Formulation of research question

The PEO format was used to develop a specific research question and has been described in the literature by various authors when developing specific qualitative research questions [16–18].

The proposed research question is:

“In musculoskeletal physiotherapy, what impact has telehealth provision had on patient and clinician satisfaction?”

The key research aim of this critical review is to understand patient and clinician views of telehealth adoption within musculoskeletal physiotherapy services.

Trial registration

This review was registered in the PROSPERO database: CRD42024498878.

Selection of articles.

Each stage of the PRISMA process included a double-screened peer review whereby two researchers (AS and SI) independently screened and reviewed the literature at the title, abstract and full text stages. This process gained agreement that comprised studies met the inclusion criteria (Table 1). Any disagreements between reviewers on the inclusion/exclusion of articles were discussed fully and where agreement could not be reached a third independent review person was enlisted to assist with resolving any discrepancies of the included articles. It was decided that 100% agreement was needed between independent reviewers for inclusion of the specific study. Where agreement could not be reached by a third-party reviewer, the study was maintained for review and inclusion within the study to avoid missing relevant research.

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Table 1. Inclusion/Exclusion Criteria.

https://doi.org/10.1371/journal.pdig.0000789.t001

Database searches yielded a total of 394 articles. No duplicate articles were identified. An additional 8 articles were included via reference list and citation searching. 402 articles remained which were further screened by study title. 290 articles were excluded after screening by title with most articles deemed irrelevant to the research question or excluded as systematic reviews. The second round of screening followed by review of abstracts with a further 92 articles excluded leaving the total remaining articles to be screened by full text review as 20. The reasons given for exclusion at the abstract stage were recorded (Fig 1), with the largest number of articles excluded as they did not meet the inclusion criteria. Screening of full text excluded another 10 studies (S2 Panel). The reason for exclusion included incorrect population, outcomes, and poster presentation. The remaining 10 studies were deemed to meet the inclusion/exclusion criteria and were included in the final review.

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Fig 1. PRISMA Flowchart.

https://doi.org/10.1371/journal.pdig.0000789.g001

Characteristics of studies

A summary of results characteristics was formulated to identify key characteristics of the included studies. (Table 2).

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Table 2. Characteristics of studies.

https://doi.org/10.1371/journal.pdig.0000789.t002

Key findings

Despite the synonymy between the different dimensions studied, firm conclusions between studies are limited by the heterogenous nature of methodology, however, a narrative exploring themes of satisfaction from the collected studies is possible.

1. Overall Satisfaction

Bennell et al. [24] and Miller et al. [12] shared similar findings on patient satisfaction with a high percentage reporting a good response to telehealth (92%-94%). The studies highlight a moderate to high number (47%-92%) of patients would engage in telehealth beyond the Covid-19 pandemic. Fernandes et al. [31] reported 77% of patients selected that they would participate in telehealth, yet the same study highlights 39% feel telehealth is inferior to in-person care.

Clinician experiences with telehealth demonstrated high levels of satisfaction [24,26]. Albahroah & Buabbas [26] suggested that 93.8% of physiotherapists were happy using telehealth as a mode of service delivery with 89% willing to deliver physiotherapy via telehealth. Bennell et al. [24] reported moderate to high effectiveness and satisfaction with telehealth at 70-80% for both 1:1 and class-based services amongst physiotherapists. Physiotherapist’s experiences and confidence with using telehealth was high within this study [24], with 70% reporting confidence and positive experiences. Reynolds et al. [25] reported 60% of physiotherapists view telehealth as a sustainable alternative mode of healthcare delivery. However, the same study highlights 40% of physiotherapists feel telehealth is a ‘stop gap’ during the Covid-19 pandemic and 57% feel telehealth reduces overall job satisfaction, despite 52% reporting an overall positive experience. This sentiment was shared by Fernandes et al. [31] with 55% of clinicians reporting telehealth is not as effective as in-person care and 35% reporting lack of confidence in providing telehealth.

