Patients' experiences of telerehabilitation at home after shoulder joint replacement

Abstract

We investigated the experience of ten patients who received video-based physiotherapy at home for two months after a shoulder joint replacement. Videoconferencing took place via the patient's home broadband connection at a bandwidth of 256–768 kbit/s. Qualitative interviews were carried out, transcribed and analysed. Through qualitative content analysis six categories were identified: (1) a different reinforced communication; (2) pain-free exercising as an effective routine; (3) from a dependent patient to a strengthened person at home; (4) closeness at a distance; (5) facilitated daily living; and (6) continuous physiotherapy chain. The access to bodily knowledge, continuity, collaboration and being at home were all aspects that contributed to the patients' recovery. The patients described experiences of safety, and strengthening during their daily exercise routine at home. The frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgement about each patient; this could be one reason for the positive findings. Home video-based physiotherapy may be useful in other kinds of physiotherapy.

Introduction

Patients undergoing a shoulder joint replacement are at high risk for pain and dysfunction.^1–4 Therapeutic exercises are important after shoulder joint surgery and early exercises help the patient to achieve the best possible shoulder function.^5–8 The usual procedure after shoulder joint replacement includes physiotherapy at the hospital, followed by home exercises at the time of discharge. These are supplemented with supervision by a physiotherapist based at the local treatment centre.² The patient-physiotherapy meetings can lead to a lot of travelling. Lack of appropriate rehabilitation and resources can result in permanent disabilities.^1–3,9 In-home services are typically provided over small geographical areas due to restrictions associated with travel time.

The success of remote service delivery depends on being able to provide a specialist with the same information about individual competences and environmental demands as would be obtained through a conventional in-home assessment.¹⁰ Lewis et al. claimed that telerehabilitation minimises the barrier of distance in the delivery of comprehensive rehabilitation services and provides consumers with access to clinical services.¹¹ Potential benefits of telemedicine have been described as improvements in access to information and services. Further benefits include increased care delivery, increased professional education, provision of care not previously delivered, quality control in screening programmes and reduced health-care costs.^12,13

We have previously explored the use of telerehabilitation after shoulder joint surgery where interactive video-based physiotherapy at home was used.¹⁴ The patients in the telemedicine group improved significantly in terms of decreased shoulder pain, mobility and function, as well as in pain and vitality domains in health-related quality of life in comparison with the control group.¹⁴

Studies of orthopaedic telerehabilitation^8,9,15–18 have shown reduced need for travel, and improvements in physical and function outcomes. However, despite the wide range of potential benefits, telemedicine might also have disadvantages such as a breakdown in the relationship between health professionals and patients.¹² The risk from using a video-link might relate to poor communicative skills and lack of formal training in using telemedicine equipment. There is anecdotal evidence that elderly patients do not always accept that a physician, appearing on what looks like a TV screen, can see and listen to them properly.¹² On the other hand, when delivering physiotherapy services via low-bandwidth telemedicine after knee replacement, the patients felt empowered even though the physiotherapist was not able to deliver hands-on treatment.¹⁹

The aim of the present study was therefore to describe patients' experiences of physiotherapy at home by video-link after shoulder joint replacement.

Methods

A qualitative approach was chosen in order to describe the patients' experiences of physiotherapy at home.

Participants and research context

Patients were selected from a previous study of patients who had undergone a shoulder joint replacement.¹⁴ The inclusion criteria were Swedish speaking adults with either primary osteoarthrosis or rheumatoid arthritis. The exclusion criteria were humeral fracture, cuff arthropathy, the presence of medical conditions that precluded safe participation in exercises, significant psychiatric or neurological disease, serious impaired hearing or vision, or dementia.¹⁴ Before the start of the telerehabilitation at home the patients received, as part of the usual routine, a written three-phase programme of exercise at the hospital and were instructed by the physiotherapist to combine the physiotherapy sessions with a progressive home-exercise programme of their own.¹⁴

The group in the present study participated in a two-month programme of video-based physiotherapy at home. They were supervised by a physiotherapist with a long experience of patients with shoulder problems. The physiotherapist was located at the hospital. Standard commercial videoconferencing units were used in the patient's home and at the hospital clinic (e.g. Tandberg 800, Sony PCS-50, Polycom VSX 3000). In the home, the equipment was connected via the patient's broadband service. Initially the connection in the clinic was via ISDN lines, and later an IP connection was used instead. The connection bandwidth was 256–768 kbit/s.

