Physiotherapists’ perceptions and barriers to use of telerehabilitation for exercise management of people with knee osteoarthritis in Sri Lanka

Abstract Purpose To assess physiotherapists’ perceptions and barriers to using telerehabilitation via video and telephone for exercise management for people with knee osteoarthritis (OA) in Sri Lanka. Materials and methods Currently registered and practising Sri Lankan physiotherapists who care for knee OA patients were invited to participate in a cross-sectional online survey framed according to a previous study. A logistic regression analysis was used to assess the effect of physiotherapists’ characteristics on their interest in telerehabilitation. Results A total of 268 physiotherapists completed the survey, which was broadly representative of locations and work settings across Sri Lanka. Only three out of 16 statements received majority agreement; these were that telephone-delivered care would save patients’ time (72%), save money (68%) and improve patients’ privacy (67%). There was a consensus that video-based care would save money (79%), and many favoured this medium over telephone-delivered care. Lack of experience with telerehabilitation was associated with reduced interest in telephone-delivered care. Increased interest in video-based care was associated with frequent care of knee OA patients. Most physiotherapists perceived technical issues with telerehabilitation as a significant barrier to implementing it. Conclusions Physiotherapists perceived video-based telerehabilitation more positively than care over the telephone. Reduced interest in telerehabilitation was associated with having no prior experience with it. Moreover, technical issues with telerehabilitation were perceived as the main barrier to its use. A training programme for physiotherapists, appropriate guidelines and a framework for better implementing telereahabilitation may yield substantial benefits for knee OA patients. IMPLICATIONS FOR REHABILITATION Physiotherapists in Sri Lanka perceive telerehabilitation for exercise management for knee OA patients positively. Telerehabilitation via video or telephone is a viable option for delivering exercise management for knee OA patients in Sri Lanka. The widespread practice of telerehabilitation by physiotherapists in Sri Lanka requires appropriate strategies to mitigate barriers to its implementation.


Introduction
Osteoarthritis (OA) is a leading cause of disability that affects approximately 528 million people worldwide [1].For the age group of 50-74, OA is ranked 18th among the top 25 causes of disability-adjusted life-years from 1990 to 2019 [1].Specifically, the prevalence of knee OA increased by 27.5% between 2010 and 2019 [1], and in 2019 it resulted in 11.5 million more years lived with disabilities (YLDs) [2].In 2018, the prevalence of moderate/ severe clinical knee OA among adult females over 50 years in suburban Sri Lanka was estimated to be 29.9%[3].Commonly diagnosed clinical symptoms of knee OA are joint pain and morning stiffness, which leads to inactivity and reduced quality of life.Due to the progressive nature of the disease with ageing, managing associated symptoms and disabilities is challenging and imposes a great economic burden worldwide.
There is no cure for knee OA, and self-management with exercise and lifestyle modification to maintain a healthy body mass index (BMI) are important for relieving its symptoms long-term [4,5].Evidence shows that exercises reduce pain, increase physical function and improve the quality of life of people with knee OA [6][7][8].Physiotherapists are often responsible for managing knee OA by recommending specific exercises following an in-depth assessment of subjective and objective factors.To achieve the required benefits, they are expected to adhere to clinical guidelines when prescribing exercises.
Underutilization of exercise in managing knee OA is a global health problem.Many people complain that accessing physiotherapy is challenging due to difficulties obtaining referrals or appointments, long waiting times and limited availability of care in regional or remote areas [9][10][11].In addition, a long waiting time for outpatient physiotherapy significantly affects an individual health and increase the cost of care [12].For example, in Sri Lanka, most knee OA patients in rural areas do not have access to public health that provides physiotherapy care.As a result, the majority do not receive any physiotherapy treatments for their conditions.Moreover, the COVID-19 pandemic, travel restrictions and hygiene requirements have further limited access to clinics by increasing the waiting time for receiving support from a physiotherapist for knee OA [13].Therefore, new approaches are needed to increase to physiotherapy services for a wider population.To this end, telerehabilitation is an option that may help to increase exercise participation.
Telerehabilitation is being introduced all around the world.Evidence suggests that telerehabilitation using videoconferencing produces similar physical activity and functional outcomes to conventional face-to-face treatment in people after knee arthroplasty [14].In a recent study, physiotherapists agreed that telerehabilitation saves time and increase the privacy of knee OA patients [15].Conversely, patients with knee OA have also reported positive perception of video-and telephone-based telerehabilitation [16,17].Accounting to a recent overview of available systematic reviews, telehabilitation and in-person rehabilitation are similarly effective in managing patients with knee OA [18].
In the context of current COVID-19 pandemic, there have been several studies on the implementation of telerehabilitation in Sri Lanka.Studies assessing the effect of telephone-based care for people attempting suicide and other patients during the COVID-19 pandemic found beneficial effects compared to usual care [19,20].In addition, a review of telehealth in Sri Lanka reports its benefits and the need for proper guidelines for its more comprehensive application [21].Currently, only web-based online pharmacies have been established in Sri Lanka, and limited studies on this have been published [21].Moreover, no studies in the Sri Lankan context published to date relates to the current situation in the implementation of telerehabilitation-based physiotherapy.In addition, no studies have evaluated physiotherapists' perception and barriers to using telerehabiliation for managing knee OA patients.According to the guidelines, the core management strategies for knee OA are exercises and self-management [7].Therefore, assessing Sri Lankan physiotherapists' perceptions and experience of and interest in telerehabilitation for exercise management for knee OA patients is a crucial step to consider prior to its wider application.This study aimed to assess physiotherapists' perception and barriers to telerehabilitation via video-based and telephone for exercise management of people with knee OA in Sri Lanka.This study's findings will inform healthcare decision makers in Sri Lanka of telerehabilitation's usability, barriers to its implementation and physiotherapists' perception of it.