2. Reduced Travel Time/Reduced Physical Burden

Several studies identified reduced travel time as a positive trait of telehealth that contributed to satisfaction over traditional healthcare delivery [25,27,28,30]. Reynolds et al. [25] reported reductions in travel time for the service user and was the second highest scoring advantage for telehealth identified by physiotherapists (82.44%). This was also supported by qualitative findings from Barton et al. [30]. The highest scoring advantage was reduced transmission of Covid-19 (92.68%). Odole et al. [28] highlighted the positive nature of telehealth in terms of reducing direct (financial) and indirect (time/physical) costs to the patient when healthcare is not easily accessible. Jansen-Kosterink et al. [27] lists reduced travel time as the initial positive theme expressed by patients within telehealth acceptance and revealed qualitative findings of lowered physical burden for patients as some experienced debilitating exhaustion with travel.

3. Flexibility

Two studies identified flexibility of healthcare delivery as a positive theme of telehealth [25,27]. Reynolds et al. [25] reported that flexibility with the delivery of healthcare regarding remote or in-person care for service users, is likely to be one of the most overwhelming positive features offered by telehealth. Jansen-Kosterink et al. [27] identified service user flexibility as its second most listed theme by patients for acceptance of telehealth, highlighting the positive nature this may have for patients who adopt irregular working patterns.

4. Accessibility

Several studies mention accessibility as a positive theme of telehealth [24,25,28,30]. Bennell et al. [24] reported that 54% of patients identified ease of access as a positive trait of telehealth; this is further supported by Odole et al. [28] who reported advantages for those who do not have easy access to healthcare or face geographical restrictions. Reynolds et al. [25] showed that 49.27% of physiotherapists reported improved access to healthcare as a positive advantage of telehealth.

5. Telehealth Vs Face-to-face or Blended Approach

Bennell et al. [24] showed a moderate number of patients (59%) rated telehealth as the same or better quality as traditional face to face care. Of important note, this statement is made in reference to videoconferencing with 1:1 care, there was a slightly reduced percentage (57%) for class-based care as being similar or better in quality. Malliaras et al. [23] reported a low to moderate (42%) response from allied health clinicians reporting telehealth as equal or superior to traditional face to face care with a low number (25%) reporting that patients valued telehealth to the same degree as traditional care methods. This was further supported by the findings of Fernandes et al. [31] who reported a moderate (55%) to low (39%) number of clinicians and general population stating telehealth as being inferior to in-person care. This notion is further highlighted by Barton et al. [30] with reports that the general population felt that telehealth had overall value but was perceived as inferior to in-person care. Despite this, participants expressed surprise in the value and benefits of telehealth with 3 in 4 agreeing it was good value and financially viable. Large number (85%) of survey participants reported improvements following their telehealth consultation and reported being better or much better (50%) following consultation with participants expressing future telehealth as a supplementary method to in-person care.

Bennell et al. [24] reported a moderate number of patients (47%) were extremely likely to choose telehealth again beyond the Covid-19 pandemic with a low number (28%) reporting they are not likely to engage in telehealth in the future. This statistic was far better for class-based telehealth intervention with a moderate to high number (68%) of patients willing to partake in telehealth in the future and a low number (13%) of patients reporting they would not engage in further telehealth delivery.

Several studies mention the potential for a blended service delivery model [28–30]. Odole et al. [28] highlighted the potential practical implications of applying telehealth to a physical hands-on profession and suggests it can only work as a sustainable model if applied as an adjunct to traditional care methods. Ullah et al. [29] cited similar findings with 69.5% rehabilitation professionals agreeing that both telehealth and traditional community-based services is the best service delivery model. Barton et al. [30] reports several interview participants highlighting a hybrid approach as the best way forward with telehealth provision.

6. Associations between Variables

Albahroah & Buabbas [26] reviewed relationships between studied variables amongst physiotherapists and highlighted some insightful findings. Statistical association between participant age (35 – 50 yrs.), professional rank, technology literacy and willingness to engage in telehealth practices were apparent. These findings are not surprising, as experienced physiotherapists may feel more confident with assessment skills and pattern recognition than their less experienced counterparts. The hypothetico-deductive process is likely to be utilised by skilled clinicians and would form part of the well-recognised clinical reasoning process [32].