At the end of the telerehabilitation intervention, the outpatient physiotherapist made a home visit to the patient. Simultaneously, the physiotherapist at the hospital contacted the patient and the outpatient physiotherapist using a videoconference (i.e. three-way communication). This meeting dealt with the surgery, according to the current and future exercises and the hospital physiotherapist's prognosis of the outcome of the future training.¹⁴

Data collection

After the intervention period, qualitative interviews²⁰ were carried out. An interview guide providing a general framework for the experience of telerehabilitation home-physiotherapy was used. Supporting and clarifying questions were asked. For example, could you please tell me a little more about that? The recorded interviews lasted for 35–95 min, were transcribed verbatim and sent to the patients for corrections and acceptance. The patients did not make any corrections.

Data analysis

The interviews were analysed by qualitative content analysis by describing the manifest and latent content of the text.^21–23 Two researchers read the whole text several times independently of each other in order to gain a sense of its totality. The text was divided into meaning-units, that is words, sentences or paragraphs containing aspects related to each other through their content and context. The meaning-units were subsequently condensed. Codes were then made of key thoughts or concepts of the meaning units. Categories were then created, defined and sorted by similarities and differences compared to the original transcribed interviews (de-contextualisation). Re-contextualisation was made to confirm that the results from the categories still agreed with the original text.²⁴

The underlying meaning through the condensed meaning-units, codes and categories led to identification of one comprehensive theme, i.e. threads of meaning that appeared in all categories (see Figure 1). Finally, the whole text, the theme and the categories were reflected on and then interpreted by the researchers. The study was approved by the appropriate ethics committee.

Figure 1

An illustration of the theme and the categories

Results

All ten patients participating in the telerehabilitation group agreed to be interviewed after the intervention period. All but two patients had experiences from different arthroplasties of neck, of shoulder, of hip, of knee and of foot due to their osteoarthrosis or rheumatoid arthritis diagnosis. One patient had had a stroke several years previously. A total of eight female and two male patients participated in the interview study. The patients were 53–85 years old (median 70) (see Table 1).

Table 1

Characteristics of the patients

Characteristics	n
Age
<65 years	4
65–80 years	4
>80 years	2
Status
Co-habiting	5
Living alone	5
Type of residence
Private house	6
Flat	4
Distance to hospital
>50 km	7
≤50 km	3
Diagnosis
Osteoarthrosis	7
Rheumatoid arthritis	3

The patients' experience of video communication with the physiotherapist was positive overall. The access to continually adjusted exercises and the immediate feedback from the physiotherapist led to better knowledge about the body and the surgery, and also to motivation for daily pain-free exercises at home. The interplay during the telerehabilitation intervention was experienced as the same as, or even better than in real life. This was conducive to the patients' experiences of being dependent and passive, which changed over to being an independent and strengthened active person at home. The relation to the physiotherapist and the quality of the technique gave a feeling of being close at a distance. After the surgery the patients' experienced themselves as dysfunctional and their general status prevented them from travelling to physiotherapy services. The exercising by video-link was expressed as a facilitated daily living for the patients. The experiences of physiotherapy at the hospital, at home and finally the three-way communication were experienced as a continuous physiotherapy chain.

Six categories were identified (see Figure 1):

A different reinforced communication;

Pain-free exercising as an effective routine;

From a dependent patient to a strengthened person at home;

Closeness at a distance;

Facilitated daily living;

Continuous physiotherapy chain.

1. A different reinforced communication

The equipment was experienced by all patients as a user-friendly technical aid. Some saw themselves differently through the video communication. This was expressed as an initial feeling of being unsafe, unaware and strange. One patient compared the video image with being in front of the camera, which he disliked. However, the negative feelings disappeared after some time. Only one patient talked about uncertainty that someone could look into the home and therefore initially switched off the equipment. The communication by video-link was experienced differently compared to ordinary communication between people. The sound was delayed, which made the participants wait for each other when speaking. The TV image gave them a good view of the face and body, and the visual instructions without hands-on treatment. The image promoted trust in the communication.

2. Pain-free exercising as an effective routine

Pain and fear of pain was a central aspect for the patients. They explained about the pain before and after the surgery, about their self-confidence, sadness and inability to cope after the operation which they experienced as having a frail body and sensitive mind. The access to frequent remotely supervised feedback and support of special shoulder exercises after the surgery by the hospital physiotherapist was important for the patients when adjusting to an effective routine after discharge from the hospital. Continued corrections by the physiotherapist and learning to carry out the best movements without pain increased body awareness. The fear of damaging something after the surgery disappeared. The motivation to practice was improved. The patients learnt to be patient and realized that even simple movements gave results. They saw the exercises as hard work but at the same time, they had a new life without pain.

3. From a dependent patient to a strengthened person at home

The patients' dependence on others, and need for physiotherapy became completely changed to an independence from others and being active. By close collaboration with their physiotherapist, they learnt to handle the physical exercises and technical equipment at home. The knowledge that the physiotherapist would see them the next day made the patients take their own decisions about their home exercises. These challenges led to a feeling of being a capable person. The home was experienced as a safe and secure place where the patients could exercise in peace and quiet, alone and with the physiotherapist at the video-link. The exercises were adjusted to the home environment.