Study design
A descriptive, cross-sectional web-based survey was carried out among physiotherapists across Sri Lanka.The study was approved by the Ethics Review Committee of the Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka.Using the sample size calculator on the Australian Bureau of Statistics website, and assuming the total number of physiotherapists in Sri Lanka was 600, the sample size was calculated at a 95% confidence level.
Accordingly, the required sample size was 235 participants to fulfil the objectives of our study.

Participants
Physiotherapists working in both public and private sectors in rural, metropolitan, regional and remote city areas across the country were recruited for the study.Also recruited were physiotherapists working as academics in universities, including the University of Peradeniya, the University of Colombo and the General Sir John Kotelawala Defence University, and as well as physiotherapists working in military hospitals.The recruiting process was carried out between February and June 2021.Various strategies were exploited to recruit participants, these included advertisement on social media (Facebook), contacting the Sri Lanka Society of Physiotherapy and Government Physiotherapy Officers' Association.The inclusion criteria were that physiotherapists were registered with the Sri Lanka Medical Council and had treated at least one patient with knee OA in the past 6-months at the time of completing the survey.

Survey instrument
The survey statements were adapted from a previous study by Lawford et al. [15], and further modifications were made to develop the final survey.Since this study focussed on knee OA, the third eligibility question and the questions in parts A, B, C and D were modified accordingly (Supplementary File 1).The research team and external experts reviewed the final survey, and it was pilot tested among 10 physiotherapists who met the inclusion criteria.After addressing minor grammatical errors, the survey was emailed via a Google Form to the participating physiotherapists, and informed consent was obtained from the attending participants along with the questionnaire.
An introductory section regarding telerehabilitation and the purpose of the study was included.The rest of the survey comprised four sections; A, B, C and D. Section A contained openended, close-ended and multiple-choice questions to gather demographic data and check participants' experience with telerehabilitation.Sections B and C contained 16 statements on delivering an exercise programme for knee OA patients over the telephone (Section B) and via video (Section C).All the statements in sections B and C were framed positively with Likert scale-type responses: (1) strongly disagree; (2) disagree; (3) unsure; (4) agree; (5) strongly agree.Since the provision of rehabilitation services via telerehabilitation is not well established in Sri Lanka, identifying barriers to implementing it there is crucial.Therefore, a new component, "barriers", was introduced to Section D, into which eight custom-developed statements were inserted.

