Integrability of a Comprehensive Telerehabilitation Approach for Post-Stroke Patients and Therapists: A Feasibility Study

Abstract

Telerehabilitation can be a valuable addition to conventional rehabilitation after a stroke. The aim of the presented study was to assess the feasibility and integrability of a newly developed platform and service model to offer telerehabilitation in different settings in an initial field trial. The field trial was conducted in two clinics and a freelance therapy setting in Austria and Slovenia. Data were gathered using questionnaires for patients, therapists, and, if applicable, relatives. The data were analyzed using descriptive methods. Three patients were treated by seven therapists (occupational, physio, speech). During the test, the patients completed more than 25 exercises per week on average. The usability of the system, in general, was high, with slightly better results for the patients. Overall, the patients stated that telerehabilitation is a good addition to conventional therapy, although the quality of online therapy is not as high as face-to-face therapy. The therapists reported that the system was easy to use but had some obstacles in exercise preparation. The integrability in daily life was good, according to the patients. For the therapists, integrability was average, as the test showed some obstacles in the provision of services beyond the clinical setting. Further studies are required to elaborate on the quality of teletherapeutic interventions in the proposed flexible service model.

1. Introduction

In the rapidly growing field of digital healthcare, telerehabilitation stands as a testament to technological innovation’s potential to reshape patient care. Telerehabilitation refers to the delivery of rehabilitation via various technologies. As it becomes more widespread, it presents many new opportunities and challenges, transforming the standard patient rehabilitation experience [1]. Telerehabilitation can be therapy sessions administered by a therapist in real-time using video call software or a separate platform that includes specific rehabilitation exercises for a predetermined condition [2].

The technology acceptance model (TAM) and its further development (TAM2, TAM3), initially developed by Fred Davis in 1985 [3], is based on the theory of reasoned actions and defines two main factors that influence acceptance to use technology: the perceived usefulness (PU) and the perceived ease of use (PEOU). Ketikidis et al. explored healthcare professionals’ acceptance of incorporating health technologies within clinical settings. Notably, while perceived usefulness played a less influential role, the effective utilization of a system and awareness of its applicability significantly influenced acceptance. Moreover, the perceived endorsement and support by peers (subjective norms) for integrating technologies into daily routines strongly impacted acceptance [4]. The incorporation of digital therapeutics, including the technological components of telerehabilitation approaches, into the existing healthcare and care pathways can have a positive influence on acceptance levels [5].

The minimized need for travel paints telerehabilitation as a valuable complement to traditional therapeutic interventions and could be considered a potential replacement for traditional rehabilitation in rural areas without easy access to in-person services [6]. Within a telerehabilitation framework, patients often manifest heightened self-efficacy and motivation, particularly regarding the execution of exercises at home. Building upon the sentiment of its efficacy [1], the effectiveness of telerehabilitation mirrors that of conventional methods, especially concerning neurological disorders. An advantage for such patients lies in the intensified treatment regimen and its seamless integration into their daily routines [7].

Telerehabilitation can positively influence activity performance, quality of life, and participation of individuals with brain injury [8]. Furthermore, telerehabilitation can improve upper extremity and arm motor function in post-stroke recovery [9,10]. The application of telerehabilitation can also train cognitive functions and positively affect memory [9]. Exercise performance is dependent on patients’ motivation, while the inclusion of games, especially in place of repetitive exercises, is preferred [9].

However, telerehabilitation is not without challenges, as it lacks physical interaction, which can inadvertently lead to an oversight in patient diagnosis. Moreover, therapists express a preference for all-in-one platforms with intuitive usability. Many practitioners view the prevalent telerehabilitation methods of delivering exercises as cumbersome [11]. Common barriers to the integration and sustainable adoption of telerehabilitation are acceptance and usability of the technology, specifically regarding ease of use [12].

The gap of knowledge lies in assessing the integrability and acceptance of telerehabilitation in conventional rehabilitation pathways by applying a technology platform and service model that was developed with a clear focus on high usability for patients and therapists.