7. Lack of Physical Contact

A negative theme amongst physiotherapists and the general population within several studies was the lack of physical contact with patients from telehealth service delivery [23,24,26,30,31]. Bennell et al. [24] highlighted several issues reported by a moderate number of physiotherapists (n=74) ranging from lack of physical contact to inability to facilitate exercise, thoroughly assess and use hands on treatment techniques. Malliaras et al. [23] and Barton et al. [30] give insight into issues faced by physiotherapists through lack of physical contact; these contributed to impaired clinical reasoning and less certainty establishing the diagnosis. Psychological and physical barriers have been described resulting in over-reliance on subjective information with limited objective assessment. Physiotherapist’s ability to undertake specific physical testing, establish accurate diagnoses and formulate sound treatment plans have been impeded by telehealth. Albahroah & Buabbas [26] declared a lack of therapeutic relationship through non-contact care between patient and clinician as a potential barrier. This was further explored with managers stating issues in detecting physical problems and lack of hands-on interventions and perceived clinical effectiveness as concerns faced with telehealth care.

8. Computer Literacy/Technology Issues

Several studies mentioned technology infrastructure as a potential barrier for telehealth service delivery [24,27,31]. Bennell et al. [24] demonstrated a high number of physiotherapists (n=130) reported sub-optimal internet quality and poor computer skills as barriers to engaging in telehealth both with 1:1 care and class-based delivery methods. Jansen-Kosterink et al. [27] identified both technology issues in terms of internet connectivity and lack of computer literacy combined with computer anxiety as barriers to engagement in telehealth amongst patients. This theme was further supported by the findings of Fernandes et al. [31] with digital literacy and access to technology as barriers to good outcomes with telehealth. Alternatively, around half of clinicians (52%) were confident with telehealth and a moderate number (61%) reported as having adequate infrastructure.

9. Privacy infringements

A number of publications noted data privacy infringement as a negative feature of telehealth [26,27,29,31]. Ullah et al. [29] reported that around half (52.44%) of rehabilitation professionals had concerns around data security and patient privacy/safeguarding issues during telehealth consultation. This was also supported by the findings of Jansen-Kosterink et al. [27] and Fernandes et al. [31] with patients expressing concern about privacy infringement especially with video consultation methods as the therapist would be able to view their property and surroundings. Albahroah & Buabbas [26] expressed similar findings with a low number of physiotherapists (38%) denoting patient privacy and data confidentiality as a concern with telehealth delivery.

Risk of bias.

Methodological quality was evaluated using the QuADS (Table 3), CASP (Table 4 and 5), and JBI (Table 6) tools respectively. Each article was reviewed by a single assessor (AS) and verified by a second reviewer (SI).

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Table 3. Risk of bias (QuADS Criteria).

https://doi.org/10.1371/journal.pdig.0000789.t003

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Table 4. Risk of bias (CASP Qualitative).

https://doi.org/10.1371/journal.pdig.0000789.t004

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Table 5. Risk of Bias (CASP Cross-sectional Studies).

https://doi.org/10.1371/journal.pdig.0000789.t005

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Table 6. Risk of bias (JBI).

https://doi.org/10.1371/journal.pdig.0000789.t006

Limitations in terms of methodological quality were present in several studies and may limit their credibility and capacity to be representative to both patients and physiotherapists. Non-response rates [33] were evident amongst several studies [12,25,26] and may have been enhanced by using web surveys. They have potential to limit responders who have poor internet connectivity or have reduced computer literacy [34] despite lower delivery costs, enhanced design options and less data inputting.

Potential sampling bias in studies either via voluntary response [35] or convenience sampling [36] was evident [12,23–26,30,31] although likely employed due to low cost and time consumption. However, the purposive sampling in qualitative reviews [27,28] had the advantage of selecting information rich subjects to depict important viewpoints on the subject matter [37].