Statistical analysis
Data were downloaded from Google Forms and processed in a Microsoft Excel spreadsheet.Data analysis was carried out with SPSS and a p value less than 0.05 was considered significant.Data related to statements in Sections A, B and C of the survey were described as numbers (percentages), with 95% confidence intervals (CI) calculated around proportions.Participants who strongly agreed or agreed with each statement were used to assess the level of agreement with each statement, as defined by a previous study [15].Levels of agreement were defined as unanimity (100%), consensus (75-99%), majority view (51-74%) and no consensus (0-50%).The CIs for proportions of agreement and strong agreement were used to compare telephone and video-based exercise prescriptions by physiotherapists.A non-overlapping CI was counted as a significant difference in the proportions of participants who agreed with a statement.
In addition a univariate logistic regression analysis was used to investigate whether physiotherapists characteristics interfered with their response to the statement, "I would be interested in being involved in a service offering physiotherapist-prescribed exercise over the telephone/via video for people with knee OA".The physiotherapists responses were categorised as either agreeing (agree, strongly agree) or not agreeing (unsure, disagree or strongly disagree) with the statement.The dependent variables in this analysis were sex, work setting, location of clinical practice, frequency of treating knee OA, frequency of prescribing exercises for knee OA, previous experience with telerehabilitation, confidence using video chat over the internet, currently offering services via telephoneorvideo and belief that the cost of telephone and video-delivered care for people with knee OA.Due to the small number of responses, some response categories, including work setting, clinical practice location and frequency of prescribing exercises for knee OA were grouped.The barriers to delivering care via telephone or video were described as percentages.

Survey responses and participant characteristics
In total, 300 physiotherapists completed the questionnaire.Of the respondents, 32 did not meet inclusion criteria resulting in 268 (89.3%) eligible survey respondents.
Table 1 shows the participants' demographic and professional characteristics.The majority were female (n ¼ 157, 58.6%), and the in clinical experience in the sample was 5.76 years.Most participants did not have postgraduate physiotherapy qualifications (n ¼ 240, 89.6%).Participants with postgraduate qualifications possessed master's degrees (n ¼ 13, 46.4%) and postgraduate diplomas

Perceptions of telephone-based care
No consensus was met on any statements relating to telephonebased care (Table 2).However, the majority of the therapists agreed with three statements on telephone-based care, namely that exercise programmes over the telephone would save patients' time (72%), would save patient's money (68%), and would not violate patient's privacy (67%).Indeed, only 21% of therapists agreed that the delivering exercises by telephone would be effective.In addition, most physiotherapists (65%) believed that a telephone consultation should cost less than 25 or 50% of the cost of a face-to-face session, though 18% believed that it should cost the same.

Influence of physiotherapists' characteristics on the delivery of telerehabilitation
Four independent variables were significantly associated with interest in delivering telerehabilitation via telephone (Table 3).Having no previous experience with telerehabilitation (odds ratio (OR) 0.5 [95% CI 0.3-0.9])was associated with decreased odds of having an interest in telephone-delivered care, relative to those having previous experience with telephone or video-based care.Not currently delivering physiotherapy service by telephone (OR 0.3 [95% CI 0.1-0.7)was associated with reduced odds of being interested in telephone delivered care, relative to participants currently delivering physiotherapy via telephone.Not delivering physiotherapy using video (OR 0.2 [0.1-0.6]) was also associated with decreased odds of being interested in telephone delivered care, relative to participants currently delivering physiotherapy using video.Conversely, the belief that telephone or video-based care should cost less than 50% of the cost of face-to-face care was associated with increased odds of having an interest in telephone-delivered care, relative to participants believing that telephone or video-based care should cost more than 50% of the cost of face-to-face care.
One independent variable was associated with having an interest in delivering exercise over video for knee OA patients (Table 4): treating knee OA patients very frequently It was associated with increased odds of being interested in video-based care relative to treating OA patients infrequently (OR 0.4 [95% CI 0.2-0.8]).