The rehabilitation of stroke patients is very complex and requires an interdisciplinary team approach to achieve the best possible outcome. The conventional patient pathway in Austria starts with acute care in the primary hospital, followed by treatment in specialized neurological rehabilitation centers (in the subacute or chronic phase). After the inpatient stay, the patients are usually transferred to their private or nursing home setting. The patients receive further treatment in the outpatient area by self-occupied therapists. In Austria, the legal possibility of performing telerehabilitation with cost compensation by insurance was created in 2018. Similar to Austria, stroke rehabilitation in Slovenia begins during the acute hospitalization phase. A small number of stroke survivors are directly referred to a stroke rehabilitation department from the acute neurological department. Most patients’ first contact point with rehabilitation is spa resorts specializing in neurological rehabilitation. After this stay, they are dismissed home and can be referred to a rehabilitation clinic if they need specific treatments. This usually takes place 2 weeks to 4 months (in the early or late subacute phase) after the stroke. In the chronic phase, there are very limited possibilities for rehabilitation.

The main aim of the current study was to assess the feasibility, integrability, and acceptance of a newly developed telerehabilitation service model and technology platform in real-life contexts in Austria and Slovenia. The developed teletherapy solution aims to foster therapy and training processes for both patients and therapists.

2. Materials and Methods

All components of the newly developed teletherapy solution (technology platform and service model) were developed employing a holistic Human Centered Design approach (ISO 9241-210:2019, 2019) [13] by conducting iterative workshops, focus groups, and interviews with experts [14].

The service model not only complements but also comprehensively supports existing rehabilitation structures. It offers three core processes needed to provide qualitative, patient-centered, tele-therapeutically supported rehabilitation: face-to-face therapy (in person), synchronous therapy (via video calls), and asynchronous training (patient trains, the therapist monitors time independently). In addition to these core processes, the service model provides all necessary structures and processes to enable this form of rehabilitation. The technology platform, designed to support patients in the subacute and chronic phase after their rehabilitation stay, offers a flexible approach. It can be used for teletherapy under the supervision of clinical therapists or integrated into the therapeutic process with freelance therapists. The technology platform can already be introduced during the treatment in rehabilitation centers to help patients familiarize themselves with it. It is always the therapist’s decision whether and when teletherapy (in which rehabilitation phase) is appropriate.

The technology platform consists of the following components: a tablet and an Android app for patients, a web-based user interface for therapists, a backend that enables data exchange and storage, and a device for hand and finger rehabilitation (TYROMOTIONPablo (TYROMOTION, Graz, Austria https://tyromotion.com/en/products/pablo/ (accessed on 12 August 2024)). The technology platform offers different possibilities to support rehabilitation and training processes and has six main functions:

1.

Patient data administration: Therapists can administer patient data, such as personal information, anamnesis, or assessments, and then define the therapy goals. Patients can view their personal data and their current therapy goals on the tablet.

2.

Exercise program: The core feature of the technology platform is the planning and instruction for performing exercises (incl. Pablo). Therapists can create exercise programs with descriptions, pictures, or videos and individualize these (duration, sets, repetition) for each patient. The exercise programs are scheduled in the patient app calendar. For the serious game with Pablo, the therapist can set the game level, time, and force level (of maximum grip force)

3.

Activity monitoring: Statistical data and visualization of conducted exercises, success rate (games), or measured parameters (e.g., grip force from Pablo) are displayed on the patient’s user interface and, with more details, also on the therapist’s user interface, to show the history and the progress of conducted exercises. The data are transmitted to the therapist’s interface after the exercise has been completed. The check whether an exercise has been performed correctly takes place via video call and the visual assessment from the therapist.

4.

Communication: A video call function (with QuickBlox) has been implemented for synchronous teletherapy sessions. The patient and therapist can also use a chat for asynchronous communication (e.g., scheduling or postponing an appointment).

5.

Feedback and diary: Before and after performing exercises, the patient is asked to give feedback on the daily condition. Additionally, a private diary is available for the patient. The content of this diary is not visible to the therapist.

6.

Therapy reporting: The therapist’s platform also offers a documentation tool for progress reporting and also to report possible complications or side effects of the training.

To supplement the technology platform with an additional therapy device, requirements for an appropriate device that can be used at home were gathered in several workshops with therapists and physicians. Based on the results, Pablo was selected because it is easy to use and well-established in individual therapy and group therapy settings. Furthermore, it is safety-certified and fulfills all requirements like ease of use and patient training. As the device is usually used in a supervised setting, efforts have been made to enable the use of the device in an unsupervised home setting. To overcome the challenge of setting the correct force in autonomous usage of a technology-assisted therapy at home, the gold standard of hand force measurement (standardized measures with a hand dynamometer) was transferred to a digital level using the Pablo. With this combination of an existing standardized procedure in everyday clinical practice and the therapist’s inputs, an easy-to-use measurement procedure for the patients was set up. The hand force measurement has been integrated into the patient interface, and the graphic output has been optimized accordingly. A serious game that could be controlled with Pablo was implemented in the app [15].

