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

Abstract

BACKGROUND:

Tele-physiotherapy continues to rise, noticeably in Saudi Arabia which established a tele-physiotherapy initiative in 2018. However, data about the population’s understanding of tele-physiotherapy are scarce.

OBJECTIVE:

To explore Saudi population’s perception of tele-physiotherapy, and the correlation between quality of life and tele-physiotherapy preferences.

METHODS:

A cross-sectional online survey conducted on Riyadh residents, using a self-administered tele-physiotherapy survey and the SF-12 quality of life (QoL) index (Arabic version).

RESULTS:

Of 1011 participants, 85.3% were female, 50.8% were aged 26 to 50 years, almost 75% had university-level education, and 34.2% were employed. Only 19% had heard about tele-physiotherapy, with 43.7% of them citing social media as a source. Only 2.5% had tried tele-physiotherapy. Almost half reported uncertainty about most of the tele-physiotherapy questions, and over half recognised limitations e.g., anxiety about incorrectly performing the exercises (79.7%), therapist communication (51.7%), technical problems (70.7%), and privacy violations (66.3%). However, 58.7% said they would try tele-physiotherapy. There was no significant correlation between SF-12 QoL scores and participants’ tele-physiotherapy knowledge.

CONCLUSIONS:

Keywords

Saudi Arabia SF-12 tele-physiotherapy tele-physical therapy quality of life

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.

2.1 Survey structure

The survey included questions about demographic data, questions about their digital electronic knowledge, their perception and understanding of tele-physio- therapy, their familiarity with using tele-physiotherapy and an Arabic validated version of the quality of life (QoL) 12-item shortform survey (SF-12) [22]. The survey was divided into four sections as follows:

Section 1: Demographic data

This section included anonymous questions about age, gender, residency, nationality, level of education, occupational status, monthly income, and previous experience with traditional physiotherapy.

Section 2: Digital electronic knowledge

This section included questions to assess the level of digital electronic knowledge. The questions were constructed to evaluate the number of hours spent using electronic devices, and the subjective perception of one’s expertise when using electronic devices.

Section 3: Knowledge and perception about using tele-physiotherapy

This section aimed to evaluate the participants’ perceptions, knowledge, and familiarity with tele-physiotherapy. A survey was developed and revised by two expert physiotherapists and was validated via piloting on a sample of participants that were not included in the final analysis to ensure they understand the questions of the survey appropriately. It included questions about whether they heard about tele-physiotherapy or not and how, their understanding of physiotherapy, their knowledge about the availability and usage of tele-physiotherapy in Saudi Arabia, their perception of the effectiveness and benefit of tele-physiotherapy, its effectiveness in comparison to attending physical sessions, and if they would choose tele-physiotherapy if it was one of the treatment options. The perception about tele-physiotherapy was assessed using 15 statements where the responses were quantified on a 5-point Likert scale with options of (strongly agree, agree, disagree, strongly disagree, and not sure). Participants were also asked if they received any remote physical therapy sessions, their opinion about it, and if they would recommend it for others.

Section 4: Quality of life assessment

This section evaluated the participants’ quality of life using a validated and reliable Arabic version of the SF-12. The Short Form Survey-12 (SF-12) is a commonly used, well-researched, self-reported survey that was designated to measure the impact of health of the individual’s activity of daily living (ADL). The SF-12 is a shorter version of the SF-36 and is used to measure well-being and functional health from the patient’s perspective. SF-12 measures eight health domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. The scores range from 0–100, with higher scores indicating better health [23, 24]. The SF-12 questionnaire is available in validated Arabic version and, therefore, was selected to be used in this research [25].

2.2 Sample size calculation

The sample size was calculated using Power* software. The estimated sample size was 350 individuals.

2.3 Statistics and data analysis

Data were analyzed using SPSS 26.0 Windows version statistical software (IBM Inc, Chicago, USA). Descriptive statistics (mean, standard deviation, frequencies, and percentages) were used to describe the quantitative and categorical variables. The scores of two components of the SF-12 scale were obtained using the weights for each of the 12 items of the scale. Student’s $t$ -test for independent samples was used to compare the mean scores of mental and physical status components of the SF-12 scale in relation to the categorical study variables, which had two options. One-way analysis of variance followed by posthoc Tukey’s test was used to compare the mean scores of mental and physical status in relation to the categorical study variables, which had more than two options. A $p$ -value of $\leqslant$ 0.05 was used to report the statistical significance of the results.

