Keywords

1 Introduction

Countries worldwide face challenges linked to population ageing. This demographic trend, coupled with increasing chronic diseases and mental problems poses significant social challenges. Both the active-age and senior citizens’ health and functional ability need to be supported to lessen the growth in health care costs and thus to ensure the economic and social sustainability of societies. Therefore, there is an increasing need for effective physiotherapy measures, firstly using early rehabilitation before individuals experience debilitating problems, and secondly to alleviate the inevitable later symptoms and functional capacity problems [1–3].

The tendency toward digitalization and greater role of remote techniques in rehabilitation requires new approaches on rehabilitation research. Compared to traditional face-to-face rehabilitation remote rehabilitation, relying to a greater extent on digital technologies, increases the significance of rehabilitees’ own commitment and technological skills. This type of change in the rehabilitation paradigm calls for a deeper understanding of those factors which support the rehabilitees’ sense of purpose in their efforts to work towards recovery and thus trigger intrinsic motivation. Consequently, the scope of the current mainstream rehabilitation research should be supplemented with more research on broader biopsychosocial, cultural, environmental, or artistic aspects of the rehabilitation process. Typical rehabilitation studies focus on testing the outcomes and short-term effectiveness of a single rehabilitation technique and some- times just on one group of rehabilitees suffering from a single functionality impairment [4–6].

Even in the most recent policy reports, which cover activities in rehabilitation, the medical aspects have the primary role [7–9]. The organization of health and social services are currently at a watershed moment in Finland. In 2023, the organization of health and social services have been transferred from the responsibility of municipali- ties to 21 wellbeing services counties [10]. As part of this extensive change, it is im- portant to research and develop the use of digitalization and remote technologies even in physiotherapy, and in such a way that individuals’ sense of human dignity and meaningful life is preserved during the rehabilitation process.

In future we urgently need an open-minded approach to new technologies to ensure human resources, develop more personalized services, maintain sound public finances, alleviate sustainability crisis, and all-in-all respond to the variable challenges posed by ageing societies [11]. It is important to develop digital solutions which are useful, efficient and sustainable. During the process, rehabilitees’ and rehabilitation staffs’ attitudes and opinions should be taken into consideration [12, 13]. For example, our recently published study indicated that, 75% of Finnish physiotherapists reported that they used mainly conventional physiotherapy, and remote physiotherapy is still minimally used as the primary working method at different stages of the physiotherapy process [14]. According to physiotherapists, remote rehabilitation techniques are least suit- able for neurological rehabilitees [15], even though they are a group of rehabilitees who are in most need of very intensive therapeutic training as well as guidance, counselling and support in their everyday life [5, 16–18]. Development of rehabilitation platforms, rehabilitation applications, telemedicine solutions and even digital twin solutions are rapidly increasing [19]. There is a lack of digital and remote technology solutions which are rehabilitee-centered, holistic and reflect the biopsychosocial model of rehabilitation for use in neurological physiotherapy. For example, the main contents of commercial models for MS rehabilitees are still narrowly focused on medical care [19, 20], medical aspects of self-care [19, 21], physical activity [19, 22, 23], or self-management [19, 24].

Non-compliance with various therapies and treatments in chronic diseases is a worldwide problem of striking magnitude, making this a critical issue in population health both from the perspective of life quality, and health economics as well as of health system effectiveness [1]. The same problem concerns also home exercise that shows low adherence (as low as 50%), potentially having detrimental effects on clinical outcomes. Some studies highlight that well-designed health technologies provide us with the opportunity to better support both the patient and clinician. Of significance is a data-driven approach that incorporates features designed to increase adherence to exercise, such as coaching, self-monitoring and education, as well as the ability to re- motely monitor adherence rates more objectively [25]. However, a recently published meta-analysis showed that technology assisted self-rehabilitation (remote coaching, self-monitoring, education, and adherence) did not appear to have a significant effect on the outcomes [26]. So, as far as we can conclude, commitment and adherence in self-rehabilitation context is still an unresolved problem in remote physiotherapy [25–28].

The goal of this research was to create a rehabilitation model that aims at sustaining the sense of meaningful life and human dignity in physiotherapy, potentially having positive effects on rehabilitees´ commitment and adherence when using remote and digital rehabilitation technologies. The focus was on people with cerebrovascular accident (CVA) or multiple sclerosis (MS).

