Disability and Rehabilitation: Assistive Technology

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Physiotherapists’ perceptions and barriers to use

of telerehabilitation for exercise management of
people with knee osteoarthritis in Sri Lanka

Thusharika Dissanayaka, Piumi Nakandala & Chanaka Sanjeewa

To cite this article: Thusharika Dissanayaka, Piumi Nakandala & Chanaka Sanjeewa (2022):
Physiotherapists’ perceptions and barriers to use of telerehabilitation for exercise management of
people with knee osteoarthritis in Sri Lanka, Disability and Rehabilitation: Assistive Technology,
DOI: 10.1080/17483107.2022.2122606

To link to this article: https://doi.org/10.1080/17483107.2022.2122606

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Published online: 13 Sep 2022.

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DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2022.2122606

ORIGINAL RESEARCH

Physiotherapists’ perceptions and barriers to use of telerehabilitation for exercise

management of people with knee osteoarthritis in Sri Lanka
Thusharika Dissanayakaa,b, Piumi Nakandalac and Chanaka Sanjeewad
a
Department of Physiotherapy, Faculty of Medicine, School of Primary and Allied Health Care, Nursing and Health Sciences, Monash University,
Melbourne, Australia; bFood and Mood Centre, Deakin University, Melbourne, Australia; cNational Hospital, Kandy, Sri Lanka; dNational Hospital,
Colombo, Sri Lanka

ABSTRACT ARTICLE HISTORY

Purpose: To assess physiotherapists’ perceptions and barriers to using telerehabilitation via video and Received 24 February 2022
telephone for exercise management for people with knee osteoarthritis (OA) in Sri Lanka. Accepted 2 September 2022
Materials and methods: Currently registered and practising Sri Lankan physiotherapists who care for
KEYWORDS
knee OA patients were invited to participate in a cross-sectional online survey framed according to a pre-
Knee; osteoarthritis;
vious study. A logistic regression analysis was used to assess the effect of physiotherapists’ characteristics telerehabilitation;
on their interest in telerehabilitation. video; telephone
Results: A total of 268 physiotherapists completed the survey, which was broadly representative of loca-
tions and work settings across Sri Lanka. Only three out of 16 statements received majority agreement;
these were that telephone-delivered care would save patients’ time (72%), save money (68%) and
improve patients’ privacy (67%). There was a consensus that video-based care would save money (79%),
and many favoured this medium over telephone-delivered care. Lack of experience with telerehabilitation
was associated with reduced interest in telephone-delivered care. Increased interest in video-based care
was associated with frequent care of knee OA patients. Most physiotherapists perceived technical issues
with telerehabilitation as a significant barrier to implementing it.
Conclusions: Physiotherapists perceived video-based telerehabilitation more positively than care over the
telephone. Reduced interest in telerehabilitation was associated with having no prior experience with it.
Moreover, technical issues with telerehabilitation were perceived as the main barrier to its use. A training
programme for physiotherapists, appropriate guidelines and a framework for better implementing telerea-
habilitation may yield substantial benefits for knee OA patients.

� IMPLICATIONS FOR REHABILITATION

� Physiotherapists in Sri Lanka perceive telerehabilitation for exercise management for knee OA
patients positively.
� Telerehabilitation via video or telephone is a viable option for delivering exercise management for
knee OA patients in Sri Lanka.
� The widespread practice of telerehabilitation by physiotherapists in Sri Lanka requires appropriate
strategies to mitigate barriers to its implementation.

Introduction associated symptoms and disabilities is challenging and imposes

Osteoarthritis (OA) is a leading cause of disability that affects
approximately 528 million people worldwide [1]. For the age
group of 50–74, OA is ranked 18th among the top 25 causes of
disability-adjusted life-years from 1990 to 2019 [1]. Specifically,
the prevalence of knee OA increased by 27.5% between 2010 and
2019 [1], and in 2019 it resulted in 11.5 million more years lived
with disabilities (YLDs) [2]. In 2018, the prevalence of moderate/
severe clinical knee OA among adult females over 50 years in sub-
urban Sri Lanka was estimated to be 29.9% [3]. Commonly diag-
nosed clinical symptoms of knee OA are joint pain and morning
stiffness, which leads to inactivity and reduced quality of life. Due
to the progressive nature of the disease with ageing, managing
a great economic burden worldwide.
There is no cure for knee OA, and self-management with exer-
cise and lifestyle modification to maintain a healthy body mass
index (BMI) are important for relieving its symptoms long-term
[4,5]. Evidence shows that exercises reduce pain, increase physical
function and improve the quality of life of people with knee OA
[6–8]. Physiotherapists are often responsible for managing knee
OA by recommending specific exercises following an in-depth
assessment of subjective and objective factors. To achieve the
required benefits, they are expected to adhere to clinical guide-
lines when prescribing exercises.
Underutilization of exercise in managing knee OA is a global
health problem. Many people complain that accessing