4. Closeness at a distance

Patients expressed how the physiotherapist putting her hand on their shoulder when correcting them was not possible by video-link, but this was not missed. Almost all of the patients experienced a sense of being in the same room as the physiotherapist even if they knew that they were several miles from each other. The intimacy was experienced depending on the quality of the technical equipment, especially the image quality which made it possible to see and speak. They received medical advice and support in a close relationship with the physiotherapist.

5. Facilitated daily living

After surgery all patients experienced telerehabilitation as assistance in a practical context when being dysfunctional and avoiding long distances to travel for specific physiotherapy. It was easy to prepare before and combine activities at home during the video exercises. For some of the patients the programme represented the only possibility of obtaining physiotherapy at all. Intensive exercising five days a week and then rest during the holiday were seen as energy-saving. The patients emphasized that they saw this treatment as a supplement to the conventional physiotherapy and that face-to-face meetings could not be replaced.

6. Continuous physiotherapy chain

Some of the patients mentioned the advantages of exercising directly at home without a break after discharge from the hospital, instead of visiting the rehabilitation clinic. One patient described shortened in-hospital time. Three-way communication between the patient, the local physiotherapist and the hospital physiotherapist was arranged at the patients' home at the end of the intervention. This was appreciated by the patients, who felt safe at home. To meet the local physiotherapist at home before the continued outpatient physiotherapy was valuable for one patient. The same patient experienced the local physiotherapy as being useful after the initial exercising at home.

Discussion

The present study describes patients' experiences of participating in physiotherapy via videoconferencing at home in the first two months after shoulder surgery, immediately after discharge from the hospital. The results showed that the patients had access to continued individualized exercises at home with a physiotherapist with specific competence. The video communication and the interplay between the patient and the physiotherapist via a video-link was experienced as the same as, or even better than, realtime meetings. This contributed to the patients' feeling of being at the physiotherapists' centre of attention. The patients' initial experience of being dependent and passive changed over to being independent and active.

There appear to have been no previous studies of remote service delivery for patients who have undergone a shoulder surgery, but similar results have been reported concerning underserved elders.¹⁰ However, this is in contrast to the findings of Mair and Whitten who found that half of the patients did not appreciate telemedicine because the physician was not physically present at the consultation.²⁵

In the present study the analysis of the interviews demonstrated a different reinforced communication of physiotherapy by video communication. The different feeling of seeing oneself was expressed by many patients as temporary. In a study of elderly subjects, most did not like the telerehabilitation service.²⁶ Couturier et al. thought that the hearing and visual deficits represented a communication barrier for some of the elderly patients. In our study, serious impaired hearing or vision were therefore exclusion criteria.

Video communication requires specific communication skills, alters the nature of the meeting and the relationship between the professional and the patient.²⁷ Some characteristics found in our study were: listening with close attention and no interruptions, which are ground rules used in therapy or teaching.²⁸ Another characteristic was the gaze of the TV screen that normally together with the body position facilitates joint attention.²⁹ The gaze varies between different points and as a mark at the end of the conversation. In a study concerning distance conversations and the elderly, both nurses and the elderly persons maintained their focus by gazing on the screen almost the whole time.³⁰ In our study the patients expressed a feeling of being seen both when they spoke and when they exercised by the video-link. The gaze of the TV image gave them a feeling of being at the centre of the physiotherapist's attention.

The hands appear to be a significant source of communication and therapeutic intervention in physiotherapy.³¹ The present study showed that lack of a hands-on approach was not missed because the patients experienced the physiotherapy through the video-link so intensively. This accords with the observations of Jensen et al. who found that experienced therapists were more responsive and listened more intently compared to inexperienced physiotherapists.³¹ As in our study, the patients communicated with an experienced therapist, which could be an explanation for the feeling that the hands-on approach was not missed. We assume that this communication and the management of the technique contributed to their confidence, which may have led to the experience of close attention, i.e. a reinforced communication.

Pain-free exercising became an effective routine for the patients. They described how they looked, listened and understood the essence of the shoulder exercise. This was a learning process and patient-education is important for good postoperative results.² Following shoulder arthroplasty surgery, where pain is a central part, minimizing the pain and minimizing immobilisation is essential.^6,32 Normal good practice is summarised in the motto ‘don't do it if it hurts’,³³ which may lead to fear of pain, less activity and a fear of destroying the surgery. Optimum outcome demands active participation of the patients to obtain the balance between the surgical repair, the pain and the intensity of physical exercises.

