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The delivery of physiotherapy via telehealth could provide more equitable access to services for patients. Videoconference-based telehealth has been shown to be an effective and acceptable mode of service delivery for exercise-based interventions for chronic knee pain; however, specific training in telehealth is required for physiotherapists to effectively and consistently deliver care using telehealth. The development and evaluation of training programs to upskill health care professionals in the management of osteoarthritis (OA) has also been identified as an important priority to improve OA care delivery.
This study aims to explore physiotherapists’ experiences with and perceptions of an e-learning program about best practice knee OA management (focused on a structured program of education, exercise, and physical activity) that includes telehealth delivery via videoconferencing.
We conducted a qualitative study using individual semistructured telephone interviews, nested within the
A total of five themes (with associated subthemes) were identified: the experience of self-directed e-learning (physiotherapists were more familiar with in-person learning; however, they valued the comprehensive, self-paced web-based modules. Unwieldy technological features could be frustrating); practice makes perfect (physiotherapists benefited from the mock consultation with the researcher and practice sessions with pilot patients alongside individualized performance feedback, resulting in confidence and preparedness to implement new skills); the telehealth journey (although inexperienced with telehealth before training, physiotherapists were confident and able to deliver remote care following training; however, they still experienced some technological challenges); the
Findings provide evidence for the perceived effectiveness and acceptability of an e-learning program to train physiotherapists (in the context of a clinical trial) on best practice knee OA management, including telehealth delivery via videoconferencing. The implementation of e-learning programs to upskill physiotherapists in telehealth appears to be warranted, given the increasing adoption of telehealth service models for the delivery of clinical care.
Physiotherapy care is traditionally delivered via in-person consultations. However, for many people, access to physiotherapy is limited by geographical isolation, or limited local services, or both [
Telehealth is defined by the World Health Organization as the “delivery of health care services, where patients and providers are separated by distance. Telehealth uses information communication technology for the exchange of information for the diagnosis and treatment of diseases and injuries, research and evaluation, and for the continuing education of health professionals” [
Advancing technologies allow education and training for medical and allied health students and professionals to overcome learning barriers such as distance and the limited availability of specialist training staff while also providing a standardized experience for learners [
Osteoarthritis (OA) is a common and often debilitating chronic joint disease and is one of the leading causes of pain and disability in Australia [
Given the central role of exercise in disease management, physiotherapists in primary care settings play an important role in providing care to people with knee OA. However, physiotherapists often feel underprepared to manage OA, lacking knowledge about evidence-based practice and confidence in implementing recommendations into routine care [
In this study, we explore the experiences of physiotherapists with and their perceptions of an e-learning program aimed at educating physiotherapists about best practice knee OA management, including the implementation of a protocolized management program focused on education, exercise, and physical activity, and how to deliver such care remotely using a videoconferencing platform.
A qualitative study nested within an ongoing randomized controlled trial (RCT; Australian New Zealand Clinical Trials Registry: ACTRN12619001240134) [
All 15 physiotherapists recruited to deliver trial interventions for the PEAK RCT participated in this qualitative study. Eligibility criteria for physiotherapist participation in the RCT included current registration to practice as a physiotherapist, private practice located in metropolitan or regional Victoria or Queensland (Australia), access to a computer with internet connection, suitable workspace for confidential video consultations, and some previous experience with videoconferencing software, for example, Skype, Zoom, or Facetime (not necessarily for delivering clinical care). Physiotherapists who met the eligibility criteria were considered for the study, and participating physiotherapists were selected based on their availability and location to ensure geographical spread across metropolitan and regional areas of Victoria and Queensland. All participants provided written informed consent, and the qualitative study was approved by the Institutional Human Research Ethics Committee, separate from the RCT.
The PEAK trial training program was developed by the research team, using an e-learning approach featuring both asynchronous and synchronous learning, developed in line with the Miller Pyramid (
Schematic representation of the PEAK (Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis) training components mapped to the Miller Pyramid learning model. PEAK: Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis. RCT: randomized controlled trial.