CONTACT Thusharika Dissanayaka Thusharika.dissanayaka@monash.edu Department of Physiotherapy, School of Primary Healthcare, Faculty of Medicine,
Nursing and Health Sciences, Monash University, Melbourne, Australia
Supplemental data for this article can be accessed online at https://doi.org/10.1080/17483107.2022.2122606.
� 2022 Informa UK Limited, trading as Taylor & Francis Group
2 T. DISSANAYAKA ET AL.
physiotherapy is challenging due to difficulties obtaining referrals
or appointments, long waiting times and limited availability of care
in regional or remote areas [9–11]. In addition, a long waiting time
for outpatient physiotherapy significantly affects an individual
health and increase the cost of care [12]. For example, in Sri Lanka,
most knee OA patients in rural areas do not have access to public
health that provides physiotherapy care. As a result, the majority
do not receive any physiotherapy treatments for their conditions.
Moreover, the COVID-19 pandemic, travel restrictions and hygiene
requirements have further limited access to clinics by increasing
the waiting time for receiving support from a physiotherapist for
knee OA [13]. Therefore, new approaches are needed to increase
to physiotherapy services for a wider population. To this end, tele-
rehabilitation is an option that may help to increase exercise
participation.
Telerehabilitation is being introduced all around the world.
Evidence suggests that telerehabilitation using videoconferencing
produces similar physical activity and functional outcomes to con-
ventional face-to-face treatment in people after knee arthroplasty
[14]. In a recent study, physiotherapists agreed that telerehabilita-
tion saves time and increase the privacy of knee OA patients [15].
Conversely, patients with knee OA have also reported positive
perception of video- and telephone-based telerehabilitation
[16,17]. Accounting to a recent overview of available systematic
reviews, telehabilitation and in-person rehabilitation are similarly
effective in managing patients with knee OA [18].
In the context of current COVID-19 pandemic, there have been
several studies on the implementation of telerehabilitation in Sri
Lanka. Studies assessing the effect of telephone-based care for
people attempting suicide and other patients during the COVID-
19 pandemic found beneficial effects compared to usual care
[19,20]. In addition, a review of telehealth in Sri Lanka reports its
benefits and the need for proper guidelines for its more compre-
hensive application [21]. Currently, only web-based online phar-
macies have been established in Sri Lanka, and limited studies on
this have been published [21]. Moreover, no studies in the Sri
Lankan context published to date relates to the current situation
in the implementation of telerehabilitation-based physiotherapy.
In addition, no studies have evaluated physiotherapists’ percep-
tion and barriers to using telerehabiliation for managing knee OA
patients. According to the guidelines, the core management strat-
egies for knee OA are exercises and self-management [7].
Therefore, assessing Sri Lankan physiotherapists’ perceptions and
experience of and interest in telerehabilitation for exercise man-
agement for knee OA patients is a crucial step to consider prior
to its wider application. This study aimed to assess physiothera-
pists’ perception and barriers to telerehabilitation via video-based
and telephone for exercise management of people with knee OA
in Sri Lanka. This study’s findings will inform healthcare decision
makers in Sri Lanka of telerehabilitation’s usability, barriers to its
implementation and physiotherapists’ perception of it.
Materials and methods
Study design
A descriptive, cross-sectional web-based survey was carried out
among physiotherapists across Sri Lanka. The study was approved
by the Ethics Review Committee of the Faculty of Allied Health
Sciences, University of Peradeniya, Sri Lanka. Using the sample
size calculator on the Australian Bureau of Statistics website, and
assuming the total number of physiotherapists in Sri Lanka was
600, the sample size was calculated at a 95% confidence level.
Accordingly, the required sample size was 235 participants to fulfil
the objectives of our study.
Participants
Physiotherapists working in both public and private sectors in
rural, metropolitan, regional and remote city areas across the
country were recruited for the study. Also recruited were physio-
therapists working as academics in universities, including the
University of Peradeniya, the University of Colombo and the
General Sir John Kotelawala Defence University, and as well as
physiotherapists working in military hospitals. The recruiting pro-
cess was carried out between February and June 2021. Various
strategies were exploited to recruit participants, these included
advertisement on social media (Facebook), contacting the Sri
Lanka Society of Physiotherapy and Government Physiotherapy
Officers’ Association. The inclusion criteria were that physiothera-
pists were registered with the Sri Lanka Medical Council and had
treated at least one patient with knee OA in the past 6-months at
the time of completing the survey.
Survey instrument
The survey statements were adapted from a previous study by
Lawford et al. [15], and further modifications were made to
develop the final survey. Since this study focussed on knee OA,
the third eligibility question and the questions in parts A, B, C
and D were modified accordingly (Supplementary File 1). The
research team and external experts reviewed the final survey, and
it was pilot tested among 10 physiotherapists who met the inclu-
sion criteria. After addressing minor grammatical errors, the sur-
vey was emailed via a Google Form to the participating
physiotherapists, and informed consent was obtained from the
attending participants along with the questionnaire.
An introductory section regarding telerehabilitation and the
purpose of the study was included. The rest of the survey com-
prised four sections; A, B, C and D. Section A contained open-
ended, close-ended and multiple-choice questions to gather
demographic data and check participants’ experience with telere-
habilitation. Sections B and C contained 16 statements on deliver-
ing an exercise programme for knee OA patients over the
telephone (Section B) and via video (Section C). All the statements
in sections B and C were framed positively with Likert scale-type
responses: (1) strongly disagree; (2) disagree; (3) unsure; (4) agree;
(5) strongly agree. Since the provision of rehabilitation services via
telerehabilitation is not well established in Sri Lanka, identifying
barriers to implementing it there is crucial. Therefore, a new com-
ponent, “barriers”, was introduced to Section D, into which eight
custom-developed statements were inserted.
Statistical analysis
Data were downloaded from Google Forms and processed in a
Microsoft Excel spreadsheet. Data analysis was carried out with
SPSS and a p value less than 0.05 was considered significant. Data
related to statements in Sections A, B and C of the survey were
described as numbers (percentages), with 95% confidence inter-
vals (CI) calculated around proportions. Participants who strongly
agreed or agreed with each statement were used to assess the
level of agreement with each statement, as defined by a previous
study [15]. Levels of agreement were defined as unanimity
(100%), consensus (75–99%), majority view (51–74%) and no con-
sensus (0–50%). The CIs for proportions of agreement and strong
 TELEREHABILITATION AND KNEE OSTEOARTHRITIS 3

