Perceptions and understanding of tele-physiotherapy: A cross-sectional study in Saudi Arabia

1. Background

During the past few decades, the trend towards using tele-physiotherapy and telehealth (TH) witnessed a considerable increase globally [1, 2]. In Saudi Arabia, there was a noticeable interest in TH during the Corona Virus Disease (COVID-19) pandemic [3, 4]. Tele-physiotherapy and telehealth imply the use of telecommunication technologies, electronic devices, and the internet to deliver clinical rehabilitation and health care services remotely [5]. It constitutes a sustainable solution to allow patients to interact remotely with their physicians and/or healthcare providers [6, 7].

Currently, the scope of TH applications ranges from remote consultations with the treating physicians, physical therapists, speech therapists, psychologists to providing remote services such as education, healthcare training, and even robotic surgeries [8, 9]. Telehealth also includes medical services such as remote assessment, consultation, diagnosis, monitoring of improvement, patient education, intervention, training, and communication between patients and their therapists [7]. Several modalities are used for TH such as webcams, videophones, videoconferences, phone lines, mobile applications, and internet webpages [8, 9]. In the field of physical therapy, commonly implemented TR modalities include motor training exercises, virtual reality, community therapy, robotic therapy, and goal setting [10].

Data from recent literature showed that TH had several advantages. It reduced the duration of hospitalization, reduced rehabilitation expenses, improved treatment adherence, allowed early discharge rates from physical therapy clinics, saved both time and resources, and reduced the need for transportation. Moreover, tele-physiotherapy was reported to enhance both physical and mental health and lead to an early return to work and overall quality of life (QoL) [7, 11, 12]. Telehealth is also of benefit for physical therapists [12]. It enables them to improve health care efficiency, increase adherence to clinical guidelines, and allow them to remotely assess, educate and treat patients in their home setting and plan a personalized exercise program while simultaneously delivering continuous feedback and supervision, overall leading to a decrease in waiting lists and improved sustainability of services [12]. Despite the several advantages of the tele-physiotherapy, many limitations hinder its use on a global level [6]. The main reported disadvantages include limited flexibility to use different devices appropriate for the patients, increased errors on the exercises performed by the patients with remote interactions, skepticism about appropriate service delivery, technical challenges, lack of involvement in planning, along with resistance to change and negative attitudes of either the policymakers, the healthcare providers, or the even the patients towards using tele-physiotherapy [12, 13, 14].

In Saudi Arabia, there is an increased demand for health care and rehabilitation services, and tele-physiotherapy is a vital tool that can help the healthcare system provide a service that serves physically impaired, economically disadvantaged, or geographically remote patients [15]. The National Health Information Center (NHIC) in the Saudi Health Council (SHC) took a positive step towards a new initiative to establish a Saudi network of medicine in 2018 to provide healthcare services to remote areas in the kingdom [16]. In 2021, tele-physiotherapy guidelines in Saudi Arabia were established to standardize tele-physiotherapy practice across the kingdom [17, 18]. Even though, the number of facilities providing tele-physiotherapy and the usage of these services remain limited [19]. Recently, the Kingdom of Saudi Arabia (KSA) established the National Transformation Program (NTP) that aims to develop governmental work and establish the needed infrastructure to achieve “Saudi vision 2030” ambition and requirements [20]. The NTP 2020 report listed eight themes, the first being ‘transform healthcare’, which includes facilitating access to health services, improving the quality and efficiency, and promoting prevention against health risks [20]. The NTP report stated that tele-physiotherapy is a fundamental element of making healthcare accessible across the kingdom. Consequently, tele-physiotherapy can – in the long term – enhance healthcare services quality and reduce the financial cost on the Saudi Ministry of Health (MOH) and the government.