Physiotherapists first completed approximately 5 hours of self-directed e-learning modules delivered at the University of Melbourne Learning Management System (LMS; Canvas LMS by Instructure, 2019) covering OA management best practices (including a structured physiotherapy treatment protocol), telehealth (the delivery of care via Zoom videoconferencing), and trial procedures. Each module included a quiz to help reinforce user’s knowledge and learning. e-Learning was completed at the user’s own self-selected pace (ideally within 4 weeks) and delivered knowledge as the foundation of the physiotherapist’s learning. The PEAK training program e-learning modules have since been released for use by clinicians more widely [
The e-learning then moved to
Semistructured interviews were conducted after physiotherapists completed all components of the training program and commenced treating participants in the PEAK RCT. The interview schedule (
Semistructured interview schedule (loosely aligned with the theoretical framework of acceptability).
Topic and construct | Questions (prompts) | ||
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1. Can you tell me how confident you were in your ability to deliver an OAa management program before the PEAKb trial training? Previous OA management training? |
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2. Can you tell me about how confident you were in your ability to deliver physiotherapy to OA patients via videoconferencing, before you started the PEAK training? Training or professional development or experience in telehealth? | |
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3. What were your overall impressions and experience of the training program? Expectations? Comparison with previous professional development? | |
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4. What did you like and dislike about the training program? Consider both the web-based modules and the |
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5. To what extent did you feel your learning needs were met (or not) through the PEAK training program? Was there anything else you felt need to be covered or a required a greater focus in the training? Was there anything included that you felt was unnecessary? | |
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6. What were your thoughts on the content and presentation of the content in the PEAK web-based modules? How did you feel about the volume of text presented? How would you prefer to see the content delivered? If you were to change the content or its presentation, what would you suggest? | |
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7. What were your impressions about the usability of the web-based training platform? Like/dislikes/changes? | |
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8. How did you find the |
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9. Can you tell me a little bit about what you thought about the practice video consultation sessions with the pilot patients with knee pain? Were these consultations useful? | |
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10. Can you tell me overall how useful you found the PEAK trial training program? Intent to implement changes to usual clinical practice? | |
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11. How confident do you feel in delivering OA management to patients now, after completing the PEAK trial training? What elements do you feel most/least confident with? | |
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12. How confident do you feel in delivering physiotherapy to your OA patients over videoconference, now that you have completed the PEAK training? What elements do you feel most/least confident with? | |
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13. Given the restrictions on clinical practice imposed by the current COVID-19 pandemic, has the PEAK training program enabled you to make any changes to your own current clinical practice? | |
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14. Thank you very much for all your time today and all your time and efforts with this study. Is there anything else you would like to add about your experiences with the PEAK training program? |
aOA: osteoarthritis.
bPEAK: Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis.
Data analysis was conducted using a thematic approach [
All 15 physiotherapists recruited to deliver care as part of the PEAK RCT were invited to participate in the qualitative interviews. The sample comprised physiotherapists who worked in private practices across 2 Australian states. Physiotherapist characteristics are summarized in
Physiotherapists’ characteristics (n=15).
Pseudonym | Sex | Geographical locationa | Clinical experience (years) | Previous experience with telehealth | PEAKb RCTc videoconferencing participants at the time of the interview, n | PEAK RCT in-person participants at the time of the interview, n |
Daniel | Male | Outer regional, Victoria | 19 | Yes | 1 | 0 |
Edward | Male | Major city, Queensland | 10 | No | 1 | 0 |
Gregory | Male | Major city, Victoria | 4 | No | 0 | 0 |
Jason | Male | Inner regional, Queensland | 12 | Yes | 5 | 2 |
Robert | Male | Outer regional, Victoria | 12 | No | 2 | 2 |
Steven | Male | Inner regional, Victoria | 9 | No | 2 | 3 |
Nicole | Female | Inner regional, Victoria | 15 | No | 3 | 5 |
Anthony | Male | Major city, Queensland | 6 | Yes | 2 | 3 |
Mark | Male | Major city, Queensland | 9 | Yes | 2 | 3 |
Douglas | Male | Major city, Victoria | 18 | No | 4 | 3 |
Caroline | Female | Major city, Victoria | 7 | No | 1 | 4 |
Leslie | Female | Major city, Queensland | 9 | No | 0 | 1 |
Brian | Male | Inner regional, Queensland | 14 | Yes | 3 | 0 |
William | Male | Major city, Victoria | 10 | No | 1 | 1 |
Vicki | Female | Outer regional, Queensland | 5 | Yes | 1 | 4 |
aLevel of remoteness, based on residential postcode, in accordance with the Australian Statistical Geographical Classification-Remoteness Area.