agreement were used to compare telephone and video-based
exercise prescriptions by physiotherapists. A non-overlapping CI
was counted as a significant difference in the proportions of par-
ticipants who agreed with a statement.
In addition a univariate logistic regression analysis was used to
investigate whether physiotherapists characteristics interfered
with their response to the statement, “I would be interested in
being involved in a service offering physiotherapist-prescribed
exercise over the telephone/via video for people with knee OA”.
The physiotherapists responses were categorised as either agree-
ing (agree, strongly agree) or not agreeing (unsure, disagree or
strongly disagree) with the statement. The dependent variables in
this analysis were sex, work setting, location of clinical practice,
frequency of treating knee OA, frequency of prescribing exercises
for knee OA, previous experience with telerehabilitation, confi-
dence using video chat over the internet, currently offering serv-
ices via telephoneorvideo and belief that the cost of telephone
and video-delivered care for people with knee OA. Due to the
small number of responses, some response categories, including
work setting, clinical practice location and frequency of prescrib-
ing exercises for knee OA were grouped. The barriers to delivering
care via telephone or video were described as percentages.
Results
Survey responses and participant characteristics
In total, 300 physiotherapists completed the questionnaire. Of the
respondents, 32 did not meet inclusion criteria resulting in 268
(89.3%) eligible survey respondents.
Table 1 shows the participants’ demographic and professional
characteristics. The majority were female (n ¼ 157, 58.6%), and the
in clinical experience in the sample was 5.76 years. Most partici-
pants did not have postgraduate physiotherapy qualifications
(n ¼ 240, 89.6%). Participants with postgraduate qualifications pos-
sessed master’s degrees (n ¼ 13, 46.4%) and postgraduate diplomas

Table 1. Demographic and clinical characteristics of physiotherapists (n ¼ 268).

