Rehabilitation education videos to improve patient recovery post trauma

By Afshaun Azad*, Julianne Hendry* and Sarkhell Radha
Croydon University Hospital, UK

*Joint first-authors (Julianne Hendry and Afshaun Azad)

Current challenges with patient communication and MSK services

Effective communication remains a challenge within the healthcare environment. Generally, patients will only recall roughly half of the information given to them by healthcare professionals and occasionally even forget information ever being provided¹. Anxiety and stress may be heightened in patients with physical illnesses, and these emotions can have a profound negative effect on information recollection¹. Given these limitations of verbal patient communication, concurrent delivery of written information is considered essential for effective patient communication. Print outs of hospital-approved patient information leaflets (PILs) have conventionally been utilised as an additional educational resource, however, accessibility can be limited.

Alternative to PILs, patient education videos (PEVs) as an adjunct have also been trialled to improve information recollection and patient satisfaction². In both studies, patients viewed the videos in clinic and were offered to access the videos online, which they felt was useful. Furthermore, objective and self-reported knowledge has been shown to improve after watching PEVs². However, one meta-analysis of PEVs mentioned the open access to YouTube videos could impair the reliability of information given to patients as patients may search for information from unaccredited sources³. It is therefore suggested healthcare professionals should create their own resources to provide accurate information and can be updated as guidelines change.

Furthermore, in trauma and orthopaedics specifically, physiotherapy remains a key component of improving functionality and rehabilitation. Traditional rehabilitation includes personalized treatment plans encompassing pain management techniques and patient education on injury prevention. Musculoskeletal (MSK) services within the NHS are under growing pressure and often are unable to review patients post trauma for many weeks by which time key physiotherapy and strengthening exercises if not performed can limit range of movement and overall recovery. A report in 2018, reviewed the MSK pathway in the trust mentioning most orthopaedic referrals being discharged after just one clinic appointment and the target of 18-weeks to treatment being missed⁴.

Implementing patient education videos (PEVs) – a pilot study

Given the success of PEVs in other studies and the long waiting lists for physiotherapy referrals, we piloted an initiative of using patient education videos as an adjunct for patient rehabilitation post trauma. We created 11 PEVs in the Trauma and Orthopaedics department at Croydon University Hospital. The PEVs were created in collaboration with the physiotherapy team and senior orthopaedic surgeons using the current patient information leaflets as a template for the exercises required and general information regarding rehabilitation of the injury.  While the videos mainly focused on exercises to strengthen muscles and improve range of movement, we included generalised information on self-care and injury prevention. The PEVs were not personalised to each individual, however supporting information from clinic visits helped to tailor the information provided to optimise recovery given age, health and severity of the injury in each patient. The overall aim was to reduce pain and improve mobility enabling patients to back to their usual activities.

The videos were approved by the trust communications team and uploaded publicly on the official trust YouTube channel. We then generated QR codes from the corresponding links on the YouTube channel. These were then added to posters and PILs to signpost patients to the videos in clinic follow-ups. A patient survey created on Microsoft Forms, with no patient identifiable data, was added to the PILs and given to patients in clinic to complete after watching the videos. Patients were encouraged to fill this out whilst at their clinic appointment.

All patients that completed the survey had their responses included in the data analysis. We assessed some patient demographics including age and gender. We asked patients if they felt they had enough information about their diagnosis before watching the videos and if they found the videos useful using binary yes or no responses. We also asked if any parts of the video were confusing/could be better explained and any other general feedback in a long answer question format.

Results and patient feedback

Of the 80 patients that accessed the videos, 36 and completed the survey. Patients were aged between 18-80 years old with median age being between 25-34 years. 53% of patients were female and 47% were male. Prior to watching the videos, only 8 patients (22%) felt they had enough information regarding their diagnosis and treatment including information on rehabilitation exercises. All patients reported that they found the videos useful, and no patients mentioned finding parts of the video confusing or could be better explained. 

General feedback mentioned the videos were very helpful and easy to follow. Examples of open feedback comments directly from the survey include: “Great video!”, “Very easy to follow”, “Great visual aid and easy to follow”, “Super helpful, thank you for making these, definitely will help my recovery!”, “Very clear and handy”, “Some of the writing was a bit blurry, more pictures”, “Helped a lot. Good video, easy to follow”, “None, very useful video!”, “Video was well explained and provided useful information on knee soft tissue injury”, “No improvement required”, “I don’t have any recommendations”, “Very helpful to go through the video while doing the exercises”.

