners recognized that it was not possible to adjust prostheses and orthoses nor undertake detailed objective physical assessments (such as dermatomal testing or specific muscle strength testing) remotely.
The accuracy of some measures was also an area of concern, for example, arm circumference measurements, measures of balance, and timed walking tests.
Where possible, these issues were managed by using patientreported outcome measures, involvement of family members or carers who could assist with physical examinations (e.g., helping to move limbs or put on and take off orthotics), and seeing patients in person as soon as practicable. Some practitioners believed that patients needed to feel reassured by a physical examination, and might have the perception that telerehabilitation is 'second best' or a 'stop gap' before they can be seen in person.
'Patient perception is that objective assessment (such as feeling joints) is the most important thingbut for us, history tells us a lot more. This is a difficulty with telerehab'.  Remote work makes this model easier'.

(Patient with Multiple Sclerosis)
Practitioners reported that a positive consequence of person-centred, remote care was that it appeared to foster more independence by patients to manage their own health: 'Telerehabilitation is helping to move patients from passive recipients of care to active self-managers'. (Physician, Neurology) iii) Preparation and planning The need for preparation and planning was emphasized not only by practitioners, but also by patients and family members.
Most practitioners had learned through experience that telerehabilitation did not always save time:

| Top tips for remote physical assessments
Practitioners provided specific, practical recommendations for carrying out remote physical assessments. Some examples of these are included in Table 4.

| DISCUSSION
In this service evaluation, COVID-19 was clearly a major catalyst in increasing the use of telerehabilitation. Overall, practitioners and patients were optimistic about using remote consultations, and felt that they should be used to complement, rather than replace, face-to- The challenges of telerehabilitation identified in this service evaluation were in line with those recognized in our survey 9 and previous studies. 5 The challenges most frequently discussed by practitioners and patients were: technical issues (usability problems with hardware and software, difficulties accessing technology and a lack of digital skills); difficulty seeing or hearing patients; concerns about the lack of 'hands-on' care; and safety concerns. Technical issues, experienced by both practitioners and patients, are a frequently reported barrier to telerehabilitation. 20,22,25,26 Problems with seeing or hearing patients, and practitioners' concerns about the lack of 'hands-on' care have also been reported previously. [27][28][29] Many practitioners had safety concerns, particularly when patients T A B L E 4 Recommendations made by the practitioners for carrying out remote physical assessments

Recommendation Rationale
Use telephone triage Telephone triage was a useful tool for assessing the patient's background, medical and medication history and deciding on the best method for follow-up treatment and management Make use of patient-reported outcomes Patient-reported outcomes (e.g., validated questionnaires for pain, fatigue, mobility and quality of life) completed in advance proved useful in informing the consultation and related discussions.
Find a suitable space Considering the environment in which the consultation was undertaken was important, both for the practitioner and patient. This included ensuring confidentiality, and consent for involvement of others such as family members. Ensuring the room was well lit and without glare allowed better observation and communication.
Ask the patient to wear bright and contrasting colours of clothing Bright and contrasting coloured clothing (e.g. different coloured trousers, socks and shoes) helped practitioners to see movement and distinguish between body regions.
Involve family members and carers Family members or carers, when available, proved invaluable in providing physical assistance during assessments, and helped with using technology or moving the camera to enable a more effective assessment to be undertaken.
Safety is paramount, but avoid risk aversion Practitioners recognized that safety is essential but that there is a need to try not to be too risk averse in physical assessments. Completion of a risk assessment, clinical judgement, and making use of family members and environmental supports to optimize safety were all key considerations. There was widespread recognition that a face-to-face appointment should be employed where a safe and effective remote assessment cannot be completed. clinical judgement and patient preference where possible.
Telephone and face-to-face appointments should be offered as an option, in particular where there is a risk of digital exclusion.

| Strengths and limitations
The main strengths of this service evaluation were the representation of a range of practitioners in five different health and social care organisations, consideration of the patient's perspective, and the novel focus on the movement-related aspects of telerehabilitation.
Some limitations should be considered. First, the service evaluation was conducted in one region, South West England, which may limit generalisability. Although the COVID-19 pandemic was experienced universally, the impact on services and associated experiences may vary in different settings or contexts. Nevertheless, we believe that the findings are of relevance and practical use to practitioners and patients, in addition to service providers considering implementing or expanding their telerehabilitation services.

| CONCLUSION
Health and social care practitioners rapidly adopted telerehabilitation in response to the COVID-19 pandemic. In this service evaluation, we found that practitioners and patients had generally positive experiences of rehabilitation delivered via video and telephone, and were optimistic about its future use in a hybrid approach combined with face-to-face care. However, some challenges still need to be addressed to ensure it is safe, effective and accessible to a wide range of patients. We identified information needs and collated examples of best practice and recommendations to inform the content of the Telerehab Toolkit, an online resource for practitioners and patients, with a focus on the remote assessment and management of physical disabilities and movement impairment.

AUTHOR CONTRIBUTIONS
Jenny Freeman is the Principal Investigator and conceived the project.