Characteristics Value
Sex
Women 157 (58.6%)
Men 111 (41.4%)
Clinical experience, mean (SD) years 5.76 (5.28) (0–45 years)
Postgraduate qualifications
Yes 28 (10.4%)
No 240 (89.6%)
Work setting
Public health system 137 (51.1%)
Private health system 35 (13.1%)
Both public and private 90 (33.6%)
Other 6 (2.2%)
Clinical practice, mean (SD) hours/work 43.6 (21.7)
Main focus of clinical work
Musculoskeletal outpatients 48 (17.9%)
Musculoskeletal inpatients 11 (4.1%)
Both musculoskeletal inpatients and outpatients 131 (48.9%)
Neurological patients 23 (8.6%)
Other 55 (20.5%)
Geographic location of clinical practice
Metropolitan city (population ¼250,000) 130 (48.5%)
Regional city/town (population 18,000–249,999) 111 (41.4%)
Rural town (population 5000–17,999) 24 (9%)
Remote town (population < 5000 3 (1.1%)
Frequency of treating patients with knee OA
Infrequently (�1 in the last 6 months) 19 (7.1%)
Somewhat frequently (2–5 in the last 6 months) 34 (12.7%)
Frequently (�1 patient/month) 59 (22%)
Very frequently (�1 patient/week) 156 (58.2%)
Frequency of prescribing exercise for patients with knee OA
Occasionally (to a minority of patients) to approximately 50% of patients 8 (3%)
Usually (to most patients) 117 (43.7%)
Always (to all patients) 143 (53.3%)
Previous experience with telerehabilitation
No 133 (49.6%)
Yes, over the phone 101 (37.7%)
Yes, via video over the internet 61 (22.8%)
Confidence using video chat service over the internet
Not at all 52 (19.4%)
A little 49 (18.3%)
Moderately 104 (38.8%)
Quite a bit 49 (18.3%)
Extremely 14 (5.2%)
Currently offer PT services by telephone
No 231 (86.2%)
Yes 37 (13.8%)
Currently offer PT services via internet video
No 237 (88.4%)
Yes 31 (11.6%)
Values are the number (percentage %) unless indicated otherwise.
PT: physiotherapy; OA: osteoarthritis; SD: standard deviation.
4 T. DISSANAYAKA ET AL.
(n ¼ 14, 50%). Most of the physiotherapists worked in public health-
care (n ¼ 137, 51.1%). Few participants worked in other healthcare
services (n ¼ 6, 2.2%), including universities. Participants were dis-
tributed across metropolitan, regional, remote and rural locations
with the greatest representation of metropolitan areas (n ¼ 130,
48.5%). Approximately half of the therapists (n ¼ 131, 48.9%)
worked in both in- and outpatient musculoskeletal clinical setting
and frequently treated knee OA patients (n ¼ 156, 58.2%). Most
physiotherapists always prescribes exercises for knee OA patients
(n ¼ 143, 53.3%), while none reported prescribing no exercises.
Experience in telerehabilitation via telephone and video-
mediated service
As shown in Table 1, most of the physiotherapists had provided
telerehabilitation either via telephone (n ¼ 101, 37.7%) or video
over the internet (n ¼ 61, 22.8%), although about half of did not
have previous experience (n ¼ 133, 49.6%). A minority were
extremely confident providing services using video chat or tele-
phone (n ¼ 14, 5.2%). Most of the physiotherapists did not provide
physiotherapy services by telephone (n ¼ 231, 86.2%) or video
(n ¼ 237, 88.4%).
Perceptions of telephone-based care
No consensus was met on any statements relating to telephone-
based care (Table 2). However, the majority of the therapists
agreed with three statements on telephone-based care, namely
that exercise programmes over the telephone would save
patients’ time (72%), would save patient’s money (68%), and
would not violate patient’s privacy (67%). Indeed, only 21% of
therapists agreed that the delivering exercises by telephone
would be effective. In addition, most physiotherapists (65%)
believed that a telephone consultation should cost less than 25
or 50% of the cost of a face-to-face session, though 18% believed
that it should cost the same.
Perceptions of video-based care
Nine statements reached at least majority agreement (>50% of
physiotherapists in agreement). Of these, only one statement,
video-based care would save patients time, reached consensus
(79%). Seven statements on video-based care failed to reach
agreement. Similar to telephone-based care, most physiothera-
pists (61%) believed video-based care should cost less than 25 or
50% of the cost of face-to-face sessions, and 20% believed the
cost of video-based care should be the same.
The majority of physiotherapists showed a preference for
video-based care compared to telephone-based care, with 5 out
of 16 statements relating to video-based care reaching agree-
ment. These statements include that consulting and prescribing
exercise for knee OA via telerehabilitation was convenient (58%
[95% CI 52–64] agreement for video versus 27% [95% CI 21–32]
for telephone), that telerehabilitation was convenient for receiving
exercises for knee OA patients (53% CI [47–59] agreement for
video versus 33% CI [27–39] for telephone), that the participant
was interested in receiving exercise via telerehabilitation (55% CI
[49–61] agreement for video versus 45% CI [39–51] for telephone),
that telerehabilitation was acceptable (53% CI [47–59] agreement
for video versus 34% [28–40] for telephone) and telerehabilitation
was safe (62% [56–68] agreement for video versus 48% [42–54]
for telephone).
Influence of physiotherapists’ characteristics on the delivery of
telerehabilitation
Four independent variables were significantly associated with
interest in delivering telerehabilitation via telephone (Table 3).
Having no previous experience with telerehabilitation (odds ratio
(OR) 0.5 [95% CI 0.3–0.9]) was associated with decreased odds of
having an interest in telephone-delivered care, relative to those
having previous experience with telephone or video-based care.
Not currently delivering physiotherapy service by telephone (OR
0.3 [95% CI 0.1–0.7) was associated with reduced odds of being
interested in telephone delivered care, relative to participants cur-
rently delivering physiotherapy via telephone. Not delivering
physiotherapy using video (OR 0.2 [0.1–0.6]) was also associated
with decreased odds of being interested in telephone delivered
care, relative to participants currently delivering physiotherapy
using video. Conversely, the belief that telephone or video-based
care should cost less than 50% of the cost of face-to-face care
was associated with increased odds of having an interest in tele-
phone-delivered care, relative to participants believing that tele-
phone or video-based care should cost more than 50% of the
cost of face-to-face care.
One independent variable was associated with having an inter-
est in delivering exercise over video for knee OA patients (Table
4): treating knee OA patients very frequently It was associated
with increased odds of being interested in video-based care rela-
tive to treating OA patients infrequently (OR 0.4 [95% CI 0.2–0.8]).
Barriers to utilizing telephone or video-based care
Over two-thirds of participants (n ¼ 216, 80.6%) considered tech-
nical issues the main barrier to utilizing telerehabilitation for knee
OA care (Figure 1). Patients factor of acceptance of telerehabilita-
tion was also a commonly cited barrier (n ¼ 204, 76.2%). A per-
ceived lack of skills (n ¼ 98, 36.6%) and high costs for patients
and therapists (n ¼ 70, 26.2%) were also identified as barriers.
Approximately one-quarter of participants (n ¼ 73, 27.2%) identi-
fied the location of the healthcare institute as a barrier to utilizing
telerehabilitation for knee OA. Similarly, over one-third of partici-
pants cited physiotherapists’ cultural acceptance of telerehabilita-
tion as a barrier (n ¼ 95, 35.4%). A minority (n ¼ 26, 9.7%)
reported further barriers, including patients’ ability to understand
the content delivered by physiotherapists and the possibility of
fake physiotherapists delivering care to patients.
Discussion
This study provides novel insights into physiotherapists’ percep-
tions and barriers to using telerehabilitation via telephone and
video for knee OA care. We found that a majority of the physio-
therapists surveyed regard exercise for knee OA beneficial. While
there was no consensus on telephone care, there was consensus
agreement that video-based care would save patients time.
Additionally, video-based care was more positively perceived by
physiotherapists achieving majority agreement compared to tele-
phone-based care. Reduced interest in delivering care via tele-
phone was associated with a lack of prior and current experience
with telerehabilitation via telephone or video. Very frequent care
of knee OA patients was associated with increased interest in
delivering care via video. Finally, most physiotherapists viewed
technical issues and patient factors as barriers to utilizing tele-
phone- and video-based care for patients with knee OA in
Sri Lanka.
 TELEREHABILITATION AND KNEE OSTEOARTHRITIS 5