3. Results

3.1 Socio-demographic characteristics

Out of 1011 participants, more than 90% were younger than 50 years. Females constituted the vast majority of the sample (85.3%), and 97.9% of the total sample were Saudi. About 75% of the sample had a university-level education. Towards the specialization of their studies, 18.5% were from health specialties, 31.4% and 44.5% were with science and literary majors, respectively, whereas only 5.5% were from computer technology majors. About one-third of participants were employed (34.2%), one-third (30.3%) were university students, 16.7% were housewives, and the remaining were unemployed and retired. The household income was sufficient among 51.1% of the subjects, whereas 11.7% of them felt their household income was not sufficient and they needed to borrow money for their expenses. Table 1 details the sociodemographic characteristics of the recruited sample.

Table 1
Distribution of socio-demographic characteristics of study subjects ( $n=$ 1011)

Characteristic	No. (%)
Age (in years)
$\leqslant$ 25	413	(40.9)
26–50	514	(50.8)
$>$ 50	84	(8.3)
Gender
Male	149	(14.7)
Female	862	(85.3)
Nationality
Saudi	990	(97.9)
Other	21	(2.1)
Educational level
General education	161	(15.9)
University	762	(75.4)
Postgraduate studies	88	(8.7)
Specialization ( $n=$ 849)
Health specialties	157	(18.5)
Computer technology majors	47	(5.5)
Science majors	267	(31.4)
Literary majors	378	(44.5)
Occupation
Employed	346	(34.2)
Unemployed	119	(11.9)
University student	306	(30.3)
Housewife	169	(16.7)
Retired	70	(6.9)
Household income
Sufficient, and can save money	376	(37.2)
Sufficient	517	(51.1)
Not sufficient	88	(8.7)
Not sufficient, and need to borrow money	30	(3.0)

3.2 Digital electronic knowledge

About 40% of participants reported spending about 6 to 9 hours per day on their electronic devices per day. Few participants reported spending less than two hours daily on their electronic devices (7.8%), and fewer (5.8%) used their devices more than 14 hours a day. At least three-fourths of the participants described themselves as excellent or very good with using electronic devices (Table 2).

Table 2
Distribution of participants according to their digital electronic knowledge (computer, mobile phones, video game consoles) ( $n=$ 1011)

Digital knowledge	Number (%)
Average number of daily hours use electronic devices
0–2	79	(7.8)
3–5	297	(29.4)
6–9	395	(39.1)
10–14	181	(17.9)
More than 14	59	(5.8)
How would you describe your expertise when using electronic devices
Excellent	378	(37.4)
Very good	377	(37.3)
Good	166	(16.4)
Medium	77	(7.6)
Bad	11	(1.1)
Very bad	2	(0.2)

3.3 Knowledge and perception about physical therapy and tele-physiotherapy

Concerning knowledge about physical therapy, about two-thirds (62.1%) of participants reported they had an idea what physical therapy is, though only 29% of them have tried it before. Surprisingly, all (100%) participants chose the correct meaning of physical therapy when given choices. With regards to tele-physiotherapy, only 2.5% have tried it and only 19% heard about it. Social media were the source of knowledge about tele-physiotherapy in approximately half (43.7%) of participants who had reported they had heard about tele-physiotherapy. Other sources such as the internet, books, and colleagues, friends, or family were less common (Table 3).

Table 3
Distribution of participants according to their knowledge about and experience with using physical therapy and tele-physiotherapy ( $n=$ 1011)

Knowledge and experience	Number (%)
Tried physical therapy before
Yes	293	(29)
No	718	(71)
Having an idea what physiotherapy is
Yes	628	(62.1)
No	144	(14.2)
Not sure	239	(23.6)
Physiotherapy meaning
Traditional medicine and massage	0	(0)
Treating patients to regain motor functions after injury or disability by therapeutic exercises	1011	(100)
Herbal medicines	0	(0)
Tried tele-physiotherapy
Yes	26	(2.5)
No	985	(97.5)
Heard about tele-physiotherapy
Yes	192	(19.0)
No	819	(81.0)
Source of knowledge about tele-physiotherapy ( $n=$ 190)
Social media	83	(43.7)
Internet	30	(15.8)
Books	3	(1.6)
Medical journals	1	(0.5)
Colleagues, friends, or family	49	(25.8)
Conferences or forums	3	(1.6)
University lectures	11	(5.8)
Other sources	10	(5.3)

