International Journal of

Environmental Research
and Public Health

Article
Perspectives and Attitudes of Patients with COVID-19 toward a
Telerehabilitation Programme: A Qualitative Study
Carlos Bernal-Utrera 1,2,† , Ernesto Anarte-Lazo 3,† , Elena De-La-Barrera-Aranda 1,4 , Laura Fernandez-Bueno 5 ,
Manuel Saavedra-Hernandez 1,6 , Juan Jose Gonzalez-Gerez 1,6, *, Maria Angeles Serrera-Figallo 7
and Cleofas Rodriguez-Blanco 1,2

1 Fisiosur I + D Research Institute, Garrucha, 04630 Almería, Spain; cbutrera@us.es (C.B.-U.);

fisioelenacordoba@gmail.com (E.D.-L.-B.-A.); clinicasaavedra@yahoo.es (M.S.-H.); cleofas@us.es (C.R.-B.)
2 Physiotherapy Department, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville,
41009 Seville, Spain
3 Doctoral Program in Health Sciences, University of Seville, 41009 Seville, Spain;
anartelazo.ernesto@gmail.com
4 Department of Morphological and Socio-Health Sciences, University of Cordoba, 14071 Cordoba, Spain
5 University Hospital Virgen del Rocio, 41013 Seville, Spain; laurafernandez0895@gmail.com
6 Department Nursing, Physiotherapy and Medicine, Faculty of Almería, 04120 Almería, Spain



7 Stomatology Department, Faculty of Dentistry, University of Seville, 41009 Seville, Spain; maserrera@us.es


* Correspondence: juanjo@fisiosurid.es
Citation: Bernal-Utrera, C.; † Joint first authors.
Anarte-Lazo, E.;
De-La-Barrera-Aranda, E.; Abstract: The total isolation of patients with coronavirus disease 2019 (COVID-19) requires non-face-
Fernandez-Bueno, L.; to-face medical assistance. There is evidence of the efficacy of home treatments with exercises in
Saavedra-Hernandez, M.;
patients with respiratory disorders which could become the therapeutic method of choice for the
Gonzalez-Gerez, J.J.; Serrera-Figallo,
treatment and supervision of patients isolated due to infection during home confinement. This study’s
M.A.; Rodriguez-Blanco, C.
objective was to analyse the experience and opinions of isolated patients with COVID-19 included in
Perspectives and Attitudes of Patients
a programme of telerehabilitation exercises for 14 days and it is intended to reflect, from a qualitative
with COVID-19 toward a
Telerehabilitation Programme: A
point of view, the viability and usefulness of telerehabilitation tools in the management of these
Qualitative Study. Int. J. Environ. Res. patients. Twenty-five participants of a telerehabilitation programme were interviewed by telephone
Public Health 2021, 18, 7845. https:// through semi-structured interviews, following a positivist and objective model. The data were
doi.org/10.3390/ijerph18157845 categorised and analysed through NVIVO qualitative analysis software. The information obtained
was classified into four main topics (telerehabilitation programme, perception of clinical benefit,
Academic Editor: William psychological aspects and level of health care) and six subtopics (technical aspects, communication,
Douglas Evans improvement aspects, exercise plan, motivation and applicability to public health systems). The
telerehabilitation programme established in patients confined by COVID-19 is very well received,
Received: 17 June 2021
without considerable technical difficulties and generates physical and psychological improvements.
Accepted: 21 July 2021
Patients highlight the importance of applying this type of programme in public health systems.
Published: 24 July 2021

Keywords: COVID-19; physiotherapy; telerehabilitation; exercise therapy; qualitative analysis

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iations.
1. Introduction
Since the first case of coronavirus disease 2019 (COVID-19) was confirmed in Wuhan,
China, the virus dramatically spread and a pandemic was declared in March 2020 [1],
Copyright: © 2021 by the authors.
with more than 120 million cases one year later [2] and leading to undesirable physical
Licensee MDPI, Basel, Switzerland.
and psychological consequences to both healthcare providers and patients. Indeed, this
This article is an open access article
situation has been defined as “an apocalyptic and unexpected war” [3,4]. Nonetheless,
distributed under the terms and some authors argue that severe acute respiratory syndrom coronavirus 2 (SARS-COV-2)
conditions of the Creative Commons infection is the consequence of a systemic disease based on overpopulation, globalisation,
Attribution (CC BY) license (https:// hyperconnectivity and extreme centralisation and increasing fragility of supply chains [5].
creativecommons.org/licenses/by/ Different strategies have been established all over the world to face this situation,
4.0/). with main measures that are based on movement control, coordination with surrounding