2.1. Test Settings and Participants of the Feasibility Study

The study aimed to evaluate the feasibility of the telerehabilitation service model and the technology platform in a real-life context to receive feedback on integrability and user experience. The study did not aim to evaluate the rehabilitation outcomes in a controlled study setting or to compare the impact of different types of interventions. All interventions that were conducted, including assessments and outcome measures, were defined by each therapist individually and were left to their responsibility.

The trial was conducted in three test sites—two in Austria and one in Slovenia—representing the most common cases of providing rehabilitation. For Austria, this was the clinical setting with post-stay ambulant treatment and the freelance therapy setting with a freelance occupational therapist. In Slovenia, post-clinical aftercare was conducted at a rehabilitation institute. The tests lasted four to ten weeks, depending on therapy needs, test setting, and thus different service models in the clinical-ambulatory and freelance contexts. One fundamental property of the proposed system is the flexibility in setting up the therapeutic process and the adaption to different settings. As the proposed business model for the post-stay ambulant treatment suggests 4 weeks of telerehabilitation and a classical therapy cycle in the occupational therapist freelance setting is about 10 weeks, these durations were used for the study. An overview of the test sites is shown in

Table 1. Overview of test sites.

Country	Setting	Patients	Therapists	Duration
Austria	Freelance therapist, Carinthia	1 patient	Occupational therapist	10 weeks
Austria	Clinical aftercare, Private Clinic Laßnitzhöhe	2 patients	Occupational, physio, speech therapists	4 weeks
Slovenia	Clinical aftercare, University rehabilitation institute Republic of Slovenia	1 patient	Occupational, physio, speech therapists	4 weeks

.

2.2. Recruitment

The therapists were selected and recruited by two clinics that were partners in the project. Physical, occupational, and speech therapists participated in the study. To recruit the freelance therapist in Carinthia, a public announcement was shared on different channels (social media, work groups of therapists). The following inclusion criteria were used to recruit the therapists:

• Permission to practice as a therapist in the respective country (Austria or Slovenia)
• Access to a PC with internet access, incl. a webcam and microphone
• A current therapeutic relationship with stroke patients

The following exclusion criteria were applied:

• Lack of willingness to use digital media (e.g., video telephony).

The patients in the clinics were recruited by the therapists in coordination with other health professionals from the clinics. In the freelance setting, the therapist and patient were recruited together as a dyad (they were already in an established therapist-patient relationship). Participating patients were selected by the following inclusion criteria:

• Stroke diagnosis: the patients suffered a stroke and were in the subacute or chronic rehabilitation phase
• Able to use a tablet: the physical and cognitive ability to use a tablet; preparation of the tablet (e.g., placing the tablet on a stand on a table) can be performed by a caregiver or relative
• Referral from a medical doctor/physician: as the legal basis for the treatment of the patients by the therapists, a referral was needed
• Mobile internet connection at home (at least 3G): An internet connection is necessary for the usage of the platform; the provided tablet was equipped with a SIM card
• The current therapeutic relationship with the therapist: to ensure that the meeting phase between therapist and patient was not a hurdle and could bias the training phase, it was a prerequisite that the patient had already been cared for by the therapists
• Center of life in the private home setting: exclusion of patients living in a long-term care facility, elderly home, etc.

The following criteria were applied to exclude patients:

• Limitations in motor function of both arms/hands: at least one hand must have had the ability to control a tablet
• Severe communication impairment: the patient’s communication skills had to be available to the extent that feedback on how to use the platform as possible
• Severe hearing impairment: the patients’ hearing ability had to be sufficient for them to understand instructions
• Severe visual impairment: adequate visual ability was a prerequisite to use the tablet; slight or medium visual impairments such as short-sightedness were not a reason for exclusion
• Moderate-high dementia: the cognitive abilities of the patient must have been sufficient to understand the therapy instructions and to give feedback in the study
• Lack of compliance in previous therapies: patients who showed a lack of compliance already in therapies prior to the study were excluded

2.3. Data Collection

Data collection was split into usage data and questionnaires administered before and after (4–10 weeks) the technology usage. The pre-questionnaires were answered by the participating patients and therapists, and the post-questionnaires by patients, therapists, and, if applicable, also by relatives. The questionnaires were filled partly by the participants themselves (Likert scale questions) and partly by the researchers (open questions). The researchers noted the participants’ replies with pen and paper. Figure 1 shows the study process and data collection.