Table 2. Physiotherapists’ perception of telerehabilitation for exercise management with knee osteoarthritis (n ¼ 268).
Statement Strongly disagree Disagree Unsure Agree Strongly agree
Exercise is beneficial for knee OA 2 0 2 77 187
I would get a good understanding of a
patient’s knee OA over the
Telephone 11/4 (2, 6) 52/20 (15, 24) 130/48 (42, 54) 74/28 (22, 33) 1/0 (0, 1)
Internet video 5/2 (0, 4) 53/20 (15, 24) 88/33 (27, 38) 116/43 (37, 49) 6/2 (0, 4)
A patient’s privacy would not be
violated if I prescribed them an
exercise programme over the
Telephone 2/1 (0, 2) 27/10 (6, 13) 59/22 (17, 27) 159/59 (53, 65) 21/8 (5,11)
Internet video 1/1 (0, 1) 23/9 (5,12) 95/35 (30, 41) 137/51 (45, 57) 12/4 (2, 7)
Using the … … … … to consult with
a knee OA patient and prescribe an
exercise programme would be easy
for me
Telephone 10/4% [1, 6] 97/36 (30, 42) 89/33 (28, 39) 69/26 (20, 31) 3/1 (0, 2)
Internet 1/1 (0, 1) 49/18 (13, 23) 62/23 (18, 28) 146/54 (48, 60) 10/4 (1, 6)
I would be as satisfied talking to a
knee OA patient over the … … … ..
as I would be talking to the patient
in-person in my consulting room
Telephone 10/4 (1, 6) 139/52 (46, 58) 75/28 (23, 33) 42/16 (11, 20) 2/0 (0, 2)
Internet video 6/2 (0, 4) 86/32 (27, 38) 82/31 (25, 36) 91/34 (28, 40) 3/1 (0, 2)
An exercise programme prescribed by a
physiotherapist over the … … … ..
would improve a patient’s knee OA
Telephone 3/1 (0, 2) 15/6 (3, 8) 163/61 (55, 67) 87/32 (27, 38) 0/0
Internet video 1/0 (0, 1) 21/8 (4, 11) 113/42 (36, 48) 131/49 (43, 55) 2/1 (0, 1)
An exercise programme prescribed by a
physiotherapist over the
… … … … . would save a
patient money
Telephone 3/1 (0, 2) 15/6 (3, 8) 67/25 (20, 30) 166/62 (56, 68) 17/6 (3, 9)
Internet video 0/0 11/4 (2, 6) 67/25 (20, 30) 171/64 (58, 70) 19/7 (65, 76)
I would be able to adequately monitor
a patient’s knee OA over
the … … … ..
Telephone 11/4 (2, 6) 92/34 (29, 40) 117/44 (38, 50) 48/18 (13, 22) 0/0
Internet video 2/1 (0, 2) 54/20 (15, 25) 106/40 (34, 46) 103/38 (32, 44) 3/1 (0, 2)
I like that there would be no physical
contact with a knee OA patient
when consulting over
the … … … …
Telephone 18/7 (4, 10) 122/45 (39, 51) 42/16 (11, 20) 72/27 (21, 32) 14/5 (2, 8)
Internet video 7/3 (1, 4) 103/39 (32, 44) 49/18 (14, 23) 100/37 (31, 43) 9/3 (1, 5)
Receiving an exercise programme from
a physiotherapist over the
… … … … would be a convenient
form of healthcare for a knee
OA patient
Telephone 10/4 (1, 6) 70/26 (21, 31) 99/37 (31, 43) 87/32 (27, 38) 2/1 (0, 1)
Internet video 3/1 (0, 2) 42/16 (11, 20) 79/30 (24, 35) 138/51 (45, 57) 6/2 (0, 4)
Receiving an exercise programme from
a physiotherapist over the
… … … … would save the
patient time
Telephone 1/0 (0, 1) 26/10 (6, 13) 47/18 (13, 22) 178/66 (61, 72) 16/6 (3, 9)
Internet video 2/1 (0, 2) 12/4 (2, 7) 44/16 (12, 21) 189/71 (65, 76) 21/8 (4, 11)
I would be interested in being involved
in a service offering physiotherapist-
prescribed exercise over the
… … … … . for people with
knee OA
Telephone 12/4 (2, 7) 77/29 (23, 34) 59/22 (17, 27) 110/41 (35, 47) 10/4 (1, 6)
Internet video 7/3 (0, 4) 54/20 (15, 25) 60/22 (17, 27) 136/51 (44, 57) 11/4 (35, 47)
Using the … … … … .. would be an
acceptable way for me to deliver an
exercise programme to patients with
knee OA
Telephone 12/5 (1, 7) 79/29 (23, 35) 86/32 (26, 39) 90/34 (28, 39) 1/0 (0, 1)
Internet video 5/2 (0, 3) 50/19 (14, 23) 71/26 (20, 31) 137/51 (45, 57) 5/2 (0, 3)
Using the … … … … … would be a
useful (practical) way for me to
deliver an exercise programme to
patients with knee OA
Telephone 11/4 (2, 6) 85/32 (26, 37) 98/37 (30, 42) 73/27 (22, 32) 1/0 (0, 1)
Internet video 5/2 (0, 3) 45/17 (12, 21) 92/34 (27, 40) 118/44 (38, 50) 8/3 (1, 5)
(continued)
6 T. DISSANAYAKA ET AL.
Table 2. Continued.
Statement Strongly disagree
Using the … … … … … would be
an effective way for me to deliver an
exercise programme to patients with
knee OA
Telephone 11/4 (1, 6)
Internet video 3/1 (0, 2)
Using the … … … … … could be an
affordable way for patients to
receive a physiotherapist prescribed
exercise programme for their
knee OA
Telephone 4/2 (0, 3)
Internet video 3/1 (0, 2)
Using the … … … … .. would be a
safe way for patients to receive a
physiotherapist-prescribed exercise
programme for their knee OA
Telephone 6/2 (0, 4)
Internet video 3/1 (0, 2)
Values are the number/percentage (95% confidence interval) unless indicated otherwise. OA: Osteoarthritis.
Perceptions of video- and telephone-based care
We found consensus on one statement on video-based care: it
would save patient’s time. In addition, more physiotherapists fav-
oured video-based care compared to telephone-delivered care, as
it was considered convenient, acceptable, safe, easy and interest-
ing for therapists and convenient for the patient with knee OA.
These findings are consistent with previous studies wherein physi-
otherapists reported positive perceptions of telerehabilitation