Table 4

Distribution of participants according to their perception about tele-physiotherapy ( $n=$ 1011)

Statements about tele-physiotherapy	Strongly agree		Agree		Disagree		Strongly disagree		Not sure
Tele-physiotherapy is equivalent to conventional physiotherapy in terms of efficiency	19	(1.9)	126	(12.5)	275	(27.2)	51	(5.0)	540	(53.4)
Patients’ satisfaction with tele-physiotherapy is equivalent to conventional physical therapy	30	(3.0)	107	(10.6)	239	(23.6)	38	(3.8)	597	(59.1)
Tele-physiotherapy puts patients in some kind of risk	34	(3.4)	233	(23.0)	223	(22.1)	39	(3.9)	482	(47.7)
Tele-physiotherapy takes less time than traditional physical therapy	58	(5.7)	329	(32.5)	174	(17.2)	45	(4.5)	405	(40.1)
Tele-physiotherapy places more responsibility on the patient	337	(33.3)	521	(51.5)	15	(1.5)	0	(0)	138	(13.6)
Tele-physiotherapy may increase patient’s anxiety about incorrectly performing the therapeutic exercises	306	(30.3)	499	(49.4)	32	(3.2)	2	(0.2)	172	(17.0)
Communicating with the therapist during tele-physiotherapy is easier and more flexible than traditional physical therapy	89	(8.8)	276	(27.3)	183	(18.1)	26	(2.6)	437	(43.2)
Tele-physiotherapy is cheaper than traditional physical therapy	185	(18.3)	457	(45.2)	33	(3.3)	6	(0.6)	330	(32.6)
Tele-physiotherapy sessions are as beneficial as traditional physical therapy sessions	26	(2.6)	131	(13.0)	284	(28.1)	59	(5.8)	511	(50.5)
One of the limitations to using tele-physiotherapy is the difficulty of using electronic devices	134	(13.3)	504	(49.9)	104	(10.3)	9	(0.9)	260	(25.7)
One of the limitations to using tele-physiotherapy is the difficulty of communicating with the therapist	109	(10.8)	414	(40.9)	135	(13.4)	15	(1.5)	338	(33.4)
One of the limitations to using tele-physiotherapy is the technical and internet problems with sound and image	189	(18.7)	526	(52.0)	87	(8.6)	10	(1.0)	199	(19.7)
One of the limitations to using tele-physiotherapy for the patient is the lack of motivation	73	(7.2)	244	(24.1)	306	(30.3)	41	(4.1)	347	(34.3)
One of the limitations to using tele-physiotherapy is the lack of time	69	(6.8)	208	(20.6)	238	(23.5)	40	(4.0)	456	(45.1)
One of the limitations to using tele-physiotherapy is that it violates patients’ privacy	180	(17.8)	490	(48.5)	60	(5.9)	13	(1.3)	268	(26.5)

The participants’ perception about tele-physiotherapy was assessed via evaluating their responses (on a Likert scale) to 15 statements about tele-physiotherapy. Their responses are detailed in Table 4. Of note, approximately half of the participants were not sure about most of the questions (Table 4). More than half of them were not sure if tele-physiotherapy is as efficacious as conventional physical therapy (53.4%), and if patients’ satisfaction is equivalent to conventional therapy (59.1%). Approximately 48% of participants were not sure if the tele-physiotherapy puts the patients at a kind of risk, about 40% were not sure if tele-physiotherapy is less time consuming, 43.2% were not sure if communication is easier with the tele-therapist, 50.5% were unsure if tele-physiotherapy is beneficial, and 45.1% were unsure if lack of time is a limitation of tele-physiotherapy. Most of the participants (84.8%) thought that tele-physiotherapy places more responsibility on the patient, and 79.7% believed that it might increase the patients’ anxiety about incorrectly performing their therapeutic exercises.

Concerning the advantages of tele-physiotherapy, about 63.5% of participants agreed that tele- physiotherapy might be cheaper than traditional physiotherapy. With regards to limitations, the difficulty of using electronic devices was seen to be a limitation of tele-physiotherapy in 63% of participants, difficulty communicating with the therapist was seen as a limitation in 51.7% of participants, technical and internet problems were perceived as a limitation in 70.5% of participants, and lack of motivation and violation of patients’ privacy was seen as limitations in 31.3% and 66.3%, respectively (Table 4). Of note, the lack of time (45.1%) and motivation (34.3%) were the two limitations with the highest responses under ’not sure’ compared to other perceived limitations.

