Physical Therapy

Phys Ther. 95(3): 389-396

Physical Therapy 2.0: Leveraging Social

Media to Engage Patients in
Rehabilitation and Health Promotion
Emily Knight, Robert J. Werstine, Diane M. Rasmussen-Pennington, De-
borah Fitzsimmons, Robert J. Petrella

E. Knight, Health & Rehabilitation Sciences, University of Western Ontario, and Rehabilita-
tion & Geriatric Care Research Centre, Lawson Health Research Institute, London, Ontario,
Canada.

R.J. Werstine, HBA, BSc(PT), MSc(PT), DipManip, DipSport, FCAMPT, Fowler-Kennedy

Sports Medicine Clinic at Fanshawe College, London, Ontario, Canada.

D.M. Rasmussen-Pennington, PhD, Ashford University, Clinton, Iowa.

D. Fitzsimmons, MHSc, PhD, Health Studies, University of Western Ontario.

R.J. Petrella, MD, PhD, Schulich School of Medicine & Dentistry, University of Western
Ontario, and Aging, Rehabilitation & Geriatric Care Research Centre, Lawson Health Re-
search Institute, 801 Commissioners Road East, London, Ontario, Canada N6C 5J1.

Address all correspondence to Dr Petrella at: petrella@uwo.ca.

2015 American Physical Therapy Association

DOI: 10.2522/ptj.20130432
Published in print: March 2015
Published online: 13 March 2014
 2/24

Abstract

Care for chronic conditions and noncommunicable dis-

eases is dominating health systems around the globe.
For physical therapists, this strain presents a substan-
tial opportunity for engaging patients in health promo-
tion and disease management in the years to come.
Examples of social media being used to engage con-
sumers in the business landscape are pervasive, and
research reports suggest that patients are ready for so-
cial media to be incorporated into the way health care
systems deliver care. We propose that leveraging the
power and utility of existing technologies, such as so-
cial media, could innovate the way physical therapists
engage patients in rehabilitation and health promotion
practices, thus contributing to the evolution of the pro-
fession: Physical Therapy 2.0. To continue to be relev-
ant in the community, physical therapist practice must
respond to patients' needs and expectations. Incorpor-
ating social media into how physical therapists are both
designing and delivering care holds potential for enhan-
cing patient engagement in prescribed health behaviors
and improving treatment outcomes. This conceptual
article presents the perspective that physical therapists
can utilize social media to enhance care delivery and
treatment outcomes.

Life expectancies in developed countries are increasing at a rate of ap-

proximately 2 years every decade.13 Although people are, and can
continue to expect to be, living longer than previous generations, there
 3/24

is a disparity between longevity and healthy, independent living:

adults are living longer, but this increased longevity is not matched to
fewer years of disability and ill health.4 Global health care systems are
progressively being dominated by care for chronic conditions and non-
communicable diseases.5,6 In the coming decades, it is projected that
conditions such as cardiovascular disease, cancer, and diabetes will ac-
count for more than 50% of disease burden globally.6 As the number
of patients continues to grow and health care resources continue to
strain, the need to engage patients in self-management of these dis-
eases becomes an essential strategy.7,8 This divergence of demand on
and capacity of health care systems presents a substantial opportunity
for physical therapists to engage patients in rehabilitation, health pro-
motion, and disease management in the years to come.

Patient engagement has previously been operationalized as a means to

increase adherence to prescribed health behaviors by initiating treat-
ment regimens that attract and involve patients in the management of
their own care.5 The World Health Organization suggests that diffi-
culty engaging patients, especially those with chronic conditions, leads
to suboptimal treatment outcomes.9 We propose that leveraging the
power and utility of existing technologies, especially social media,
could innovate the way physical therapists engage patients in rehabil-
itation and health promotion practices.