[15,22–26]. A survey examining Australian physiotherapists’ per-
ceptions of telephone and video-based telerehabilitation on hip
and knee OA found that respondents were more satisfied with
video-based care in terms of saving time, protecting privacy and
increasing convenience for OA patients [15]. The patients with
knee OA were also found to be more satisfied with video-based
care as it would save them time, protect their privacy and be con-
venient and easy to use [16]. Moreover, the findings that using
video technology is easy and safe are in line with previous studies
on post-knee arthroplasty rehabilitation [25,26]. Overall, it is evi-
dent that video-based care for knee OA may be acceptable to use
in the Sri Lankan context.
Conversely, the findings did not reveal on any statements on
telephone-delivered care. This is in contrast to a previous study
that found consensus agreement that telephone-delivered care
improves patient’s privacy and saves time [15]. This difference
may be due to 14% of the physiotherapists in our study currently
providing services via telephone; they would thus have a good
understanding of the difficulties with telephone-based care. This
stands in contrast to the previous study in which only 8% of
therapists currently offered services currently through this
method. In addition, a randomized controlled study on people
attempting suicide in Sri Lanka found that brief mobile treatment
is more effective than usual in-person care [20]. However, evi-
dence highlights that the absence of visual cues and inability via
telephone to confirm the diagnosis with an examination are con-
cerns for general practitioners [27]. The physiotherapists in our
cohort may have been similarly concerned about using telephone
care for knee OA. Importantly, a previous study on perceptions of
patients with hip and knee OA on telephone- and video-based
care showed positive perceptions of telephone-delivered care,
and with a majority of patients being confident in using mobile
phones (43%) and using it every day (77%) [16]. To our know-
ledge, no study has investigated the perceptions of patients with
Disagree Unsure Agree Strongly agree
99/37 (31, 42) 102/38 (32, 43) 55/21 (15, 25) 1/0 (0, 1)
56/21 (16, 26) 92/34 (29, 40) 111/42 (35, 47) 6/2 (0, 4)
43/16 (11, 20) 88/32 (27, 38) 130/49 (42, 54) 3/1 (0, 2)
24/9 (5, 12) 101/38 (32, 43) 135/50 (44, 56) 5/2 (0, 3)
45/17 (12, 21) 90/33 (28, 39) 122/46 (39, 51) 5/2 (0, 3)
24/9 (5, 12) 75/28 (22, 33) 156/58 (52, 64) 10/4 (1, 6)
knee OA or any other condition on telephone-delivered care in
Sri Lanka. Hence, further studies on the perception of patients
with knee OA of telephone-delivered care are necessary to con-
firm the effect of patient factors on physiotherapists’ favouring
it less.
The influence of physiotherapists’ characteristics on the delivery
of telerehabilitation
Our findings showed that reduced interest in telerehabilitation via
telephone is associated with a lack of previous or current experi-
ence with it. Moreover, about 52% of physiotherapists had nega-
tive perceptions on the lack of physical contact with patients
during telephone-based care. This is consistent with previous
studies, in which physiotherapists’ lack of interest in telephone-
delivered care and telerehabilitation in general was due to the
lack of physical contact [15,22]. Although physiotherapy is trad-
itionally believed be based on hands-on skills, self-management
advice and exercises are key strategies in managing knee OA [7].
Our findings that physiotherapists’ increased interest in video-
based care is associated with very frequently treating knee OA
reflects the fact that greater experience with and understanding
the management of knee OA may facilitate the use of telerehabili-
tation. Overall, these findings suggest that telerehabilitation in Sri
Lanka requires proper guidelines, training and practice.
Barriers to utilizing telephone or video-delivered care
Physiotherapists in our cohort reported a range of barriers to tele-
phone- and video-based care for knee OA. In our study, many
identified technical issues as the top barrier to utilizing telephone-
or video-based care. Previous studies found that technology-
related issues are a major barrier to implementing telehealth
[28,29]. The availability of professional technical staff to manage
technical issues could overcome this barrier. Patients’ acceptance
of telerehabilitation was another barrier highlighted by most of
most of physiotherapists in our cohort. Although the perception
of people with knee OA of telerehbailitation in Sri Lanka have not
been previously studied, studies in other countries showed
patients had positive attitudes towards using telerehabilitation
[16,30–33]. In Australia, patients with knee OA reported positive
perceptions of physiotherapists prescribing exercises by
 TELEREHABILITATION AND KNEE OSTEOARTHRITIS 7