Barriers to utilizing telephone or video-based care
Over two-thirds of participants (n ¼ 216, 80.6%) considered technical issues the main barrier to utilizing telerehabilitation for knee OA care (Figure 1).Patients factor of acceptance of telerehabilitation was also a commonly cited barrier (n ¼ 204, 76.2%).A perceived lack of skills (n ¼ 98, 36.6%) and high costs for patients and therapists (n ¼ 70, 26.2%) were also identified as barriers.Approximately one-quarter of participants (n ¼ 73, 27.2%) identified the location of the healthcare institute as a barrier to utilizing telerehabilitation for knee OA.Similarly, over one-third of participants cited physiotherapists' cultural acceptance of telerehabilitation as a barrier (n ¼ 95, 35.4%).A minority (n ¼ 26, 9.7%) reported further barriers, including patients' ability to understand the content delivered by physiotherapists and the possibility of fake physiotherapists delivering care to patients.

Discussion
This study provides novel insights into physiotherapists' perceptions and barriers to using telerehabilitation via telephone and video for knee OA care.We found that a majority of the physiotherapists surveyed regard exercise for knee OA beneficial.While there was no consensus on telephone care, there was consensus agreement that video-based care would save patients time.Additionally, video-based care was more positively perceived by physiotherapists achieving majority agreement compared to telephone-based care.Reduced interest in delivering care via telephone was associated with a lack of prior and current experience with telerehabilitation via telephone or video.Very frequent care of knee OA patients was associated with increased interest in delivering care via video.Finally, most physiotherapists viewed technical issues and patient factors as barriers to utilizing telephone-and video-based care for patients with knee OA in Sri Lanka.

Perceptions of video-and telephone-based care
We found consensus on one statement on video-based care: it would save patient's time.In addition, more physiotherapists favoured video-based care compared to telephone-delivered care, as it was considered convenient, acceptable, safe, easy and interesting for therapists and convenient for the patient with knee OA.These findings are consistent with previous studies wherein physiotherapists reported positive perceptions of telerehabilitation [15,[22][23][24][25][26].A survey examining Australian physiotherapists' perceptions of telephone and video-based telerehabilitation on hip and knee OA found that respondents were more satisfied with video-based care in terms of saving time, protecting privacy and increasing convenience for OA patients [15].The patients with knee OA were also found to be more satisfied with video-based care as it would save them time, protect their privacy and be convenient and easy to use [16].Moreover, the findings that using video technology is easy and safe are in line with previous studies on post-knee arthroplasty rehabilitation [25,26].Overall, it is evident that video-based care for knee OA may be acceptable to use in the Sri Lankan context.Conversely, the findings did not reveal on any statements on telephone-delivered care.This is in contrast to a previous study that found consensus agreement that telephone-delivered care improves patient's privacy and saves time [15].This difference may be due to 14% of the physiotherapists in our study currently providing services via telephone; they would thus have a good understanding of the difficulties with telephone-based care.This stands in contrast to the previous study in which only 8% of therapists currently offered services currently through this method.In addition, a randomized controlled study on people attempting suicide in Sri Lanka found that brief mobile treatment is more effective than usual in-person care [20].However, evidence highlights that the absence of visual cues and inability via telephone to confirm the diagnosis with an examination are concerns for general practitioners [27].The physiotherapists in our cohort may have been similarly concerned about using telephone care for knee OA.Importantly, a previous study on perceptions of patients with hip and knee OA on telephone-and video-based care showed positive perceptions of telephone-delivered care, and with a majority of patients being confident in using mobile phones (43%) and using it every day (77%) [16].To our knowledge, no study has investigated the perceptions of patients with knee OA or any other condition on telephone-delivered care in Sri Lanka.Hence, further studies on the perception of patients with knee OA of telephone-delivered care are necessary to confirm the effect of patient factors on physiotherapists' favouring it less.

The influence of physiotherapists' characteristics on the delivery of telerehabilitation
Our findings showed that reduced interest in telerehabilitation via telephone is associated with a lack of previous or current experience with it.Moreover, about 52% of physiotherapists had negative perceptions on the lack of physical contact with patients during telephone-based care.This is consistent with previous studies, in which physiotherapists' lack of interest in telephonedelivered care and telerehabilitation in general was due to the lack of physical contact [15,22].Although physiotherapy is traditionally believed be based on hands-on skills, self-management advice and exercises are key strategies in managing knee OA [7].Our findings that physiotherapists' increased interest in videobased care is associated with very frequently treating knee OA reflects the fact that greater experience with and understanding the management of knee OA may facilitate the use of telerehabilitation.Overall, these findings suggest that telerehabilitation in Sri Lanka requires proper guidelines, training and practice.