2.4. Pre-Questionnaires

The pre-questionnaire comprised demographic data, affinity for technology, and questions about the therapy, experiences, and expectations with telerehabilitation. The affinity for technology interaction scale [16] was used in the short form for patients (four items) and the long form for therapists (nine items). The last part of the pre-questionnaire consisted of six questions for patients and seven questions for therapists and dealt with experiences with telehealth, information about prior therapy (number of sessions, time spent on therapy, costs, travel time to sessions, training at home), and expectations with the technology. The pre-questionnaires can be found in S.1 and S.3 in Supplementary Materials.

2.5. Post-Questionnaires

The post-questionnaire consisted of two parts. A comprehensive questionnaire for patients and therapists assessed the system’s usability. It contained the following categories: usefulness, ease of use and learnability, interface quality, interaction quality, reliability, satisfaction, future use, and intention to use, based on the TUQ [17]. The intention to use questions originated from the Technology Usage Inventory (TUI) [18]. The format was a 7-point Likert scale, where one indicated “completely disagree” and seven signified “completely agree.”

The second part consisted of open questions, different for patients, therapists, and relatives. For patients, twelve questions addressed the experience with the combined therapy concept (therapy with the platform, potential obstacles, motivation, advantages, willingness to pay, and therapy progress).

For therapists, twelve questions focused on the user experience (e.g., system evaluation, obstacles, most used features, advantages, and disadvantages) and organizational aspects of the therapy, such as the number of therapy sessions per week and integrability into daily work life with the time needed to learn to use the system, evaluation of the quality of teletherapy sessions compared to standard therapy, or preparation of exercises. Furthermore, four patient-related questions were asked (patient exercised more or less, patient’s motivation, the therapist’s rating of the system, and overall satisfaction).

Relatives who supported the patient in using the technology platform were asked four questions on demographic data and ten questions on their support in using the technology platform. The post-questionnaires can be found in Supplementary Materials S.2, S.4, and S.5.

2.6. Data Analysis

The questionnaires were transferred into a digital format and analyzed using descriptive statistical methods. Technology affinity was assessed based on the description of the Affinity for Technology Interaction Scale [16]. The responses were first coded on a six-point Likert scale (completely disagree = 1, …, completely agree = 6), negatively worded items were reversed, and a mean score for every participant was computed. Additionally, mean scores for both patients and therapists were calculated for the seven categories. Similarly, the usability questionnaires were translated, and mean values for each patient and therapist were calculated. Subsequentially, the overall means of the categories for patients and therapists, with the standard deviation, were calculated. All data analysis was performed using Microsoft Excel (Microsoft Excel Version 2108, Microsoft, Redmond, WA, USA).

Qualitative data were digitalized and translated into English. The content was categorized depending on the particular questions either in certain aspects (e.g., the expected usage of face-to-face or synchronous therapy) or positive or negative associations with the usage of the technology platform. The results of the qualitative questionnaires were then summarized. Data analysis was performed using MAXQDA, (MAXQDA Version 24, VERBI GmbH, Berlin, Germany).

3. Results

In total, four patients and seven therapists were recruited to participate in the study. One patient was excluded from the data analysis because he barely used the system due to private circumstances. Therefore, only the results of three patients are considered for the data analysis. Pablos was provided for those three patients. One patient trained only once with Pablo because the therapist decided to use other exercises for the patient. That’s why Pablo-related data analysis was only performed from data of two patients.

As shown in

Table 2. Demographic Data and ATI Scale of Participating Patients.