Web 2.0

Web 2.0 is a popularized term that began to surface following the dot-
com collapse in 2001.10 The term describes the evolutionary frame-
work of the Internet, with a focus on widespread engagement. Web 2.0
is a dynamic platform where content and applications are
 4/24

continuously modified by all users in a participatory and collaborative

way.11 It has been suggested that users are more likely to consume
health information when they are active participants in the dialogue.12
Therefore, Web 2.0 allows for the creation and exchange of content
generated by the users and connects people through an interactive
platform.11,13 Creating a people-powered health system through the
bridging of social and health paradigms may facilitate improved treat-
ment outcomes.1 The inherent dynamic and social nature of Web 2.0
supports its potential for engaging patients in prescribed health beha-
viors to enhance ongoing care and self-management.5

Social media is a broad descriptor, and platforms can be grouped ac-

cording to common features. Similar to other authors,11 Knight5 previ-
ously reported 5 classifications of social media: (1) blogs, (2) content
communities (eg, YouTube, Flickr), (3) collaborative projects (eg, wi-
kis, consumer review sites), (4) social networking sites (eg, Facebook,
Twitter), and (5) virtual worlds (eg, Second Life, World of Warcraft).
Like other sectors and industries, health care delivery could improve
by leveraging existing and emerging social media platforms. Previ-
ously, Knight5 explored the evidence base and research opportunities
for leveraging these platforms for improved treatment outcomes with
patients. The perspective explored in this conceptual article furthers
the conversation about engaging patients in prescribed health behavi-
ors using social media by drawing specific attention to the need for re-
search informing best practices to address the gap between physical
therapist and patient in health care service delivery, as well as high-
lighting areas for future research.
 5/24

Health 2.0

In North America, it has been reported that the majority

(range=60%83%) of Internet users seek health information on-
line.11,14,15 Health 2.0 is a popularized term representing the presence
of health information in Web 2.0.16 It differs from other technological
evolutions in health (eg, eHealth) given its collaborative nature and
emphasis on personalized health care.17 The large proportion of
people seeking health information online necessitates the involvement
of health care professionals, such as physical therapists, in the online
dialogue. As consumers, individuals have been attracted to, retained,
and engaged in the commercial landscape using social media.15,18 It
has been suggested that these individuals, in their roles as patients,
are ready for social media to be implemented as a part of their health
care delivery.14

Physical Therapy 2.0

Incorporating social media into the way physical therapists both

design and deliver care holds potential for engaging patients in pre-
scribed health behaviors. Commentaries discussing the application of
Web 2.0 in the practice of physical therapy date back to 2008.19 Social
media have been described by physical therapists as a simple medium
to reach individuals, answer questions, and educate.20 Building on un-
derstandings of Web 2.0 and Health 2.0, we propose that physical
therapists can leverage social media platforms to engage in user-gen-
erated dialogues with their patient populations, thereby enhancing
care delivery models and contributing to the evolution of the physical
therapist practice: Physical Therapy 2.0. By extension of previous
 6/24

definitions in the Health 2.0 landscape,17 we conceptualize Physical

Therapy 2.0 as the use of Web 2.0 tools and platforms by physical
therapists, utilizing principles of user-generated content and collabor-
ation among networks and individuals to personalize health care and
promote health education. We consider this approach a means to de-
velop patient engagement in ongoing care, thereby enhancing patient
self-management of health and contributing to optimal treatment
outcomes.

The Evidence

Building on the Experiences in Other Industries

Examples of social media in the commercial landscape are pervasive.
Social media sites are routinely near the top of the list for most visited
websites. At the time this article was written, of the top 500 websites,
the social media sites Facebook and YouTube were in the top 3sur-
passed only by Google.21 Other social sites in the top 10 include collab-
orative sites (eg, Wikipedia) and consumer-review sites (eg, Amazon),
with various social networking and blog sites (eg, Twitter, Blog-
spot.com, LinkedIn) rounding out the top 15.21 These data support the
intuitive understanding that social media are pervasive in modern
North American culture. Yet, the challenge to the health sector is
leveraging this popularity to influence health care delivery in a positive
and significant way for patients and practitioners.

Based on previous literature, how can a health care practitioner en-

gage in the social dialogue in a relevant and meaningful way? In a
study comparing images with high versus low relevance on a social
media platform (ie, Flickr), there was a statistically significant
 7/24

relationship between highly relevant pictures and both the number of

views and number of favorites or likes, which suggested a relation-
ship among views, favorites, and relevance.22 This information could
be extended to suggest that when information is deemed important
online (ie, ranked highly by search engines), there is a strong correla-
tion with it also being viewed and being favorited by more site
traffic.