Barriers to utilizing telephone or video-delivered care
Physiotherapists in our cohort reported a range of barriers to telephone-and video-based care for knee OA.In our study, many identified technical issues as the top barrier to utilizing telephoneor video-based care.Previous studies found that technologyrelated issues are a major barrier to implementing telehealth [28,29].The availability of professional technical staff to manage technical issues could overcome this barrier.Patients' acceptance of telerehabilitation was another barrier highlighted by most of most of physiotherapists in our cohort.Although the perception of people with knee OA of telerehbailitation in Sri Lanka have not been previously studied, studies in other countries showed patients had positive attitudes towards using telerehabilitation [16,[30][31][32][33].In Australia, patients with knee OA reported positive perceptions of physiotherapists prescribing exercises by Values are the number/percentage (95% confidence interval) unless indicated otherwise.OA: Osteoarthritis.
telerehabilitation via the telephone or video [16].In addition, physiotherapists' skills, their acceptance of telerehabilitation and policymakers' attitudes were also significant concerns that physiotherapists considered barriers to implementing telerehabilitation.This finding is further supported by our finding that physiotherapists lack experience in telerehabilitation.This deficit could be resolved by proper training.A recent review of telehealth/telemedicine in Sri Lanka highlights the need for a national framework for providing this service to benefit people [21].Given the number of barriers, a well-established framework for overcoming those and providing telerehabilitation would benefit Sri Lankan people in the context of the pandemic and in future.

Strengths and limitations
This study has a number of key strengths.Our multifaceted recruitment strategy supported Sri Lanka wide participation of physiotherapists from all work settings and locations.Given the large sample size, it is important to note that findings can be generalized to the entire physiotherapy workforce in Sri Lanka.This study also has several limitations, including that its findings cannot be generalized to the physiotherapy populations of other countries.This study utilized the overlap of CIs approach similar to Lawford et al. [15] to assess the difference between perceptions of the telephone-and videobased care.Although we used non-overlapping CIs as a significant difference between telephone-and video-based care, such significant differences may exist with overlapping CIs [34].

Conclusion
Sri Lankan physiotherapists agreed that exercises are important in managing knee OA.Moreover, many physiotherapists favoured

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indicates a significant difference.Values are the number (%) unless indicated otherwise.OA: osteoarthritis; OR: odds ratio; 95% CI: 95% confidence interval.video-basedcare over telephone-delivered care for knee OA.Reduced interest in delivering telephone-based care was associated with having no prior experience with telerehabilitation.Very frequent care of knee OA patients was associated with greater interest in using video-based care.While most physiotherapists viewed technical issues as the main barrier, other barriers included patient and physiotherapists factors.In this context, appropriate strategies to overcome the barriers, proper guidelines and a framework for better implementing of telerehabilitation in Sri Lanka are essential.

Figure 1 .
Figure 1.Barriers to utilizing telephone or video-delivered care.

Table 1 .
Demographic and clinical characteristics of physiotherapists (n ¼ 268).Most of the physiotherapists worked in public healthcare (n ¼ 137, 51.1%).Few participants worked in other healthcare services (n ¼ 6, 2.2%), including universities.Participants were distributed across metropolitan, regional, remote and rural locations with the greatest representation of metropolitan areas (n ¼ 130, 48.5%).Approximately half of the therapists (n ¼ 131, 48.9%) worked in both in-and outpatient musculoskeletal clinical setting and frequently treated knee OA patients (n ¼ 156, 58.2%).Most physiotherapists always prescribes exercises for knee OA patients (n ¼ 143, 53.3%), while none reported prescribing no exercises.

Table 3 .
Influence of therapist characteristics on interest in offering physical therapist-prescribed exercise over the telephone for knee osteoarthritis.

Table 4 .
Influence of therapist characteristics on interest in offering physical therapist-prescribed exercise over the internet video for knee osteoarthritis.