Patient	Usage Duration	Treated by	Setting	Age	Gender	Pablo Used	Technology Affinity
Patient 1	4 weeks & 2 days	Occupational, Speech, Physio	Post-clinical Slovenia	42	m	Yes	2.75
Patient 2	3 weeks & 3 days	Occupational, Speech, Physio	Post-clinical Austria	55	m	Yes	3.25
Patient 3	10 weeks & 3 days	Occupational	Freelance Austria	60	m	Yes	3.00
				52.3 (sd = 9.29)			3.00 (sd = 0.25)

, the participating patients were, on average, 52.3 years old, and all were males. The average technology affinity was 3 (with 6 indicating the highest possible technology affinity). One patient reached a technology affinity of 3.25, whereas the patient with the lowest technology affinity had 2.75. The relatives of the two Austrian patients who supported them using the system were included in the study.

The participating therapists are listed in

Table 3. Demographic Data and ATI Scale of Participating Therapists.

Therapist	Setting	Age	Gender	Technology Affinity
Occupational	Clinic	61	f	3.78
Speech	Clinic	32	f	4.22
Physio	Clinic	50	f	1.89
Occupational	Clinic	25	f	4.33
Speech	Clinic	33	f	4.56
Physio	Clinic	35	f	6.00
Occupational	Freelance	40	m	4.33
		39.4 (sd = 11.35)		4.16 (sd = 1.13)

The average age of the therapists was 39.4 years; six of them were female and one male. The mean technology affinity was 4.16, which indicates a slightly higher technology affinity in the therapists than in the patients. One therapist had the highest possible technology affinity of 6, and the lowest value was 1.89.

3.1. Usage of the System

The total number of exercises performed per patient ranged between 112 and 299. Figure 2 shows the number of performed exercises. Notably, the last week for all three patients consisted of only 2–3 days. Therefore, the number of exercises was lower for all patients. Initially, the number of exercises performed was relatively less for all patients but higher in the next few weeks. The patients performed more than 20 exercises each week except for the beginning and last uncompleted week.

Furthermore, all patients used the Pablo frequently. A peak in frequency occurred at the beginning, followed by a drop where it remained at a constant high level. In total, patient 1 performed 26 Pablo exercises, and patient 3 performed 58 exercises.

3.2. Usability of the System

The mean usability score for the therapists was 5.03, and for patients, it reached 6.16 (1 indicating poor usability, 7 indicating best usability) (Figure 3), suggesting a generally favorable perception of the system’s usability across both groups.

The exact mean values of the categories are displayed in the table below

Table 4. Usability Comparison between Therapists and Patients.

	Usefulness	Ease of Use and Learnability	Interface Quality	Interaction Quality	Reliability	Satisfaction and Future Use	Intention to Use
Mean-Therapists (n = 7)	4.9	6.0	5.3	5.1	3.4	5.5	5.0
Mean-Patients (n = 3)	5.9	6.9	6.7	6.3	4.6	7.0	5.8

. The highest rating by patients was given to satisfaction and future use, where all patients gave the system the highest possible score. The lowest rating from the patients and the therapists was given to the reliability of the system. The therapists, on average, did not rate any category above six, with the highest rating for ease of use and learnability.

3.3. Pre-Questionnaires

In the pre-questionnaires, patients and therapists reported their expectations related to the therapy and training with the technology platform and their plans to set up therapy sessions and exercises. All three patients expected improvements in their motor or speech skills, increased training motivation, and more training at home with the technology platform. From the therapist’s point of view, five of seven therapists expected the therapy progress of the patients. The therapists also expected high motivation from the patients and that the system help them to support the therapy process and to offer a variety of therapies (through different exercises).

3.4. Post-Questionnaire for Patients

The three patients reported that the most used features of the technology system were the exercises and the calendar to view the scheduled exercises and appointments. The training to learn to use the system was sufficient for the patients, and support was mainly provided by the therapists. Two patients reported having trained more with the system, and one reported having approximately trained the same amount. Similar to this was the patients’ motivation, where two stated that the system motivated them to train more, and one patient estimated his motivation to be as high as that without the system.

When asked about the quality of the therapy with the system compared to conventional (face-to-face) therapy, all patients stated that they perceived the quality of the therapy via the tablet as worse compared to face-to-face. The reason for this is the need for more efficiency and supervision during video calls. The system was rated positively as an addition to conventional therapy. Integrability in daily life was rated good by all patients as there was no effort to use the system. The advantages for the patients of the combined therapy concept (face-to-face, video calls, asynchronous training) were the possibility to contact therapists and have supervision, less traveling, and more motivation through different exercises. Patients who also used the Pablo reported an increased motivation through its integration into therapy and training.