In our study the knowledge of how to exercise without pain and the loss of the fear of destroying the surgery were perhaps due to continuity, and equally frequent exercises under the supervision of the same competent physiotherapist which gave a feeling of safety. Similar experiences were found where parents of infants at home felt safe when directly accessing remote staff via a video-link.³⁴

The analysis of the patients' experiences indicated a change from a dependent patient to a strengthened person at home. In the first phase after the surgery, the patients had little knowledge about shoulder surgery and shoulder exercises. They saw the physiotherapist as the expert in terms of instructions about the body, the technique and as a problem solver. A way to gain a quick recovery after shoulder surgery is to pay attention to the patient as an active and not a passive receiver, who simply ‘delivers the body’ to the health care.^6,35,36 The patients described a process of becoming experts in relation to their own bodies and themselves, which accords with realtime collaboration and other studies.^37,38 It may be that the patients put aside their autonomy at the beginning of the treatment in order to pick it up again in another situation.³⁹

The fact that the exercises were performed at the patients' home, instead of at the physiotherapists' office, may have shifted the balance of power between the patient and the physiotherapist in favour of the patients.³⁸ This is quite contrary to conventional treatment when the patient goes to the physiotherapist's office. The home was experienced as an exercising arena adjusted to the home environment, which was of positive importance for the success of the exercises. The feeling of safety, and the security and freedom expressed was partly related to the home and is consistent with Zingmark's study.⁴⁰

The patients experienced a feeling of closeness at a distance. They did not perceive the geographical distance between themselves and the physiotherapist. If they had already met the physiotherapist at the hospital, it was easier to meet at a distance.³⁴ The patients expressed that the technical quality and the image were important in terms of experiencing intimacy.⁴¹ The videoconference session constitutes a virtual room with both a physical and social presence and the experience of intimacy is an important quality in all relations between the therapist and the patient.^42,43

In comparison to conventional care, the video-based physiotherapy at home and access to the physiotherapist facilitated daily living for the patients. Physiotherapy through video was experienced as a support which was independent of others and the patients did not experience any need for assistance with travelling. The reduced inconvenience gave them time and energy for other activities. In spite of the many advantages, they emphasized that they saw this as a supplement to conventional physiotherapy and that personal contact with the therapist could not be replaced.³⁴

A continuous rehabilitation chain with physiotherapy guidance, from the hospital to the home without delays or breaks, made the patients prepared to continue the outpatient physiotherapy exercises. The greatest drop in compliance with exercise regimes is associated with the time of discharge and short-term compliance consisting of frequent supervision by the physiotherapist.⁴⁴ Telerehabilitation offers shortening of the period in hospital⁴⁵ and continuity of expert consultation from the hospital to the patients' home.¹⁰ The avoidance of hospitalization through access to specific care services⁴⁶ also accords with our findings.

Methodological considerations

During fieldwork with earlier interviews,⁴⁷ the interviewer became aware of a pre-understanding dependent on earlier experiences and awareness of physiotherapy and of patients who had undergone a shoulder joint replacement. This led to encouraging the patients with additional questions during the interviews. The findings illustrate the complex character of the physiotherapy treatment. The results of physiotherapy treatment are not only dependent on the treatment method.⁴⁸ We saw an integration of many important aspects: one competent physiotherapist,⁴⁹ the home-and-the-technique context of the patient, a confident treatment relation, and a physiotherapy treatment process with patients initially dependent and passive and later independent and active participants in a mutual process between two active parts. The findings also showed that this modality of physiotherapy would be important in future research in the field of physiotherapy.

Aspects that may have influenced our findings were: the physiotherapist had met many patients who had undergone a shoulder joint replacement and was experienced in the problems following a shoulder surgery. These findings are similar to those of Donovan and Blake.⁵⁰ Furthermore, also among women with chronic pain, being met with recognition, confidence and awareness achieved a recovery competence when handling pain and illness.³⁷ Being treated with familiarity by the physiotherapist was an aspect that promoted presence.⁴¹ We have tried to obtain knowledge about various experiences of patients of both sexes, of different ages and with two common diagnoses. We assume that this knowledge would contribute to a richer variation of the phenomena of patients' experiences of telerehabilitation physiotherapy at home after shoulder surgery. The findings would therefore be transferable to other patients in similar contexts.

Conclusion

The patients' experiences of interactive video-based physiotherapy at home after shoulder joint replacement indicated that they felt safe, competent and strengthened in their daily exercise routine. Access to frequent support and feedback, continuity, reinforced communication, specific body knowledge and being at home were aspects contributing to an enhanced recovery competence. The findings also illustrate the extensive character of physiotherapy treatment. After the present study, telerehabilitation physiotherapy has been permanently incorporated into a new standard of physiotherapy in the county of Norrbotten.

Footnotes

Acknowledgements

We are grateful to the patients, to the physiotherapists and to the staff at the physiotherapy and orthopaedic department who participated in this study. We also thank the Norrbotten County Council, the Centre for Distance-Spanning Healthcare and the Department of Health Sciences, Luleå University of Technology.

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