Barriers and facilitators to telerehabilitation implementation: a mixed-methods study of German physiotherapists

BACKGROUND: The COVID-19 pandemic accelerated telehealth service adoption in physiotherapy, including telerehabilitation (TR). However, the extent of TR use and factors influencing its implementation in Germany remain unclear. This study aimed to evaluate TR use in physiotherapy (during COVID-19 lockdowns, current use, future intentions, conditions treated, content, setting, and session type) and identify barriers and facilitators from physiotherapists' (PTs) perspectives. METHODS: A mixed-methods sequential explanatory design was employed, combining a cross-sectional online survey (n = 152) with two focus group interviews (n = 9). The survey collected data on demographics, TR use, barriers, and facilitators. Focus groups explored themes emerging from the survey in greater depth. Data were analyzed using descriptive statistics and content analysis, integrating quantitative and qualitative findings. Quantitative and qualitative findings were integrated through explanatory linking and joint display in a comparative analysis table. RESULTS: TR use peaked during COVID-19 lockdown (32.26%) but decreased to 18.06% by October 2022, with 26.45% intending future use and 43.87% considering it. Among TR users, musculoskeletal conditions were most commonly treated (75%), followed by sports (38%), pulmonology (33%), and neurology (27%). The primary barrier was lack of physical examination (74% agreement). While technical challenges were not reported as a major barrier in the survey, interviews revealed significant concerns about insufficient internet bandwidth and technical infrastructure. Common reasons for using TR included promoting patient self-management (78% agreement) and broadening therapy options (69% agreement). Qualitative data identified additional implementation facilitators, including structured implementation processes, appropriate technical infrastructure, and patient involvement in decision-making. CONCLUSION: While TR implementation in German physiotherapy shows growth potential, several barriers currently limit its adoption. Successful implementation requires addressing PTs capabilities, knowledge gaps, professional identity concerns, and environmental factors. Addressing these issues could enhance patient care quality, increase service accessibility, and advance healthcare delivery models.