2 Materials and Methods

CVA and MS rehabilitees are very suitable study populations for the purpose of this study. CVA and MS have an impact on persons’ physical, psychological, social, and cognitive functioning, affecting their daily life activities, participation, and quality of life. In addition to the affected individuals, CVA and MS also place a considerable burden on their families, caregivers, and in overall on the entire society [29, 30]. Since 1990, the prevalence of CVA has increased over 70% worldwide in less than 30 years [31]. Each year, approximately 1.1 million Europeans suffer a stroke, and in 2020 there were an estimated 9.5 million stroke survivors in Europe [32, 33]. By 2030, the stroke prevalence is expected to rise by 35% [34]. An increasing trend can also be seen in people with MS showing a 30% increase from 2013 to 2020 worldwide [35].

This study is a secondary analysis using thematic analyses and inductive synthesis of detected meanings in the materials [36], considering both the results of rehabilitee experiences of meaningful physiotherapy and the results of the experiences in using rehabilitation technology. The primary analyses have been produced as part of our previous line of research using two extensive systematic literature reviews (publication dates extending from Jan. 2001 to Nov. 2017), the first one focusing on CVA rehabilitees and the second one on MS rehabilitees.

The reviews included 50 qualitative studies in total (711 rehabilitees) [16, 17]. The literature search of qualitative studies was conducted from the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (Ovid MEDLINE), and the Education Resources Information Center (ERIC). In addi- tion, the searches were supplemented with manual and reference searches. According to the qualitative PICoS framework, the inclusion criteria were adult CVA and MS rehabilitees (age ≥ 18 years) (P = population or problem, i.e. patient). Our focus of interest was on rehabilitees’ views, perceptions, and experiences of physiotherapy (I = interest). In the literature search, the content of physiotherapy was not limited, and different methods, practices and operating environments of physiotherapy used in Finnish physiotherapy were accepted (Co = context). All original studies conducted using a qualitative research design (S = study design) were included. Studies published in English, Swedish, German and Finnish were accepted as data.

The original idea of the study was to use the literature reviews to investigate reha- bilitee experiences of meaningful physiotherapy. The analysis of the systematic litera- ture (CVA/MS) review data was conducted in five phases: 1) Classifying and summa- rizing the study results according to the PICoS criteria and main results, 2) narrative synthesis of the results [cf.37], 3) constructing lower and upper themes of meaningful experiences [cf. 38], 4) metasynthesis of qualitative research results by rehabilitee-specific (CVA/MS) groups, and 5) combining both rehabilitee groups [cf.38]. The stages of the analysis were carried out as triangulation by two pairs of researchers [16, 17].

The results of our primary research have been published in Korpi et al. 2022 [16], Sjögren et al. 2022 [17, 18]. These results have served as the materials for our secondary analysis, which we have divided into three phases. For the first phase of the analysis, we have focused on the rehabilitee experiences of meaningful physiotherapy and re- classified the findings in such a manner that we can create a coherent synthesis (i.e., phase three) when combined the outcomes with the outcomes of the second phase. For the second phase, the sense of meaningfulness in physiotherapy was examined from the perspective of rehabilitation technologies, including remote technologies. Technology use in rehabilitation was not a specific issue in our primary study, but it frequently had come up as part of the experiences tackled by the rehabilitees. These data were analyzed following a standard thematic content analysis process [cf.38]. For the third phase, we have integrated the main results of the previous secondary analysis phases to create a theoretical model as a synthesis of this study. The model is expected to provide tools for sustaining the sense of meaningful life and human dignity in physiotherapy for CVA and MS rehabilitees, particularly when using digital rehabilitation technologies and techniques of remote physiotherapy.

The key concepts used throughout this study are human dignity and sense of mean- ingful life. Human dignity has generally been identified as a concept or phenomenon intertwined with human rights [39] or defined in several various ways [40]. From the perspective of physiotherapy science or rehabilitation we have not tied the concept of human dignity with any single human characteristic (e.g., gender, functional ability) or operational environment (e.g., clinical work). Our perspective is more linked to the general idea that every individual holds a special value that is tied with their humanity. In our research context, human dignity means that during physiotherapy rehabilitation rehabilitates should be treated in such manner that their individual human value and basic human rights, needs and wishes are consistently respected. The sense of meaningful life, in turn, can be associated with, e.g., safety, dependency, flexibility and one’s physical and social world [41].