Moreover, previous work concluded that images displaying positive

emotions (eg, happiness) were more likely to be viewed.22 This finding
suggests that positive reinforcement through social media may lead to
more views of the content posted (ie, user engagement with the con-
tent). Additionally, it has been demonstrated in the literature that
emotions elicited (eg, happy, funny), impressions aroused (eg, intense,
enjoyable), and perceived utility (eg, useful to self, network, or society)
through user-generated content factor into an individual's decision to
share the content with others.23

This information about relevance, tags, emotion, utility, and engage-

ment can be used by clinicians to ensure that their participation in the
social dialogue is not only high quality but also reliable and relevant to
a respective patient population. In turn, this type of participation may
also relate to increased engagement by patients with the content.
However, it remains to be established whether this increased engage-
ment will lead to better self-management of chronic conditions or im-
proved treatment outcomes for patients.

Examples From the Health Sector

Despite the abundance of experience with social media in many indus-
tries, evidence reporting its utility in the health landscape is only now
 8/24

emerging. Predominantly, the existing evidence base is descriptive and

observational, with fewer examples of interventions using social me-
dia.24 In an experiment to influence social health policies, a project
from the United Kingdom explored the efficacy of social media tools
(eg, blogs, social networking) in conjunction with viral marketing
techniques to engage end-users and policy makers in health policy
development.25 More specifically, the project used blogs with reader
comments, Twitter, and online polling to engage the public and
showed that social media were a powerful dissemination and discus-
sion forum that may help to enable strategic change in health
policies.25 This example illustrates how Web 2.0 tools can be used in
the health sector to influence changes to policy that respond to patient
and practitioner views.

Exploration of content on social media sites, such as YouTube, is pro-

gressively becoming more prevalent in the research landscape. Re-
ports describe available social content for specific conditions and dis-
ease states (eg, concussion, obesity), health promotion practices (eg,
physical activity, smoking behaviors), and communicable disease pre-
vention (eg, vaccination).2630 Research to date has suggested that a
gap exists between the effort to define best practices for the inclusion
of social media in health care design and delivery and the transfer of
this information to educate end-users.29 Despite this gap, health care
and educational organizations should continue to explore social media
platforms for dissemination of evidence-based information and pro-
motion of the health care profession.29,31

Establishing the credibility of information collated through collaborat-

ive sites (eg, wikis) is commonly cited as a challenge by practitioners
and researchers, yet it has been suggested that individuals may view
these media as extensive, useful, and credible sources of informa-
tion.5,32 Moreover, it has been reported that patients with chronic
 9/24

conditions are more likely to seek out information through this land-
scape.12,32 The ability of patients and physical therapists to critically
appraise user-generated content to discern which information will im-
prove care delivery and patient-important outcomes in an ethical and
evidence-based way remains a challenge. Increased involvement of
physical therapists in the social media dialogue may help to populate
the landscape with credible information.33 For example, wikis specific
to the physical therapy profession exist and provide an opportunity for
collaborative sharing of physical therapyrelated content. Although
such wikis are promoted as having the potential to improve patient
care, contribute to global health, and support the practice of physical
therapy as well as connect practitioners,34 evidence of these outcomes
has yet to be reported. The presence of physical therapist experts in
the social media landscape will help to contribute credible, evidence-
based information to the online dialogue.

Evolving Physical Therapist Practice

Establish Best Practices for Incorporating Social

Media
It has been suggested that the use of social media in professional prac-
tice facilitates meaningful communication with patients, colleagues,
and researchers, in part by providing clinicians with an online voice
through which the profession may enhance its reputation and share
credible health information.20 Recent reports have suggested that the
cohorts of physical therapy graduates in the years to come are going to
be versed in the use of social media in their educational and personal
lives.35,36 However, what remains to be established is how this
 10/24

experience will translate into professional use of social media.

Moreover, a previous report20 that largely focused on fundamentals
and how-to cautions for online communication also included valuable
insights from practitioners currently engaging with various forms of
social media in physical therapist practice, research, and education.
The outcomes of these initiatives have yet to be reported and may
provide evidence for the utility of including social media in care deliv-
ery and clinical education as well as contribute to the establishment of
best practices for incorporating social media.