Tele-physiotherapy in Saudi Arabia faces barriers, including acceptance from both physicians and patients, along with cultural, ethical, and legal issues. There is scarce data about the Saudi populations’ perception of tele-physiotherapy. Therefore, this study aims to measure the participants’ understanding and perception regarding tele-physiotherapy and explore the correlation between the participants’ quality of life and their preference of tele-physiotherapy in Riyadh, Saudi Arabia.

2. Methods

This was a cross-sectional survey conducted on adult participants (18 years or older) living in Saudi Arabia during the period from June 2020 to February 2021. The survey was distributed to residents in Riyadh city which is the Capital and largest city in Saudi Arabia [21]. Riyadh is inhabited by approximately 7.5 million individuals constituting almost one-fourth (24.9%) of the total Saudi population [21]. Having a population profile that is highly representative to the total Saudi population. Riyadh was selected for this survey to be conducted. Participants were selected using the non-probability sampling techniques (convenience sampling). A self-administered online survey was developed by four researchers and constructed using an online google form tool. The survey was distributed through social media e.g., Twitter, WhatsApp, Facebook and emails. Prior to accessing the survey questions, the participants were asked if they agree to use their anonymous data for research purposes. Only those who consented to participate were redirected to the survey.

3. Results

The kingdom of Saudi Arabia has in place a Saudi network of medicine established in 2018 to provide healthcare services to remote areas in the kingdom [16]. Moreover, guidelines were developed and released in 2021 to standardize tele-physiotherapy practice across the kingdom [17, 18]. Saudi Arabia is one of the few Middle East countries that adopt tele-physiotherapy in its healthcare systems [28]. Even though, the data are scarce about the utilization of telehealth services in Saudi Arabia, and the population’s knowledge and perception about using these services. In this study, a population cross-sectional survey was conducted to tackle this point of lacked evidence. We studied the knowledge and perception of more than 1000 Saudi individuals about tele-physiotherapy and evaluated their QoL in correlation with knowledge about tele-physiotherapy.

Most of the participants were highly educated (at least three-fourths had a university-level education), and more than two-thirds of them reported they had excellent or at least very good digital knowledge. The vast majority of the participants spent between 3–9 hours daily on digital devices. Even though, there was a considerable lack of knowledge about tele-physiotherapy. In comparison to more than 60% knowing about conventional physiotherapy, only less than 19% had an idea what tele-physiotherapy is. This is significantly lower than what was reported in the literature in Saudi Arabia. For instance, Alqahtani [29], in his cross-sectional survey on 90 patients, reported that at least 47% of the participants recruited had an idea about tele-physiotherapy. The population studied by Alqahtani was different from ours. He studied 90 patients aged 50–75 years undergoing traditional physiotherapy. Therefore, they might have been educated by their physiotherapists about tele-physiotherapy [29]. The remaining studies in Saudi Arabia targeted the physiotherapists rather than the general population. Sami Ullah et al. [30], for example, conducted a cross-sectional study on 82 physiotherapy professionals working in different regions of Saudi Arabia and reported that 46% of them had good knowledge about tele-physiotherapy. Similarly, Aloyuni et al. [19] conducted a cross-sectional survey on 347 physiotherapists to evaluate their knowledge, attitude, and perceived barriers to tele-physiotherapy. They found that at least 58.8% of participants had a piece of adequate knowledge about tele-physiotherapy [19]. The rate of knowledge about tele-physiotherapy was higher among physiotherapists in the western countries such as Unites states ( ∼ 65%) [31] but lower among other Middle East countries such as Kuwait (48.4%) [32] and other Asian countries such as India (41%) [33]. In our sample, only 18.5% were health specialists. Taken altogether, the data in the literature are too scarce and most of the populations studied are directly linked to physiotherapy. Hence, the knowledge among the general population is expected to be lower. To the best of our knowledge – this is the first study to target the general population for evaluation of the knowledge and perception about tele-physiotherapy rather than patients or healthcare professionals.