The entire process of secondary analysis was carried out using researcher triangulation conducted by the authors. At first, the researchers worked independently by adding the relevant factors of a meaningful physiotherapy process and the use of technology in the same context to the framework originating from the primary analysis (“meaningful experiences of physiotherapy”). Secondly, the researchers formed a consensus over the results by discussing as well as by forming the principal essential prerequisites for meaningful physiotherapy, also focusing on the use of digital and remote technologies.

3 Results

Our secondary analysis confirmed that the most fundamental generic elements in physiotherapy, based on the interpretation of the rehabilitee feedback (mostly interviews), should be preservation of meaningfulness in life and maintenance of human dignity. These elements were primarily reinforced by treating the rehabilitees as individuals, respecting their independence and freedom of choice, promoting their participation in ordinary life, and ensuring that they could preserve faith and hope for the future (see the middle sections in Fig. 1).

Fig. 1.
figure 1

Technology assisted personalized physiotherapy model: The Human Dignity Centered Rehabilitation approach

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Striving for the above listed goals requires a physiotherapy model, which takes into account the following seven factors related to the content of physiotherapy treatment:1) Improving self-confidence, 2) strengthening psychological and cognitive wellbeing, 3) maintaining the meaningfulness of rehabilitation, 4) using reflective discussions to overcome rehabilitation linked challenges, 5) conducting a fair and professional rehabilitation process, also recognizing the need for a holistic biopsychosocial approach to rehabilitation, 6) enabling improvements in body awareness/image, physical functioning and physical activity as well as accessibility, and 7) enabling empowerment through dynamic interaction with others. Table 1 is a concise presentation of all these factors, which have been derived from the systematic literature review data using the applied qualitative analysis approach.

Table 1. Rehabilitees´ experiences in physiotherapy focusing on the elements of human dignity and sense of mea`xningful life.
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Keeping in mind the key generic elements of rehabilitation, the process should sup- port the sense of meaningful life and respect rehabilitees’ human dignity, even when conventional physiotherapy is supplemented with remote and digital physiotherapy technologies. Such technologies pose obvious challenges, particularly in terms of pro- fessionals’ competence requirements, but our results show that digital and remote technologies can also open a window for new opportunities, supposing that the technological solutions are innovative and fit for people facing various disabilities (see Table 2). Such technologies could enable rehabilitees’ self-management, ensuring their autonomy, flexibility, and progressive ownership of the rehabilitation process. Rehabilitation technologies could also offer opportunities for equal dialogue, easy communication and fast contact with rehabilitation professionals thus empowering an equal, professional, comprehensive, and fair rehabilitation process. The important elements of (digital) technology assisted physiotherapy consist of the following issues: 1) Motivation and commitment support, 2) enablement of social interactions and social relationships, 3) design of safe and variable training environments, 4) flexibility in choosing relevant and meaningful activities for oneself, 5) identification of rehabilitation needs and goals, 6) support for rehabilitees to understand their current functioning status and the appropriate paths to improvement (see the left and right edge in Fig. 1).

Table 2. Examples of rehabilitees´ experiences focusing on rehabilitation technology assisted physiotherapy.
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4 Discussion

The goal of this secondary analysis was to create a practical model for implementation of physiotherapy treatment which support the maintenance and reinforcement of the sense of human dignity and meaningful life among physiotherapy rehabilitees, particularly when using remote and digital techniques in physiotherapy. Based on our primary research [16, 17] human dignity and sense of meaningful life appeared to be the most fundamental generic elements in aspired physiotherapy, based on the interpretation of the rehabilitee feedback. This central finding was reinforced by our secondary analysis, which also increased our understanding of the key factors which are considered essential in the content of physiotherapy treatment, both in conventional and remote/digitally supported physiotherapy. The results also gave ideas about the plausible advantages of digital rehabilitation techniques as well as the challenges related to the use of such techniques, the latter being largely linked with current competence requirements of the physiotherapy professionals.