In general, the three patients were very satisfied with the telerehabilitation concept. Two of them experienced good therapy progress with improvements in different areas, and one patient reported no therapy progress.

3.5. Post-Questionnaire for Therapists

The therapists positively mentioned the video call function and the possibility of treating patients after the clinical stay. The most criticized point by the therapists was exercise preparation. It took them a lot of time to implement exercises in the system, and it was not possible to automatically include exercises from PDF files.

The most used features of the system were exercise creation for the patients, activity monitoring, and the video call function. The therapists learned to use the system in less than two hours. Six of the therapists reported that the instruction to the system was sufficient (note: it was about 1 h of instruction). The introduction of the system to the patients took approximately 0.5–1 h and was sufficient, according to the therapists.

The quality of the combined therapy concept compared with conventional therapy was rated as good, with quality improvements through the possibility of treating the patient after discharge from the clinic. It was also clearly mentioned that it is still necessary to hold face-to-face sessions as these cannot be replaced by video calls alone.

Asked about the practicability of the combined therapy concept in daily work, the therapists clearly stated that it would be necessary to have extra time for this kind of treatment. Positively mentioned were time savings compared with conventional therapy. The preparation of exercises was the most time-consuming task. However, it offers the potential for exercises to be used for multiple patients, leading to much more efficient exercise planning. In general, the combined therapy concept could lead to a more efficient treatment of patients by using asynchronous training and video calls, according to five therapists.

Five therapists mentioned the possibility of aftercare treatment at home as the main advantage. Further advantages mentioned by single therapists are higher motivation, an easy-to-use system, the inclusion of the home setting in the therapy, time-saving due to less traveling, a combination of face-to-face and synchronous therapy, and the possibility to adjust the therapy easily. The greatest disadvantage mentioned by four therapists is the lack of control during the patient’s training (correct movements, changes in the patient’s state).

All therapists stated that their patients definitely trained more with the system than without it. Estimations of some therapists reached up to twice the training frequency with the system. All therapists except one saw the tablet with the exercises as a significant motivating factor for the patients to continue their training and exercise. Regarding Pablo, therapists stated that motivation increased in their patients. Positively mentioned was the activity monitoring, where the performance of the patients was visible and supported tracking the progress.

3.6. Post-Questionnaire for Relatives

From the two relatives participating in the study, one relative actively supported the training, especially in speech exercises, and one relative stated that no active support was necessary but was there when questions occurred. The time for traveling to face-to-face meetings was lower because of the synchronous therapy, and thus, there was less pressure. Both relatives stated that they recognized a higher motivation of the patients and saw positive effects, e.g., that the patients were reminded to do regular exercises.

4. Discussion

The results of the presented study show that the proposed telerehabilitation platform is rated as a useful and user-friendly solution by both patients and therapists after a stroke. The usability scores showed overall good results, with slightly better ratings from the patients. Only the reliability was rated average by the participants. The participants in the study—three patients and seven therapists—showed average technology affinity according to the Affinity for Technology Interaction Scale, with slightly higher technology affinity in the therapists.

The most used features by the patients who used the platform were the exercise and the calendar functions. Patients reported good integration of the platform into daily life routines as it was easy to use. Patients further stated that they trained more with the platform and were more motivated.

The most used features by the therapists were the exercise preparation, activity monitoring, and video call functions. The integrability in daily work life was average due to the time-consuming exercise preparation. All therapists estimated that their patients trained more with the platform.

Furthermore, the study showed that telerehabilitation does have undeniable benefits, especially for patients, but it also offers new possibilities for therapists. Although the quality of synchronous therapy was rated worse compared to conventional face-to-face therapy, the possibility of having additional ways of providing therapy and training was mentioned positively by the participants of the study.

Due to the service model of rehabilitation clinics, where the service delivery is solely based on therapy sessions with patients within their stay at the clinic, treatment after their discharge from the clinics goes along with uncertainties in how this service can be implemented. However, exactly this contact with the patients beyond their inpatient stay was mentioned positively, especially by the therapists of the Slovenian clinic, as there is a possibility to guide and treat patients in their transition from the clinical to the home environment. Similarly, Nuara et al. suggested the usage of telerehabilitation as an addition to the current rehabilitation process to ensure continuity of care, longer support, and long-term functional improvements [19]. Nonetheless, for therapists using telerehabilitation, it is necessary to perform novel tasks that require different competencies, which should be considered in the adoption of telerehabilitation [20].