The Canadian Medical Association has reported beginning the process

of developing social media practice guidelines for physicians in
Canada.37 Also, while the Canadian health landscape may be playing
catch-up, American corporations in the health sector (eg, Kaiser Per-
manente, Mayo Clinic) have already developed social media policies to
guide employee best practices. However, a challenge remains for im-
plementing corporate social media policies in clinical practice. The
American Physical Therapy Association has published standards of
conduct for the use of social media by members.38 Moreover, it has
been suggested that virtual communication by a health care practition-
er should mimic that in real clinic settingsfor example, maintaining
patient privacy, confidentiality, and best practices for professional
conduct.20

While implementing social media among regulated health professions

may have similarities with its use in other industries, inherent, and
perhaps unique, challenges also exist. In an interview with a repres-
entative of Kaiser Permanente, blogger daryl_perieira39 posted sug-
gestions that similarities include taking action when unsatisfied con-
sumers (eg, patients) voice their concerns online and that challenges
to overcome include identifying when action needs to be taken to alert
regulating bodies regarding information posted publicly by patients
 11/24

and perhaps practitioners. It has been suggested that when social me-
dia platforms are used appropriately, with common sense and with
professional integrity, they may offer many advantages to clinicians.20
Best practice guidelines may help direct health care practitioners in
ethical and effective ways to engage in the online dialogue.

Clinician Adoption
Similar to the introduction of other new information and communic-
ations technology systems, the readiness of clinicians to adopt social
media practices in the process of delivering routine care may vary
among health care professions. The Canadian Medical Association re-
ported that among a survey of 600 association members (ie, physi-
cians), 46% had downloaded an app to use in practice, 49% believe so-
cial media will improve their practice by increasing patients' sense of
community, and 30% believe it will facilitate collaborative sharing of
information.37 Moreover, a recent publication from the Canadian
Physiotherapy Association highlights examples of clinicians who are
actively engaged in social media to augment their existing practices.20
This information suggests that some health care practitioners are cur-
rently adopting various aspects of social media in clinical practice.

Clinician adoption of social media practices also may be limited by

factors that commonly arise when considering changes to health ser-
vice delivery such as legislation, liability, scope of practice, access,
safety, privacy, and time. These factors should be considered when de-
veloping the evidence base to inform practice guidelines for inclusion
of social media in care delivery. To further enhance clinician adoption,
funding and billing options need to be considered. Social media are af-
fordable, accessible, and user-friendly, allowing clinicians to utilize ex-
isting tools in practice to engage with social media, and existing
 12/24

platforms are generally free. However, the funding model to support

the time clinicians are engaged in social media remains to be estab-
lished. It is not clear whether billing platforms for practitioner in-
volvement in the social media landscape will be developed and adop-
ted. We speculate that evidence for cost-savings to payers would need
to be demonstrated, for which many research opportunities exist. Al-
ternatively, social media may find their place under the umbrella of
online professionalism, which presents opportunities for continuing
education as well as essential competency development for future
clinicians (eg, physical therapist students).

Issues that have previously been identified for involving social media
in care delivery include tensions over perceived loss of control of the
information available to patients, safety risk of inaccurate informa-
tion, and challenges regulating ownership and privacy with the grow-
ing body of available information.17 Although these stumbling blocks
were identified a number of years ago and sourced from a single health
profession (physicians), they could be leveraged as reasons to support
clinician engagement in the online dialogue. Engaging in the online
dialogue may help to offset these issues by providing credible,
accessible, evidence-based information. Moreover, timely develop-
ment of evidence-informed best practices will help to ensure that pa-
tient safety and privacy are maintained as clinician practices evolve to
meet the new demands of Physical Therapy 2.0. Establishing best
practices is crucial for effective and appropriate integration of social
media in current physical therapy delivery, as well as for the education
and training of future clinicians.
 13/24

Measuring the Effect of Social Media

In cases where patients have the expectation to be able to use social
media and clinicians are willing to implement online conduits for
communications, how do we determine whether engaging in the social
dialogue leads to improved treatment outcomes? Three principal con-
structs have been proposed for developing metrics to analyze the ef-
fectiveness of social strategies40: (1) determining what needs to be
measured, (2) determining how to best measure it, and (3) determin-
ing whether using these metrics for analysis is related to improvement
in patient engagement with prescribed health behaviors. Metrics need
to be representative of a clinician's patient population. Moreover, in
terms of building the evidence base to support the use of social media
for realizing improved treatment outcomes, there would be benefit to
using standardized metrics to allow for comparisons across studies
and professions.