bPEAK: Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis.
cRCT: randomized controlled trial.
A total of five themes, with associated subthemes, emerged and are described in
Physiotherapists found the self-directed e-learning modules to be of high quality, comprehensive, and user-friendly and that they would “benefit the least experienced physiotherapist and the most experienced physiotherapist”. Although physiotherapists were more familiar with “hands-on” in-person professional development training for furthering their knowledge and clinical skills, they highly valued the web-based structure. In particular, the self-paced nature of the program was highly regarded and enabled the physiotherapists to fit the training into their busy daily lives and complete it as time allowed. However, the physiotherapists spoke of feeling annoyed and frustrated by some unwieldy features of the delivery platform (including log-in and navigation). Although most physiotherapists spoke highly of the web-based modules, 3 physiotherapists with divergent views spoke of the e-learning modules being “slow going”, “tedious”, or “fatiguing”. The telehealth learning module content, in particular, was felt to be “dry” and “overtly obvious”.
Physiotherapists frequently referenced the benefit gained from individualized performance feedback from the research team during or after the practical components of the training. They spoke of “learning from applying” and that feedback was helpful ahead of implementing their new skills in a true clinical scenario. Physiotherapists found the mock consultation with the researcher (simulated patient) facilitated the transition from theory to implementation, commenting it “gave us a feel of what to expect for the upcoming pilots” and that it prevented them having to “worry about looking silly with the patients.” Similarly, the practice consultations with the pilot patients with chronic knee pain were valued, with physiotherapists reporting that this stage of practical e-learning was “hugely beneficial” and “consolidated everything” ahead of consulting with actual patients. Upon completion of the practical components of the e-learning program, physiotherapists expressed a high level of confidence and readiness to go into their first patient consultations using their new skills and knowledge. Two physiotherapists with divergent views felt that the mock consultation with the researcher was “daunting” or “confronting”, with one feeling that it was not necessary. The same physiotherapist also felt that the practice consultations with pilot patients were “surplus to needs”.
For the most part, physiotherapists were inexperienced in telehealth before training. Experience was largely constrained to videoconferencing for social purposes rather than for health care delivery. Physiotherapists in general were nervous or uncertain about providing care to patients via telehealth before undertaking the training program. However, 3 physiotherapists felt that they were moderately confident in telehealth before training, with one stating that “it didn’t seem like too much of a leap to deliver these services [exercise prescription via telehealth] to people.” After completing the training, most physiotherapists were much more confident and reported that they felt ready to deliver OA care via telehealth using videoconferencing. Despite improved confidence and feelings of preparedness, physiotherapists still felt that telehealth posed some challenges, particularly in supporting patients with OA to be able to navigate videoconferencing technology effectively.
Physiotherapists highlighted the benefits of the structured approach of the e-learning program. They found that the combination of self-directed e-learning modules, followed by practical components (mock consultation and pilot patient consultations), was very effective as a “whole package” to develop the knowledge and skills required for best practice OA care via telehealth. Physiotherapists valued the resources and patient information booklets that accompanied the training program, stating that the resources “made it really easy” to navigate the consultations and supported the implementation of their knowledge and skills into practice. One physiotherapist with a divergent view appreciated the package but felt that they would get more out of in-person training because of their learning style.