Table 3. Influence of therapist characteristics on interest in offering physical therapist–prescribed exercise over the telephone for knee osteoarthritis.
Agree Disagree OR p
Sex Female 65 92 1.0 (Ref)
Male 55 56 1.39 (0.8–2.2) 0.18
Work setting
Public health system 62 75 1.0 (Ref)
Private health system 14 21 1.21 (0.2–6.2) 0.82
Both public and private 41 49 1.5 (0.2–8.5) 0.64
Other 3 3 1.1 (0.2–6.2) 0.83
Geographic location of
clinical practice
Metropolitan city 51 79 1.0 (Ref)
Regional city/town 56 55 1.4 (0.6–3.3) 0.39
Rural/Remote town 13 14 0.9 (0.3–2.1) 0.83
Frequency of treating
patients with
knee OA
Infrequently 7 12 1.0 (Ref)
Somewhat frequently 14 20 1.3 (0.4–3.5) 0.57
Frequently 31 28 1.1 (0.5–2.3) 0.79
Very frequently 68 88 0.6 (0.3–1.2) 0.24
Frequency of prescribing
exercise for patients
with knee OA
Occasionally (to a minority of 3 5 1.3 (0.3–5.8) 0.68
patients) to approximately 50%
of patients
Usually 53 64 0.9 (0.5–1.5) 0.93
Always 64 79 1.0 (Ref)
Previous experience with
telerehabilitation
No 51 82 0.5 (0.3–0.9) 0.03*
Yes, over the phone or 69 66 1.0 (Ref)
internet video
Confidence using video
chat service over
the internet
Not at all 14 38 1.0 (Ref)
A little 18 31 3.6 (1.0–12.2) 0.39
Moderately 54 50 2.2 (0.6–7.6) 0.17
Quite a bit 26 23 1.2 (0.4–3.8) 0.71
Extremely 8 6 1.1 (0.3–3.9) 0.78
Currently, offer PT
services by telephone
No 95 136 0.3 (0.1–0.7) 0.004*
Yes 25 12 1.0 (Ref)
Currently, offer PT
services via
internet video
No 98 139 0.2 (0.1–0.6) 0.003*
Yes 22 9 1.0 (Ref)
Belief about the cost of
telephone-
delivered care
50% more than the cost of a face-to- 10 15 1.0 (Ref)
face physiotherapy session
25% more than the cost of a face-to- 10 12 1.6 (0.6–4.0) 0.28
face physiotherapy session
The same cost as a face-to-face 22 25 1.3 (0.5–3.3) 0.57
physiotherapy session
25% less than the cost of a face-to- 30 52 1.2 (0.6–2.5) 0.55
face physiotherapy session
50% less than the cost of a face-to- 48 44 1.8 (1.0–3.4) 0.04*
face physiotherapy session
�Indicates a significant difference of p<0.05, Values are the number (%) unless indicated otherwise. OA: osteoarthritis; OR: odds ratio; 95% CI: 95% confi-
dence interval.