We believe that our rehabilitee-oriented model emphasizing the essential role of in- dependence and freedom of choice, promoting social interactions, participation in the society and in ordinary life, and preservation of faith in the future, all of which help to promote the sense of human dignity and meaningful life, enables stronger adherence to physiotherapy as well as positive effects on biopsychosocial functioning and quality of life among rehabilitees. Rehabilitees´ strong commitment to their rehabilitation process is likely to become even more important in the future, because due to population ageing and cost pressure on public expenditure it is unavoidable that digital services are becoming more significant across all sectors of the society, including medical and rehabilitation services [4, 6]. Digitalization of rehabilitation services is likely to increase the role of remote activities in physiotherapy, a central topic in our research effort. This will be a huge paradigm change because, so far, physiotherapy services have mostly been offered as face-to-face treatment [14, 15].

From this perspective, our study approach is valuable, because so far scientific re- search has largely reflected the traditional rehabilitation research paradigm of quantitative effectiveness studies [e.g., 4]. The expected new physiotherapy and rehabilitation paradigm calls for new approaches to rehabilitation research. To our knowledge, this kind of modelling we have carried out in this paper has not been done before in physiotherapy, at least not among people with CVA and MS rehabilitees.

Our secondary analysis is linked to authors’ previous study efforts, in which the goal has been to evaluate effectiveness of physiotherapy and increase understanding of the meaningfulness of physiotherapy among CVA and MS rehabilitees [see 5]. The strength of the study and created physiotherapy model is that it is based on extensive and comprehensive research data (50 studies, 771 rehabilitees) [16, 17] and supported by the authors’ long-term experiences in the field of physiotherapy and their intensive researcher triangulation working method extending over all the phases of the research process. During the entire development process (2021–2023) of the model we have also subjected its earlier versions to expert scrutiny at different occasions (conferences, workshops). Expert feedback (researchers, clinicians, teachers) reinforced the view that our research scope focusing on understanding the elements of meaningful physiotherapy, and of even multidisciplinary rehabilitation, in the context of remote and digitally assisted activities is important.

The limitation in our research is that it focuses only on neurological rehabilitees suffering from CVA and MS. Despite the specific disease etiology of CVA and MS, we are quite confident that the generic results of our secondary analysis are generally applicable to physiotherapy. Whatever is causing the limitations in persons’ physical, psychological, social, or cognitive abilities, their fundamental desire is to get treatment that makes them feel that they are valued as individuals and promotes their sense of meaningful life, regardless of the degree of improvement in their condition. However, the role of the more practical elements of physiotherapeutic activities can vary depending on what is causing the need for rehabilitation. Therefore, it would be important to study also other rehabilitee groups, e.g. cardiac, chronic pain or dementia patients. Moreover, the study of various rehabilitee groups is essential considering the use of remote and digitally assisted physiotherapy to learn more about how technology can best be utilized with individuals suffering from various health and functionality related issues. All in all, it is important to test our research-based physiotherapy model and future variations of it in real-life settings evaluating the degree of improved adherence and effectiveness of physiotherapy and improved meaningfulness, compared to the results of conventional physiotherapy [cf. 4–6]. The scope of future research should also be extended to the different stages of functioning (primary, secondary and tertiary prevention).

The general opinion appears to be that increased availability of technology, particularly digital technology, is the driving force when societies are moving towards more effective and cost-effective availability of services [42]. However, there are still few studies in rehabilitation that have investigated the cost-effectiveness of technology assisted rehabilitation [cf. 5, 43]. This would be a challenging and complex research topic because one should be able to project simultaneously both short- and longer-term cost effects. For example, enhancing primary (preventive) rehabilitation may increase spending in the short term but making relevant technology accessible and alluring could decrease future costs in secondary or tertiary rehabilitation. Furthermore, as we have pointed out, factors which strengthen rehabilitees’ own commitment to physiotherapy may increase initial costs in physiotherapy but can be of major importance in terms of short- and mid-term effectiveness as well as longer-term impacts. This kind of thinking is crucial in terms of our research approach, and we hope that our research findings will pave the way for developing new modes of rehabilitation services provision. For example, in Finland, people receiving intensive medical rehabilitation has increased from 20000 to almost 40000 individuals in less than 15 years [3].

Countries worldwide are facing similar challenges, at least to some degree. Effective rehabilitation, particularly when extended to preventive rehabilitation, is expected to lessen the burden on health care costs in the long-run and ensure the maintenance of functional capabilities of the working age population. On top of these practical policy issues, we hope that our research and the human dignity and sense of meaningful life centered physiotherapy contribute to the development of theoretical and even philosophical understanding of physiotherapy.