Although the greatest knowledge gains from the training program were regarding the practical implementation of telehealth for the PEAK randomized trial, physiotherapists also described their intent to apply new knowledge and skills in OA management more broadly to their own private practice. They spoke of how the training program filled “knowledge gaps”, particularly regarding patient education, and provided them with a more structured approach to OA management that could be used when treating their own clients. Given that the training was completed before the COVID-19 pandemic, physiotherapists felt they were “well equipped for this COVID situation” and expressed feeling “ahead of the curve” when it came to implementing telehealth physiotherapy services more broadly, given social distancing and lockdown restrictions. They felt that the skills they had learned allowed them to confidently switch their private practice service delivery to telehealth as well as teach their colleagues about telehealth. Overall, 4 physiotherapists commented that despite the COVID-19 pandemic, they had not ramped up telehealth services or experienced demand for telehealth in their clinical practice.
Our study shows that physiotherapists accepted e-learning despite their lack of familiarity with professional development delivered entirely via the internet. Physiotherapists valued both the theoretical and practical components of training, which together formed the
Schematic representation of emergent themes and their contribution to the development of confidence in delivering osteoarthritis care via telehealth. OA: osteoarthritis.
Physiotherapists perceived the asynchronous aspect of the self-directed e-learning modules to be generally user-friendly; however, the unwieldy technological features of the delivery platform could be frustrating. A previous systematic review of enablers and barriers affecting e-learning in health science education found that 33% (8/24) of the studies identified the lack of user-friendly ICT as a barrier to successful e-learning [
Telehealth practical components of our e-learning program were valued by physiotherapists, which supports previous research highlighting the importance of practical components in health care education, given the need to develop
Although most physiotherapists described increased confidence in the delivery of telehealth after training, we do not have quantitative measures in this study documenting changes in telehealth proficiency over time. Thus, we cannot draw strong conclusions about how clinical skills in telehealth changed as a result of the training. A previous study of e-learning in physiotherapists showed that asynchronous e-learning was effective in increasing quantitatively measured confidence and knowledge in delivering self-management interventions for OA and lower back pain to patients and that the intervention was delivered with high fidelity despite a lack of supervised practical training [
Our sample of Australian physiotherapists was inexperienced with telehealth before training and lacked confidence in delivering care remotely. This is unsurprising given that the uptake of telehealth across Australian health services before 2020 was minimal [
Strengths of our study include the evaluation of an e-learning program for which the e-learning modules are now freely accessible to clinicians globally. Our qualitative evaluation allowed for a thorough understanding of participants’ experiences and perceptions of participating in the e-learning program. Our interviews were conducted and the analysis was led by a person who was unknown to the participants and who was not a physiotherapist, minimizing the chances of personal or professional bias influencing findings. Limitations include that our sample was of limited size and comprised solely of physiotherapists who had applied and been selected to deliver the intervention as part of the PEAK RCT. Participants were bound by their clinical trial agreement to complete the training, and they were financially compensated for their time. Therefore, we cannot generalize our findings to the general population of physiotherapists who may be unwilling or unmotivated to complete training in their own time. As the training program is also only available in English, we cannot generalize the findings to non-English speakers nor to countries that may have a different scope of physiotherapy practice to that of Australia.
In conclusion, this study provides evidence for the perceived effectiveness and acceptability of an e-learning program to train physiotherapists (in the context of a clinical trial) on best practice knee OA management, including telehealth delivery via videoconferencing. The implementation of e-learning programs to upskill physiotherapists in telehealth appears to be warranted, given the increasing adoption of telehealth service models for the delivery of clinical care.
Standardized competency checklist used to provide personalized verbal feedback to physiotherapists during a mock consultation with a researcher (simulated patient).
Themes, subthemes, and exemplary quotes.
information and communication technology
Learning Management System
osteoarthritis
Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis
randomized controlled trial
This work was supported by the National Health and Medical Research Council (grant 1157977). RSH was supported by the National Health and Medical Research Council Senior Research Fellowship (grant 1154217). KB was supported by the National Health and Medical Research Council (grant 1174431). NEF is a senior investigator at the UK National Institute for Health Research.
None declared.