Metrics inherently exist among individual social media platforms,

which could be tracked and reported. For example, websites such as
YouTube include information such as video titles, tags (ie, key words),
text, and viewer comments. Previous research analyzing condition-
specific content on YouTube has used metrics such as top-5 tags, num-
ber of views, and months since the video was uploaded.29 Another
metric worth considering would be cross-pollination of information:
for example, amount-specific content (eg, a clinician's blog about a
specific treatment approach) was reposted or shared on another social
media platform. Moreover, extending metrics previously identified for
social media sites,40 we propose that clinicians and researchers con-
sider the following metrics when implementing social media in care
delivery: (1) social patient relationship management, (2) referred so-
cial traffic, (3) social impressions, and (4) social treatment outcomes.
 14/24

Social patient relationship management.

Synonymous with social customer relationship management from the
consumer landscape, this metric would provide insight into the value
being created for patients as well as size of the engaged patient popu-
lation. This insight could be achieved by tracking the size of the popu-
lation that is enrolled in regular interaction with their care provider
through social media platforms over time.

Referred social traffic.

This metric would provide information about reach of a user's social
media involvement. This information could be collected by tracking
the number of users who accessed a site from a referring social media
site (eg, blogs, social networking, content communities) using existing
analytic tools (eg, Google Analytics, which is free of charge).

Social impressions.
This metric would help to provide information about the pervasive
spread of a user's social presence over a specified time period. Using
alert tools will help track reference to the user-generated content (eg,
clinician's Twitter feed, professional organization's YouTube channel)
in the greater online social community.

Social treatment outcomes.

This metric would help in determining whether social media engage-
ment leads to improved treatment outcomes, which could be achieved
by reporting the relationship between a patient's treatment outcomes
and his or her engagement in care delivery that is augmented with so-
cial media.
 15/24

These 4 metrics, for example, may be tracked, which would facilitate

comparison of care delivery within clinics and across treatment condi-
tions and perhaps allow for comparisons with other care providers,
jurisdictions, or industries. Engaging through social media may help
facilitate a patient's retention of the information discussed during
treatment sessions.20 To determine whether including social media in
care delivery is beneficial, physical therapists need to not only track
involvement and online presence but also collect patient-centered out-
come measures to evaluate whether this strategy improves treatment
outcomes.

Implementation in Practice
For practitioners, researchers, and regulating bodies, there are many
opportunities to implement various aspects of social media in practice.
However, for the novice user, it can be daunting to make the foray into
social media. It is an ever-evolving platform, and new opportunities
will continue to present themselves. As previously mentioned, social
media can be classified into 5 categories based on the platform,5 each
of which presents opportunities for research and care delivery.

Blogs.
Blogs can be used by individual clinicians or groups of practitioners to
engage in dialogue with each other and with patients about experience
in practice and evidence for care delivery. They can be established to
incorporate reader comments, which adds to the social nature of the
platform. Additionally, they can be protected or secured to limit user
access, which may be a feature attractive to clinicians or professional
associations who want to engage with a limited population through
this platform. One of the primary challenges with this platform is
maintaining and updating the blog regularly. Therefore, it is
 16/24

recommended that bloggers consider establishing a regular time frame

for contributing to their blog (eg, weekly, monthly) and post this in-
formation so that users can set expectations for their own engagement
with the blog.

Content communities.
Content community platforms such as YouTube and Flickr offer op-
portunities to share images and audio with the greater professional
network. Posted content may be used to help patients remember prop-
er execution of prescribed health behaviors after they leave the clinic
and serve as an education tool for sharing evidence-informed practices
with patients and fellow practitioners.

Collaborative projects.
Collaborative projects such as wikis and consumer review sites hold
much potential for physical therapy. In addition to profession-specific
wikis (eg, Physiopedia), clinicians, researchers, and professional asso-
ciations can contribute to more general wikis to enhance the
profession's online credibility and brand identity by posting evidence-
based information. Moreover, engaging in this practice will help to en-
sure that the information accessed by lay-users (eg, patients) is more
likely to be credible. Utilizing user-generated reviews (eg, patients' re-
views) on practice websites could help to ensure that the practice is re-
sponsive to its patient population and may help to generate increased
business by allowing new or potential patients to learn about the ex-
periences of current and past patients.