The efficacy of physiotherapy has been shown to be non-inferior to conventional physical therapy in several literature studies [10, 34, 35, 36, 37]. In our survey, however, the participants did not only hear little about tele-physiotherapy, but also, they were unsure about its effectiveness and benefits in comparison to conventional therapy. Being perceived as a cheaper modality for physiotherapy by at least 63% of the participants, tele-physiotherapy can be a promising tool in economically disadvantaged countries with high demand of physiotherapy.

However, at least half of the participants in our survey were unsure if tele-physiotherapy is as efficacious, beneficial, less time-consuming, and easier than conventional physiotherapy. Moreover, a significant proportion of them thought that it adds to the patients’ risk, increases patients’ anxiety about incorrect performance of the session, and violates patients’ privacy. Most of them thought that tele-physiotherapy might carry several limitations such as internet and technical communication problems, lack of motivation, difficulty to communicate with therapists, and difficulty to use electronic devices. This is different from what is reported in the literature in other countries. For instance, a survey on 200 students from Nigeria showed a positive attitude towards tele-physiotherapy in at least 39% of participants [38].

Tele-physiotherapy received an excellent rating in about 95% of participants who tried it [29]. This shows the discrepancy between the expectation and actual trial of tele-physiotherapy and signifies the importance of public education about the efficacy, safety, and advantages of tele-physiotherapy, and encouraging patients to try it. In our population, however, the vast majority of the participants who tried tele-physiotherapy reported that COVD-19 was the main reason for trying it to follow the precautions of staying home. This is an expected result due to the timing of the survey which was conducted during the COVD-19 pandemic. Other reasons such as therapist recommendations, non-availability of a conventional therapy unit nearby, lack of transportation, less time consumption, lower cost, or better results constituted negligible percentage of the reasons of trying tele-physiotherapy.

Along with the lack of knowledge about tele-physiotherapy – where ‘not sure’ was the response in a considerable proportion of participants in many questions –, less than 19% of the participants in our study knew that tele-physiotherapy is available in Saudi Arabia. Of them, 12.2% knew someone who had tele-physiotherapy before. Despite the poor perception about tele-physiotherapy, almost 59% of participants said they might try tele-physiotherapy if available. This signifies the importance of educating the Public about tele-physiotherapy. Whilst the kingdom of Saudi Arabia exerted major efforts to implement tele-physiotherapy in the kingdom and had in place guidelines for tele-physiotherapy practice [16, 17, 18], it seems that the general population knows very little about it. The healthcare and governmental authorities in the country should pay comparable attention to increase public awareness about tele-physiotherapy. Of note, social media was the main source of information about tele-physiotherapy in the sample of the population we studied. This may provide a good clue on what to target during public education. Healthcare authorities should make strategies to educate the population about tele-physiotherapy via social media, televisions, conferences, and training courses.

Concerning the correlation between the QoL and tele-physiotherapy, it did not seem that the knowledge about tele-physiotherapy is correlated to the QoL indices (measured by the SF-12 survey) in our cohort. According to McCue et al. [40], there is strong evidence indicating that delivering the intervention in the patient’s familiar environment has a superior effect over traditional therapy in the clinic. Consequently, the patient’s QoL will be improved. What we found, in our survey, was that some sociodemographic variables were significantly correlated with the QoL and the use of conventional therapy as well. Poor physical component scores were found among elderly patients, which is mostly attributable to physical illnesses with advancing age. It is worth mentioning that patients with physical impairment were less knowledgeable and less likely to try tele-physiotherapy despite being the target population for the studied strategy. In contrast, mental wellbeing was more evident among the elderly. This may be attributed to the anxiety and stress among young individuals during their university studies or occupational career. This is emphasized by the poor mental scores encountered among university students and those working with stressful specialties such as health, and the high mental scores among retired individuals. Poor physical scores were also prevalent among low-income participants. A significant correlation was found between the physical and mental score and using physiotherapy. Patients who used physiotherapy had poorer physical scores. Patients who seek physiotherapy are usually physically ill, and that is why they might have had physiotherapy sessions. In contrast, their mental scores were high which might reflect their satisfaction with physiotherapy. In our study, we did not find a relation between tele-physiotherapy knowledge or attitude and QoL. In contrast to our findings, Schutte et al. [41] found that disabled patients with low QoL prefer tele-physiotherapy over traditional physical therapy to improve their functional abilities.