Int. J. Environ. Res. Public Health 2021, 18, 7845. https://doi.org/10.3390/ijerph18157845 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 7845 2 of 12

countries and early detection of the virus by the performance of tests [6]. Closing/opening
models have been shown to be the least expensive [7]. Other complex systems of radio-
diagnostics, which are accessible, efficient and fast, have been developed, although they
have not been implemented by all health systems [8,9].
One of the most common measures to mitigate the virus spread, however, has been
isolation [6]. Isolation after being diagnosed with COVID-19 or being in contact with
someone infected is one of the essential measures proposed by authorities. In that sense,
the World Health Organisation (WHO) recommends for 80% of patients who do not
require hospital admission the need for very restrictive home isolation and confinement
in individual rooms at home to avoid dissemination of the virus [10]. However, home
isolation limits activity and implies a notable deconditioning at the musculoskeletal level,
indicating negative metabolic changes [11,12], repercussions on one’s emotional state and
mental health decline [4,13,14].
In such a situation, a patient’s total isolation requires non-face-to-face medical at-
tendance, using telematic control to monitor the evaluation of the patient affected by
COVID-19. There exists evidence regarding the efficacy of domiciliary exercise-based
treatments in patients with respiratory disorders. Based on this, it could become the thera-
peutic method of choice to allow the treatment and supervision of isolated patients due to
infection during home confinement [15–17]. It has been suggested that a session of exercise
through a telerehabilitation system may be a feasible option to manage quarantined pa-
tients with COVID-19 [18,19], enabling physiotherapists to provide interactive treatments
by means of different devices [20].
Telemedicine and, more specifically, telerehabilitation have been analysed and recog-
nised as feasible and practical options for managing different conditions and is an emer-
gent area among healthcare providers [21–25]. However, the exceptional characteristics of
COVID-19 patients, due to the isolation and saturation of public health systems [4], could
become barriers to implementing and maintaining the implementation and maintenance of
these methods in managing these patients.
Therefore, this study’s objective was to assess and analyse the experiences and opin-
ions of isolated patients with COVID-19 included in a telerehabilitation exercise-based
programme for 14 days [19]. Our aim was to reflect, from a qualitative point of view, the
feasibility and utility of telerehabilitation tools in managing these patients.

2. Material and Methods

2.1. Research Design
A qualitative exploratory study was conducted based on an interpretive framework
following the Standards for Reporting Qualitative Research (SRQR) and Consolidated
Criteria for Reporting Qualitative Research (https://www.equator-network.org/ accessed
on 4 July 2021). The aim of this explorative descriptive qualitative study is to evaluate the
participants’ viewpoints of this novel method of telerehabilitation, with the peculiarities of
the SARS CoV-2 infection.
This research used the qualitative method through the semi-structured interviews of
the patients affected by home confinement due to COVID-19 in a two-week telerehabilita-
tion programme based on tonic and respiratory exercises [19]. Due to logistical aspects,
we were obligated to reduce the planned intervention from the initial three to two weeks,
primarily since 14 days was the time period that patients diagnosed with COVID-19 were
obligated to stay at home in Spain. Interviews were performed in subjects who performed
either the tonic or respiratory exercise programme.

2.2. Intervention
The telerehabilitation programme was based on two video calls at baseline and an-
other during the middle of the programme, on day 7. During these video calls, physical
therapists taught, revised and adapted exercises relevant to the patients’ perceived fatigue.
In addition, a link to a website where exercises could be consulted was provided to the pa-
Int. J. Environ. Res. Public Health 2021, 18, 7845 3 of 12

tients. Follow-ups were performed daily through WhatsApp; the objective of the follow-up
was to ask the patients regarding any difficulty or trouble they might be experiencing with
the exercises and any worsening health status. Participants were also given a telephone
number that could be called in case of urgent contact.