Social networking sites.

Social networking sites such as Twitter and Facebook offer the oppor-
tunity to collaborate with users in real time. Clinicians, researchers,
and regulating bodies can use social networking sites to update
 17/24

patients and practitioners by sharing announcements for administrat-

ive updates (eg, hours of operation, equipment, services provided) and
practice updates (eg, treatment guidelines, emerging evidence) as well
as professional and research opportunities (eg, funding, training, em-
ployment). Moreover, private social networking sites in the health
landscape (eg, tyze, patientslikeme) hold potential for engaging with
patients and peers through a secure and confidential platform, which
may further enhance care delivery and self-management.

Virtual worlds.
Virtual worlds require the establishment of a virtual environment and
persona (eg, avatar) and may further require the establishment of a set
of rules to confine avatar conduct in the virtual environment. This
platform holds potential for education and engaging patients in virtual
conduct of prescribed health behaviors. For example, augmenting pa-
tients' visualization of their engagement in a prescribed behavior by
allowing them to virtually execute it may help to build confidence and
knowledge for on-going self-management. Although limited research
exists demonstrating the utility of virtual worlds for improving
health,5 more research is needed to establish the evidence base for us-
ing them in physical therapist practice.

The ideas above for implementation are intended to incite and en-
hance the use of social media both in practice and research. In the ab-
sence of best practice guidelines for the evidence-based implementa-
tion of social media in physical therapist practice, it is suggested that
clinicians and researchers use sound judgment to guide their practice.
Ethical and patient-centered practices for safety and confidentiality
should not be negated when adopting a new platform to augment care
design and delivery.
 18/24

Conclusion

Augmenting, Not Replacing, Existing Patient Care

As presented previously, the statistics indicate that the majority of In-
ternet users seek out health information while online and that patients
are ready for social media platforms to enter the health space. Yet, not
all patients are likely to support adoption of Web 2.0 platforms in
their care delivery. Patients who are skeptical of its value may be hesit-
ant to engage in rehabilitation and health promotion care programs
that involve social media. Moreover, regulating bodies (eg, profession-
al health care licensing colleges and other government agencies) have
yet to engage in the discussion of Health 2.0.16 Lack of regulation may
limit a health care professional's willingness to engage in the social
media dialogue and may limit a user's ability or confidence in determ-
ining both the accuracy and applicability of information on Web 2.0
platforms to his or her personal health.29 However, the current lack of
regulation may allow for practitioners to shape how social media can
best be used in practice, in turn, influencing the development of future
regulations. Our perspective is not that social media should replace ex-
isting care models and treatment regimens but that these existing Web
2.0 platforms, which have been successful in other sectors, could be
leveraged to augment care delivery and potentially improve treatment
outcomes.

Build the Evidence Base

Social media are pervasive in our daily lives, and research investigat-
ing their clinical utility is crucial so that the physical therapy profes-
sion can respond to, and not avoid, this reality. The engagement of
 19/24

physical therapists in the Health 2.0 landscape will help to build the
brand identity of the profession by creating and maintaining a social
voice and contributing to the development and sharing of credible and
evidence-based health information across this platform. Physical
Therapy 2.0 involves participants (eg, clinicians, patients, regulating
bodies) interacting collaboratively to influence practice, health care
service delivery, and both clinician and patient education. This con-
ceptual article presents our perspective that physical therapists may be
able to leverage the power and utility of social media to enhance care
delivery and treatment outcomes. However, the evidence to support
this aim in clinical practice remains sparse. To help build the evidence,
clinicians should continue to explore social media in their physical
therapist practices and report their utility and feasibility for engaging
patients in prescribed health behaviors. To inform the development of
best practices, it is suggested that metrics be identified and reported to
help determine whether incorporating social media does, in fact, lead
to improved treatment outcomes and cost-savings.

Footnotes
All authors provided concept/idea/research design, writing, and consultation (including
review of manuscript before submission). Ms Knight provided project management and
clerical support. Ms Knight and Dr Petrella provided institutional liaisons.

Ms Knight is supported by a Doctoral Research Award from the Canadian Institutes of

Health Research/Canadian Physiotherapy Association/Physiotherapy Foundation of
Canada.

Articles from Physical Therapy are provided here courtesy of Americ-

an Physical Therapy Association
 20/24

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