In Saudi Arabia, the patients who had tried tele-physiotherapy reported high levels of satisfaction and high efficacy rate than what the cohort of the general population we studied thought [39]. For example, in a cross-sectional survey conducted by Magadmi et al. [39] on 407 adult patients in King Abdulaziz University hospital, the patients’ perception of the effectiveness of tele-physiotherapy was 71.4–88.7% and their satisfaction ranged from 59.4 to 83.9%. Similarly, most of the 90 elderly patients studied by Alqahtani et al. [29] agreed about the several benefits of tele-physiotherapy such as the convenience of no travel (84%), usage in an emergency (83%), ease performance at home (97%), and availability of specialist consultation (84%). It is to be noted, however, that the data reported by Magadmi et al. [39] and Alqahtani et al. [29] represent perceptions of patients who have tried tele-physiotherapy, which is different from our sample where only 2% of participants have actual experience with it. Accordingly, the perceptions and limitations of tele-physiotherapy we report in our study represent real concerns of the general population.

In summary, there is a significant lack of knowledge among the cohort of individuals recruited to this study about the availability, advantages, and limitations of tele-physiotherapy. Their perception about tele-physiotherapy seems to be poor. However, their attitude towards using it was generally positive. Authorities in Saudi Arabia should implement strategies to educate the Saudi individuals about tele-physiotherapy. Such willingness to try tele-physiotherapy makes it a promising vital tool that can help the healthcare system provide a service that serves physically impaired, economically disadvantaged, or geographically remote patients in Saudi Arabia where there is a considerable increased demand of telerehabilitation [15].

The main limitation of this study was the characteristics of the sample of participants who responded to the survey. This is because most of the participants were females, younger than 50 years, had university-level education, and used to spent 6–9 hours a day on electronic devices. This is likely not adequately representative of the Saudi general population.

5. Conclusions and recommendations

There was a significant lack of knowledge among our cohort of patients about tele-physiotherapy. Even though, the willingness to try tele-physiotherapy was generally positive. Accordingly, healthcare authorities in Saudi Arabia are highly recommended to implement strategies to educate the Saudi individuals about tele-physiotherapy, and to have in place strategies to deliver tele-physiotherapy to individuals particularly in geographically remote regions whose access to conventional physical therapy is limited.

Author contributions

CONCEPTION: Kholood M. Shalabi.

PERFORMANCE OF WORK: Arwa N. Almodaraa, Raghad Ali Alrajhi, Lamia N. Alotaibi and Wejdan H. Batt.

INTERPRETATION OR ANALYSIS OF DATA: Kholood M. Shalabi.

PREPARATION OF THE MANUSCRIPT: Arwa N. Almodaraa, Raghad Ali Alrajhi, Lamia N. Alotaibi and Wejdan H. Batt.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: Kholood M. Shalabi, Arwa N. Almodaraa, Raghad Ali Alrajhi, Lamia N. Alotaibi and Wejdan H. Batt.

SUPERVISION: Kholood M. Shalabi.

Ethical considerations

Ethical approval for conducting the study was approved by Health Sciences Research Center, Princess Norah Bent Abdurrahman University, Saudi Arabia. An Institutional Review Board (IRB) approval was obtained from the graduate studies and scientific research Vice-Rectorate at Princess Nourah Abdulrahman University, Ministry of Education in Kingdom of Saudi Arabia on February 22 nd , 2021 (IRB log number: 21-0097, Category: EXEMPT).