3.4 Knowledge about availability and usage of tele-physiotherapy

Only 18.9% of participants knew that tele-physiotherapy is available in the Kingdom of Saudi Arabia, and only 12.2% knew someone who had received tele-physiotherapy. Even though, about 58% responded positively that they would choose tele-physiotherapy as an option of rehabilitation treatment if available. Out of 26 subjects who had received tele-physiotherapy, 18 (69.2%) reported they would recommend it to others. On evaluating the reasons for choosing tele-physiotherapy among those who received it, about two-thirds (64%) reported that they chose tele-physiotherapy because it helped following the precautionary measures (e.g., social distancing) during the COVID-19 pandemic. Other less reported reasons are detailed in Table 5.

Table 5
Distribution of study participants according to their responses about the availability and usage of tele-physiotherapy

Tele-physiotherapy availability and usage	Number (%)
In your opinion, how available is tele-physiotherapy in the Kingdom of Saudi Arabia?
Available	191	(18.9)
Not available	165	(16.3)
I do not know	655	(64.8)
Do you know someone who have received tele-physiotherapy?
Yes	123	(12.2)
No	669	(66.2)
I am not sure	219	(21.7)
If tele-physiotherapy was an option of rehabilitation treatment for you, would you choose it?
Yes	593	(58.7)
No	176	(17.4)
I am not sure	242	(23.9)
After receiving tele-physiotherapy, would you recommend it to others? ( $n=$ 26)
Yes	18	(69.2)
No	3	(11.5)
I am not sure	5	(19.2)
Why did you choose tele-physiotherapy? ( $n=$ 25)
Therapist’s recommendation	2	(8.0)
Traditional physiotherapy is not available in my area	2	(8.0)
Lack of transportation	2	(8.0)
It gives better results	1	(4.0)
It takes less time	1	(4.0)
It is less expensive	1	(4.0)
It helps me follow the precautionary measures (e.g., social distancing) during the COVID-19 pandemic	16	(64.0)

Table 6

Comparison of mean mental and physical component values of SF-12 scale scores of participants in relation to socio-demographic characteristics of study subjects

	Mental component score				Physical component score
Characteristic	Mean $\pm$ SD		$t$ -value/ $f$ -value	$p$ -value	Mean $\pm$ SD		$t$ -value/ $f$ -value	$p$ -value
Age (in years)
$\leqslant$ 25	40.04	$\pm$ 10.7	33.95	$<$ 0.0001	47.91	$\pm$ 7.6	27.05	$<$ 0.0001
26–50	44.32	$\pm$ 9.3			44.91	$\pm$ 7.4
$>$ 50	48.01	$\pm$ 8.7			42.73	$\pm$ 7.3
Gender
Male	42.63	$\pm$ 10.3	$-$ 1.88	0.061	45.97	$\pm$ 7.8	0.15	0.878
Female	44.32	$\pm$ 9.5			45.86	$\pm$ 6.8
Nationality
Saudi	42.80	$\pm$ 10.2	$-$ 1.68	0.094	46.01	$\pm$ 7.5	1.50	0.134
Other	46.57	$\pm$ 7.5			43.48	$\pm$ 11.7
Educational level
General education	44.94	$\pm$ 10.2	8.31	$<$ 0.0001	44.71	$\pm$ 7.3	2.77	0.063
University	42.14	$\pm$ 10.2			46.25	$\pm$ 7.7
Postgraduate	45.51	$\pm$ 8.8			45.65	$\pm$ 7.8
Specialization
Health specialties	40.60	$\pm$ 10.8	5.53	0.001	49.33	$\pm$ 7.7	12.75	$<$ 0.0001
Computer technology	41.47	$\pm$ 10.9			46.83	$\pm$ 7.9
Science majors	41.61	$\pm$ 9.8			44.74	$\pm$ 7.1
Literary majors	43.99	$\pm$ 9.7			45.87	$\pm$ 7.7
Occupation
Employed	43.91	$\pm$ 9.3	15.08	$<$ 0.0001	45.94	$\pm$ 7.0	7.79	$<$ 0.0001
Unemployed	40.97	$\pm$ 9.9			45.56	$\pm$ 7.8
University student	39.97	$\pm$ 10.8			47.50	$\pm$ 7.6
Housewife	45.73	$\pm$ 9.9			44.88	$\pm$ 8.2
Retired	46.96	$\pm$ 8.8			42.51	$\pm$ 7.4
Household income
Sufficient, save money	43.47	$\pm$ 10.3	1.91	0.126	46.73	$\pm$ 7.8	3.78	0.010
Sufficient	42.91	$\pm$ 9.9			45.82	$\pm$ 7.5
Not sufficient	40.93	$\pm$ 10.1			44.24	$\pm$ 7.3
Not sufficient, borrow	40.80	$\pm$ 12.68			43.63	$\pm$ 7.8

No: Number; SD: Standard deviation.