Several studies incorporated a large volume of physiotherapists [12,23,24,31] whilst others had very low numbers [25,29] or did not provide taxonomy of specialities [26,28] limiting adequate representation of MSK physiotherapy views on satisfaction.

Four studies included [24–27] adopted a universal healthcare system with moderate cross-over relevance to UK National Health Service (NHS). Socioeconomic inequalities may well exist in countries that endorse self-funded healthcare with the wealthy and highly educated having better access than poorer or less educated populations [38].

Sample size calculations were absent for all but one study [25] but are important aspects of a study design to draw realistic conclusions from gathered results [39]. Only two studies [23,24] had patient response rates above the threshold set by Krejcie and Morgan [40] to produce a low margin of error of 0.5% and confidence interval of 95%.

Content thematic analysis was used in mixed method and qualitative studies [12,23–28,30,31] allowing for the development of themes extracted from written data and then coded via systematic process [41]. Several studies [23–25,31] analysed textual data from free text answers, whilst others [12,26–28,30] employed the use of interviews and focus group discussion with field notes [12,27], audio recordings [26–28], response validation [26], and topic guides [26,27,30]. Response validation is a tool used in qualitative research to ensure credibility and rigor of collected data [42] whereas potential subjectivity and unconscious bias may occur from field note taking [43,44].

Future recommendations

Future longitudinal studies will depict whether clinician and service user views remain positive beyond the pandemic. It could be postulated that positive satisfaction is likely when other services for in-person care were not readily available.

Future research should explore satisfaction of telehealth within condition specific musculoskeletal care and the use of advanced technologies as this may depict a differing view of telehealth for patients and clinicians. For example, the use of advanced technologies may impact and minimise the negative perceptions of telehealth as identified within this critical review. This may also help with implications for clinical practice such a telehealth integration into healthcare services, adopting patient-centred telehealth and expanding regulatory and policy considerations.

Addressing methodological weakness within studies such as non-response bias would seem a logical option in view of some of the low response rates received in several studies [12,25,26]. Future studies would benefit from collection of data from non-responders which all studies failed to achieve. Even with high numbers of responders, non-response bias could still occur if sociodemographic details are inherently different between groups.

Albahroah & Buabbas [26] produced some interesting findings with statistical cross tabulation of variables such as significant associations between age and willingness to use telehealth. Further studies may also benefit from the use of statistical analysis of studied variables as they may highlight correlation between variables that may not necessarily be evident from descriptive statistics and narrative themes alone.

Recommendations for improving external validity of future studies include the engagement of stakeholders in research design and ensuring a disaggregation of physiotherapy specialities. Engaging stakeholders from the outset of research conception will ensure that maximal impact is achieved, and that policy makers and health care institutions are able to appropriately apply and transfer research findings into a clinical context [67]. Disaggregation of physiotherapy specialities will aid future studies in ability to generalise to specific contexts of physiotherapy as patient population and physiotherapy needs are likely to differ considerable within each of these specialities.

Strengths and limitations of this study

This review highlights and supports the use of telehealth in physiotherapy services and has provided insightful implications for clinical practice and future regulatory and policy considerations. However, it is fundamental to note that this review has explored values associated with satisfaction of telehealth and this should not be confused with efficacy. This review considered the satisfaction of telehealth across a diverse range of patient and clinician populations and a range of varying demographics, age, and geographical locations allowed a broader view of satisfaction of telehealth.

Acknowledgement of the role and contribution of the authors professional background within physiotherapy and extensive clinical and academic experience has enabled a robust understanding of the research topic, highlighting current healthcare contemporary issues.

Limitations exist in drawing firm conclusions on the satisfaction of telehealth between studies due to heterogeneity in patient/clinician populations, healthcare settings, and telehealth technologies used. Several studies had methodological limitations which limit their ability to generalise results. Although this review portrays a positive narrative of telehealth, findings should be applied cautiously to the wider population. This review provided a content thematic analysis of findings, no statistical analysis was undertaken to identify significance between studies.