Obstacles found in literature, like the disadvantage of different technologies needed [11], were partly dissolved by the system as it offers an all-in-one solution for patients and therapists. The system, together with the service model, combines different forms of therapy (face-to-face therapy, synchronous teletherapy) and training (asynchronous) and offers many possibilities and support throughout the therapy process. Face-to-face therapy describes the conventional therapy setting where the patient and therapist meet in person, either at the practice of the therapist or at the home of the patient. This type of therapy offers all possibilities for the therapist in terms of physical measures and live supervision of services. Synchronous teletherapy is the meeting of therapist and patient via a video call. This offers the possibility of anamnesis, therapy planning, and progress checks but is limited in terms of exercise supervision and lacks physical measures. Asynchronous training means the patient is trained without the live supervision of the therapist. The platform records data from the training (e.g., conducted exercises, training duration, Pablo Stats, etc.) that can be reviewed by the therapist afterward. Combining these three forms of training and therapy in one platform offers flexible rehabilitation possibilities for both the patient and the therapist. Findings in the literature show the importance of manyfold possibilities and benefits for patients and therapists in telerehabilitation, like flexibility in the location of therapy, different types of interventions, and new feedback possibilities [21]. This is especially important as patients, in general, appear to be worried about less involvement of therapists and a lack of guidance in telerehabilitation [22], which again underlines the benefit of a combined concept with different possibilities of therapy administration and patient-therapist interaction.

A concern raised in other studies [11] was the limited quality of teletherapy compared to conventional therapy. This disadvantage was also found in this study, where therapists and patients expressed a higher quality of face-to-face therapy. Reasons for this are the missing control and supervision during synchronous sessions and the lack of efficiency. Nevertheless, the proposed combined therapy concept addresses this issue by offering flexible planning of face-to-face and synchronous sessions.

The perceived endorsement and support by peers (subjective norms) for integrating technologies into daily routines strongly impact acceptance [4]. This can also be seen in this study, as therapists and relatives were the first contact points for (technical) support. The integrability in conventional structures can impact product acceptance [5]. The current study showed that telerehabilitation is a great addition to conventional therapy, especially in clinics, but that integration in existing structures holds obstacles.

The Austrian healthcare system, with patients treated in a freelance setting, seems to be a better fit for offering telerehabilitation as it can be integrated better into the working structures. For clinics, telerehabilitation must be offered additionally when considering the current structures. Thus, changes in the Slovenian therapy provision system would be necessary to offer telerehabilitation. Extra time for therapists in the clinics would be needed to offer treatment beyond the stay in the clinics.

A limitation of the study was implementing the combined therapy concept (face-to-face, video calls, asynchronous training) in the clinics. Most of the therapy took place via video calls, and the most used feature was the exercises. Thus, statements on the quality of this concept were directed towards remote therapy only, which is less effective than on-site therapy. Furthermore, the therapists did not use video calls as therapy sessions but rather as update meetings and questions.

A further limitation of the study was the small number of participants. As the platform was newly developed, an initial test in a real-life setting was intended to give first insights into practicability, integrability, and acceptance. Additionally, the duration of the study centers differed due to the different characteristics of the service model (post-clinical vs. freelance setting). These differences might impact the evaluation of the participants, but it was necessary to test the system in different settings.

Further studies are needed to prove the effectiveness of the combined therapy concept of face-to-face, synchronous, and asynchronous sessions and to elaborate deeper on the aspects that lead to high acceptance and, thus, usage in the field.

5. Conclusions

The presented study showed promising results regarding the acceptance and integrability of a newly developed telerehabilitation platform and service model for patients and therapists. Overall, the patients stated that telerehabilitation is a good addition to conventional therapy, although the quality of online therapy is lower than face-to-face therapy. The therapists reported that the system was easy to use but had some obstacles in exercise preparation. The integrability in daily life was good, according to the patients. For the therapists, integrability was average, as the test showed some obstacles in providing services beyond the clinical setting. In general, the proposed telerehabilitation service model and technology platform proved to be a promising concept to support rehabilitation. Advantages for patients are undeniable, for example, reduced traveling times to therapists, increased motivation, monitoring of exercise conduction, or the sole possibility of receiving treatment after clinical rehabilitation. For therapists, the newly developed approach enhances the possibilities of offering therapy, although the approach is not equally integrable in different settings.