2.3. Study Subjects

Using a random sampling method, we selected 25 of the 98 subjects studied in the
telerehabilitation project from November 2020–January 2021. None of the respondents
refused the interviews. Participants enrolled in the telerehabilitation programme presented
with mild to moderate symptomatology due to COVID-19. They did not require hospitali-
sation and were confined in their homes after being tested positive by a polymerase chain
reaction (PCR) test. The interviewed patients were required to meet the following criteria:
(1) allowed the study of their speech regarding the interview and (2) completed at least
90% of the sessions of the telerehabilitation programme.

2.4. Interview Outline

We determined the interview’s scheme by consulting the relevant literature, seeking
the opinions of those responsible for the telerehabilitation programme and covering all the
areas of interest under our criteria. The main interview questions posed to the participants
are listed in Appendix A. These questions were selected through a blinded poll by the
seven members of the research group, who chose questions among a broad group of
questions under their criteria and generated a semi-structured and complete interview. All
the selected questions obtained at least five of seven votes.

2.5. Data Collection

One interviewer, with a Master’s Degree in New Healthcare Trends in Health Sciences,
and the second interviewer, with a Master’s Degree specialised in Research Methodology,
were previously coordinated and trained to interview for the purpose under study.
The individual interviews were scheduled at the interviewer’s convenience and car-
ried out by telephone. The interviews were recorded and kept strictly confidential, with
no one but the participants and researchers present during the sessions. The interviews
lasted between 10–30 min for each participant. Study subjects were allowed to withdraw
consent at any time. The researchers remained neutral in data collection and established
good relationships with the participants, using active listening and clarification techniques
to promote the authenticity of the data and avoid bias. Interviews were not repeated.

2.6. Data Analysis

The interviews were transcribed and analysed by NVIVO qualitative software. Two
researchers independently reviewed the interview materials, summarised and extracted
meaningful statements and formulated the presenting themes. Conflicting opinions on the
contents of a theme were discussed and resolved by the director of the study. A thematic,
inductive analysis consisting of a codification process from the participants’ narratives was
performed. The information was divided into main themes and subthemes through codes.

2.7. Rigor and Trustworthiness

To establish trustworthiness of the data by reviewing the issues concerning data
credibility, transferability, dependability and confirmability, specific strategies were used.
Firstly, investigator triangulation, in which each interview was analysed by two researchers,
occurred. Thereafter, team meetings were conducted, in which the analyses were compared
and categories and themes were identified. Triangulation of the methods of data collection
also occurred, in which semi-structured interviews were conducted and researcher field
notes were kept. Researcher reflexivity was encouraged through previous positioning,
performance of reflexive reports and description of the rationale behind the study. In-depth
descriptions of the study were made, providing details of the characteristics of researchers,
Int. J. Environ. Res. Public Health 2021, 18, 7845 4 of 12

participants, contexts, sampling strategies and data collection and analysis. An audit
by an external researcher was performed, in which an external researcher assessed the
study research protocol, focusing on the aspects concerning the applied methods and
study design. In addition, the external researcher specifically checked the description of
the coding tree, the major themes, participant quotations, quotation identification and
theme descriptions.

2.8. Ethical Review

This study complies with the Helsinki guidelines for human research and was ap-
proved by the ethics committee of the University Hospital Virgen Macarena -Virgen Rocio
(ethics code: 1465-N-20). All participants signed informed consent forms.

3. Results
This study analysed 25 interviews regarding a telerehabilitation programme in patients
with COVID-19 [19]. Participants did not provide feedback on the findings. Participants’
baseline characteristics are presented in Table 1.

Table 1. Participants’ baseline characteristics.

Age (years) 41.36 ± 13.36

Gender % (n) Female 76% (18) Male 24% (7)
Civil status % (n) Married 52% (13) Single 40% (10) Divorced 8% (2)
Nationality % (n) Spanish 100% (25)
Education % (n) Secondary 16% (4) Bachelor 32% (8) Graduate 16% (4) Master’s 36% (9)
Employment situation % (n) Active 76% (19) Not active 20% (5) Retired 4% (1)

The data analysis revealed 1568 codes and nine categories. In addition, four main
themes (telerehabilitation programme, perception of clinical benefit, psychological aspects
and health assistance level) and six subthemes (technical aspects, communication, aspects
of improvement, exercise learning, motivation and applicability to public health systems)
emerged from the data analysis.