The advantages of PEV usage

Our results show incredibly positive feedback from PEV usage as an alternative to traditional PILs. This is in keeping with results from other studies reviewing patient knowledge and information recollection being improved as well as increased patient satisfaction. While we did have a small number of patients complete the survey, all patients reported utility of the PEVs. Unlike other studies, we specifically encouraged patients to access the PEVs on their own using QR codes and did not show the PEVs in clinic. The advantage therefore of these results is that we know that patients can access the resources on their own and complete the feedback anonymously. The feedback is therefore not affected by the relationship between the clinician and the patient. Although we did not assess the preference between the PEVs and the printed PILs, the feedback received implies that PEVs are the superior method of delivery for ease of patient understanding and the retention of clinically relevant information.

As there are growing numbers of patients using technology to access healthcare information, we found that patients found PEVs more useful in comparison to the traditional printed PILs despite the content not being different in the two delivery methods. Statistics from NHS England published in 2023 mention an increase of nearly 10 million people using NHS websites or digital applications in 2021 compared with 2020, and NHS App registrations increasing from two million in 2021 to 30 million in 2023. Additionally, the COVID-19 pandemic brought about the innovative use of existing technologies to reduce the rate of viral transmission and maintain social distancing. In this context, QR codes have frequently served as alternative means of information sharing. Digital acquisition of PILs or equivalent patient information using QR codes has been used to disseminate information to patients regarding care of orthopaedic casts^5,6  where the QR code was either printed directly onto the cast itself or provided as a business card for access to educational videos. In other instances, the technology has been employed for surveying patients or for patients to access information in waiting rooms, both in emergency department and general practice settings. Clinicians have piloted posters as a way of providing patients with PILs, in some cases for surgery or with general information e.g. regarding sexually transmitted infections and contraception.

We chose QR code technology due to the widespread use of QR codes in healthcare practices following the COVID-19 pandemic to allow patients to access the PEVs and the survey easily. All patients that completed the survey were able to watch the video via the QR code thus demonstrating that this technology was a suitable method for accessing the PEVs.

Limitations of using PEVs

Limitations of PEV usage and access to QR technology include patient access to smartphones and ability to use the technology. While we did not review these limitations to access of QR smartphone technology, our results did indicate better access to the resources in younger age groups. This is in keeping with previous research mentioning smartphone ownership and confidence with the technology both being significantly associated with younger age⁷.  This paper did, however, mention an increase in confidence with the technology from 50% to 67% after being demonstrated in clinic. It should also be noted that since current smartphone users will age, we expect to see a greater acceptability in older age groups in years to come. NHS England have mentioned consequences of increased digital patient services impacting healthcare disparities in different socio-economic groups and older age groups; however, our resources are intended simply as an adjunct and not a replacement of current services.

Conclusion and practical implications

During our quality improvement project we found PEVs serve as a suitable and environmentally friendly alternative to PILs for dissemination of clinical material. We found the QR code technology is a suitable means of access to information across a range of patient demographics. As with all research, patient participation is paramount for developing new modalities and engaging patients in research for improvement purposes. Our qualitative approach in using a patient survey to assess allow patients to anonymously feedback on our early innovations research has allowed us to utilise and improve the patient information resources. We hope that this can improve patient satisfaction in our service and their clinical recovery. In turn, we hope our early-stage research validating the use of PEVs can be expanded and used in other clinical settings.

Given the results from our pilot and the growing evidence base supporting the utility of patient education videos, we encourage PEVs as a suitable and environmentally sustainable alternative to printed leaflets for patient access to relevant clinical information. Significant improvement in patient satisfaction justifies its use as an adjunct to written and verbal information provided in clinics. Further data on recovery outcomes and the benefits of the PEVs over standard PIL usage should be assessed in the future.

Acknowledgements

We acknowledge the participation of patients in completing our patient survey, our physiotherapy team for help in creation of the patient education resources, and our communications team for dissemination of the videos. We also acknowledge Dr Emilio Schweighart Gate, Dr Pengfei Li and Dr Mohammed Usman for contribution to the creation of the patient education videos.

Contributions

Both joint first authors contributed equally to the creation of the manuscript.

AA: Creation of the patient education videos, patient information leaflets, dissemination, data collection through patient survey, and writing of manuscript.
JH: Creation of the patient education videos, patient information leaflets, dissemination, data collection through patient survey, and writing of manuscript.
SR: Supervision and manuscript review.

References

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