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PhD Defense Karlijn Cranen

Acceptance of telerehabilitation in chronic pain: the patients’ perspective

Karlijn Cranen is a PhD Student in the research group Biomedical Signals and Systems and the research group Health Technology and Services Research. Her supervisors are prof.dr. M.M.R. Vollenbroek-Hutten from the faculty of Electrical Engineering, Mathematics and Computer Science and prof.dr. M.J. IJzerman from the faculty of Behavioural, Management and Social sciences.   

In addition to the physical and emotional burden that chronic pain brings, it gives rise to significant health care costs. The use of telerehabilitation, providing remote care via communication technologies, is expected to offer several advantages over conventional clinic-based rehabilitation because it affords patients to rehabilitate within their own social environment. However, despite the great potential of telerehabilitation, its intended benefits will only be realized when these treatments are accepted and used by patients as fully fledged alternatives to conventional care. Therefore, an understanding of patients’ reasons for accepting or refusing telerehabilitation is crucial.

The aim of this thesis is to identify drivers and barriers related to patients’ acceptance of exercise-based telerehabilitation for chronic pain. This will provide more insight into strategies that may improve telerehabilitation design and as such can facilitate the uptake of prospective telerehabilitation services.

In this thesis, acceptance of telerehabilitation is considered a dynamic process, since it is presumed that acceptance and underlying beliefs are likely to change as patients gain knowledge of and experience with telerehabilitation. In the first two studies, acceptance of telerehabilitation services was measured of patients with no prior experience with such services. During the third study, patients’ acceptance was analysed before and after brief exposure to a telerehabilitation service in an experimental setting. In the last two studies a group of patients was subjected to a telerehabilitation service that was actually implemented and used during their chronic pain rehabilitation program, and their acceptance behaviour was investigated.

It is concluded that alongside patients’ characteristics (e.g. exercise motivation and pain catastrophising behaviour), patients’ attitudes and perceptions of perceived usefulness, as well as internal and external constraints are important drivers/barriers of patients’ acceptance for telerehabilitation. Since, in line with our presumptions, these perceived drivers and barriers regarding telerehabilitation appeared to change with patients’ experience, patients’ acceptance should not be considered static but dynamic. Offering patients the possibility to gain experience with telerehabilitation prior to their decisions to use these treatments, as well as monitoring and addressing patients’ perceptions during use are considered promising strategies that need further exploration. Although patients seem to value certain benefits of telerehabilitation (e.g. the possibility to acquire exercise skills at home and have flexible exercise times), we also conclude that it is important –in order to facilitate patients’ acceptance– to take into consideration patients’ needs for immediate performance feedback and therapist face-to- face contact, as well as their needs for emotional and motivational support. To address these needs, the implementation of a ‘blended’ care model, i.e., a combination of telerehabilitation and conventional rehabilitation is recommended. This allows for the incorporation of face-to-face contact with the therapist, the opportunity to exercise in a clinical environment and the inclusion of remote monitoring and feedback technology; these features were found to be principal driving forces for patients’ acceptance of telerehabilitation. Further research is necessary to establish to what extent different approaches, such as the use of virtual communities, (movement) tracking sensors, virtual reality, motivational and persuasive strategies, and the integration of psychological counselling, constitute effective means to address patients’ needs. Furthermore, future studies are necessary to provide insight into the ideal combination of telerehabilitation and conventional care and to understand how this combination may vary over time.