telerehabilitation via the telephone or video [16]. In addition,
physiotherapists’ skills, their acceptance of telerehabilitation and
policymakers’ attitudes were also significant concerns that physio-
therapists considered barriers to implementing telerehabilitation.
This finding is further supported by our finding that physiothera-
pists lack experience in telerehabilitation. This deficit could be
resolved by proper training. A recent review of telehealth/tele-
medicine in Sri Lanka highlights the need for a national frame-
work for providing this service to benefit people [21]. Given the
number of barriers, a well–established framework for overcoming
those and providing telerehabilitation would benefit Sri Lankan
people in the context of the pandemic and in future.
8 T. DISSANAYAKA ET AL.

Table 4. Influence of therapist characteristics on interest in offering physical therapist–prescribed exercise over the internet video for knee osteoarthritis.
Agree Disagree OR p
Sex Female 89 68 1.0 (Ref) 0.47
Male 58 53 0.8 (0.5–1.3)
Work setting
Public health system 79 58 1.0 (Ref)
Private health system 19 16 1.4 (0.2–8.2) 0.66
Both public and private 45 45 1.6 (0.2–10.4) 0.57
Other 4 2 2.0 (0.3–11.4) 0.43
Geographic location of
clinical practice
Metropolitan city 67 63 1.0 (Ref)
Regional city/town 64 47 1.3 (0.5–3.1) 0.46
Rural/Remote town 16 11 1.0 (0.4–2.5) 0.88
Frequency of treating
patients with knee OA
Infrequently 9 10 1.0 (Ref)
Somewhat frequently 16 18 1.2 (0.4–3.1) 0.7
Frequently 41 18 1.2 (0.5–2.5) 0.6
Very frequently 81 75 0.4 (0.2–0.8) 0.02*
Frequency of prescribing
exercise for patients with
knee OA
Occasionally (to a minority of 4 4 1.3 (0.3–5.4) 0.71
patients) to approximately 50%
of patients
Usually 62 55 1.1 (0.7–1.8) 0.55
Always 81 62 1.0 (Ref)
Previous experience with
telerehabilitation
No 66 67 0.6 (0.4–1.0) 0.08
Yes, over the phone or 81 54 1.0 (Ref)
internet video
Confidence using video chat
service over the internet
Not at all 20 32 1.0 (Ref)
A little 21 28 2.1 (0.6–7.0) 0.21
Moderately 63 41 1.7 (0.5–5.9) 0.34
Quite a bit 35 14 0.8 (0.2–2.6) 0.8
Extremely 8 6 0.5 (0.1–1.8) 0.31
Currently, offer PT services
by telephone
No 126 105 0.9 (0.4–1.8) 0.8
Yes 21 16 1.0 (Ref)
Currently, offer PT services via
internet video
No 129 108 0.8 (0.4–1.8) 0.7
Yes 18 13 1.0 (Ref)
Belief about the cost of
video-delivered care
50% more than the cost of a face-to- 13 11 1.0 (Ref)
face physiotherapy session
25% more than the cost of a face-to- 19 9 1.1 (0.4–2.7) 0.84
face physiotherapy session
The same cost as a face-to-face 25 28 0.6 (0.2–1.5) 0.3
physiotherapy session
25% less than the cost of a face-to- 51 43 1.4 (0.7–2.9) 0.3
face physiotherapy session
50% less than the cost of a face-to- 39 30 1.0 (0.5–2.0) 0.77
face physiotherapy session
�indicates a significant difference. Values are the number (%) unless indicated otherwise.
OA: osteoarthritis; OR: odds ratio; 95% CI: 95% confidence interval.

Strengths and limitations the difference between perceptions of the telephone- and video-
based care. Although we used non-overlapping CIs as a significant
This study has a number of key strengths. Our multifaceted recruit-
difference between telephone- and video-based care, such significant
ment strategy supported Sri Lanka wide participation of physiothera-
pists from all work settings and locations. Given the large sample differences may exist with overlapping CIs [34].
size, it is important to note that findings can be generalized to the
entire physiotherapy workforce in Sri Lanka. This study also has sev-
Conclusion
eral limitations, including that its findings cannot be generalized to
the physiotherapy populations of other countries. This study utilized Sri Lankan physiotherapists agreed that exercises are important in
the overlap of CIs approach similar to Lawford et al. [15] to assess managing knee OA. Moreover, many physiotherapists favoured

Figure 1. Barriers to utilizing telephone or video-delivered care.
video-based care over telephone-delivered care for knee OA.
Reduced interest in delivering telephone-based care was associ-
ated with having no prior experience with telerehabilitation. Very
frequent care of knee OA patients was associated with greater
interest in using video-based care. While most physiotherapists
viewed technical issues as the main barrier, other barriers
included patient and physiotherapists factors. In this context,
appropriate strategies to overcome the barriers, proper guidelines
and a framework for better implementing of telerehabilitation in
Sri Lanka are essential.
Acknowledgements
We thank all the physiotherapists that participated in this study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
The author(s) reported there is no funding associated with the
work featured in this article. This study received no specific grant
from any funding agency in the public, commercial, or not-for-
profit sectors.
ORCID
Piumi Nakandala http://orcid.org/0000-0003-2353-223X
Data availability statement
The data that support the findings of this study are available from
the corresponding author on request.
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