3.5 SF-12 scale

By using the short form scale, which consists of 12 items, the participants’ mental components and physical components scores were calculated using the weights for each of the 12 items [22]. These two components’ scores provide the measurement of health status in subjects with mental or physical disorders. Lower scores indicate disorders [26, 27]. The mean mental component score of the participants was 42.88 $\pm$ 10.19 (15–69), and the mean physical component score was 45.95 $\pm$ 7.64 (23–61).

3.6 SF-12 mental and physical scores in relation to socio-demographics

Table 6 depicts the mean mental and physical SF-12 scores in relation to the sociodemographic characteristics of participants. Of note, age, educational level, specialization, occupational status, and household income were the factors significantly correlated with mental scores, physical scores, or both.

Among the three age groups studied (i.e., $\leqslant$ 25 years, 26–50 years, and $>$ 50 years), the SF-12 mental component mean score was significantly higher among participants above the age of 50 years ( $p<$ 0.0001). In contrast, the physical component score was highest among participants 25 years old or younger ( $p<$ 0.0001). Participants with a postgraduate educational level had the highest mental scores ( $p<$ 0.0001). Concerning specialization, the mental component score was highest among participants specialized in literacy ( $p=$ 0.001), whereas the physical component score was highest among health specialists ( $p<$ 0.0001). Occupational status had also a significant impact on both mental and physical component scores. University students have the lowest mental but highest physical scores ( $p<$ 0.000). In contrast, retired participants had the highest mental, but lowest physical component scores ( $p<$ 0.0001). Of note, the household income was significantly correlated with physical but not mental scores. The lower the household income, the lower the physical component score ( $p=$ 0.010).

3.7 SF-12 mental and physical scores in relation to knowledge and experience with physical therapy and tele-physiotherapy

Table 7
Comparison of mean mental and physical component values of SF-12 scale scores of participants sin relation to their knowledge about physical therapy and tele-physiotherapy

Knowledge items	Mean $\pm$ SD		$t$ -value/ $f$ -value	$p$ -value	Mean $\pm$ SD		$t$ -value/ $f$ -value	$p$ -value
	Mental component score				Physical component score
Tried physical therapy
Yes	44.89	$\pm$ 9.9	4.02	$<$ 0.0001	43.75	$\pm$ 7.4	$-$ 5.94	$<$ 0.0001
No	42.06	$\pm$ 10.2			46.85	$\pm$ 7.5
Have an idea about physical therapy
Yes	43.30	$\pm$ 10.4	1.65	0.193	46.01	$\pm$ 7.8	7.60	0.001
No	41.74	$\pm$ 9.9			43.92	$\pm$ 6.9
Not sure	42.46	$\pm$ 9.7			47.03	$\pm$ 7.5
Heard about tele-physiotherapy
Yes	43.26	$\pm$ 10.5	0.58	0.564	45.72	$\pm$ 8.0	$-$ 0.46	0.0643
No	42.79	$\pm$ 10.1			46.0	$\pm$ 7.6

No: Number; SD: Standard deviation.

Table 7 demonstrates the relation between SF-12 mental and physical component scores and the participant’s knowledge and experience with physical therapy and tele-physiotherapy. Physical component scores were significantly higher among participants who did not try physiotherapy (46.85 $\pm$ 7.5) than participants who tried it (43.75 $\pm$ 7.4) ( $p<$ 0.0001). In contrast, participants who had an idea about physiotherapy had higher physical scores (46.01 $\pm$ 7.8) than participants who had no idea (43.92 $\pm$ 6.9) ( $p=$ 0.001). There was no significant relationship between having heard about tele-physiotherapy and SF-12 mental or physical components.

4. Discussion

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 ( $\sim$ 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 ${}^{\text{nd}}$ , 2021 (IRB log number: 21-0097, Category: EXEMPT).

Footnotes

Acknowledgments

The authors have no acknowledgements. The authors received no funding for this research.

Conflict of interest

The authors have no conflicts of interest to declare.

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