3.1. Telerehabilitation Program

Participants were generally satisfied that they had participated in this telerehabilitation
programme. They considered it conducive for them because they felt they took part in
their treatment and recovery, which was a significant issue for them due to isolation.
They appreciated the personalised care and follow-up performed by healthcare providers
in uncertain moments of difficulty. It is noteworthy that very few of the interviewed
participants were aware of the applicability of physical therapy in respiratory disorders.
After completing the programme, all participants stated they would participate again
if necessary and would agree to perform a telerehabilitation programme in other areas.
Significant aspects highlighted by participants are detailed below and most highlighted
answers can be found in Appendix B.

3.2. Technical Aspects

Regarding the technical aspects, the participants were not expected to encounter
trouble performing the exercises since they were familiar with the instruments used. Most
of the participants did not have any incidence concerning the technical aspects and a few
participants had difficulties that they could solve quickly. Only one participant found
incidences that could not be resolved and made no possible intervention to remedy them.
Int. J. Environ. Res. Public Health 2021, 18, 7845 5 of 12

3.3. Communication
The contact form used during the video calls and messaging apps were qualified as
well suited, primarily due to the circumstances of the pandemic. This communication
was considered very useful and well adapted. Regarding the interaction, the possibility of
being in daily contact with a therapist has been excellent. The level of confidence between
the patient and therapist increased as the programme advanced. Participants referred to
the professionalism of the therapist and they felt security and tranquility.

3.4. Exercise Planning

The learning and performance of the exercises were not challenging for the patients
since they were easily performed through video calls. Small doubts were successfully
solved by the physical therapists involved in the study.
Occasionally, symptomatology caused by COVID-19 made the programme’s devel-
opment difficult; however, complications were solved by adaptations in the exercise pro-
gramme in all cases.

3.5. Aspects to Improve

A minority of interviewed participants proposed options to improve our programme.
They suggested that more information could be provided concerning the role of exercises for
the body, what does they produce and why. Some considered that the programme allowed
them to better understand how exercise works and how it can help in their recovery. The
number of exercises and intensity were increased in those patients whose symptomatology
subsided in a few days. Moreover, the time of the programme was also increased because
when the participants completed the original 14-day regimen, they stopped performing
the exercises, without the therapist’s follow-up or direction. Since it was considered that
some patients still needed to continue with this intervention, the duration of the exercise
programme was individualized.
On a technical level, pulsations were suggested for measurement of contrast sensa-
tions, as well as ways through the media for the older population to facilitate access to
the programme. Nonetheless, despite these opinions, the programme appeared to have
been innovative and easy to perform, a view shared by many participants who thought
improvements are not needed.

3.6. Perception of Clinical Benefit

Regarding clinical benefit, most of the interviewed participants found positive evolu-
tion in respiratory capacity. In terms of physical symptomatology, such as fatigue, weakness
and myalgia, they felt that they improved significantly since the exercises helped them
drastically reduce symptoms. In addition, most patients did not only find improvement in
the physical aspect, but also psychologically. Finally, a few participants did not know how
to explain the clinical benefit since they experienced very mild symptoms.

4. Psychological Aspects
Concerning psychological aspects, most of the interviewed participants stated that
the programme gave them emotional support because it became a distracting escape from
confinement and disease. In addition, most participants felt more confident due to physical
therapists’ presence, who took care of them. Most of them also inferred that when they saw
daily improvement or felt that they could do more things, they felt encouraged, compared
to the starting point.

Motivation
Most participants told us they felt motivated to perform the exercises proposed by
our telerehabilitation programme. A majority related that their motivation increased
throughout the programme and they felt better, feeling evolution in the recovery process.
Conversely, most of them inferred that they felt more motivated to perform exercises
Int. J. Environ. Res. Public Health 2021, 18, 7845 6 of 12

daily since the monitoring performed by the physiotherapists indirectly obligated them to
participate with continuity in the telerehabilitation programme.

5. Level of Health Assistance

The attention, kindness and flexibility of the physiotherapists that guided the partici-
pants during the programme were highlighted. Participants felt safeguarded with being
enrolled in the programme. Participants related that the health care provided by the general
practitioners in the public health system was deficient during the different pandemic waves
and they positively valued the presence of another healthcare provider during the process.

Applicability to the Public Health System

All of the participants felt it was indispensable and convenient to incorporate telere-
habilitation programmes in the health system when managing patients with COVID-19
since they considered it essential to perform follow-ups and subsequently obtain clinical
benefit and prevent possible complications and sequelae. In addition, the participants
expressed that they felt that such a programme could be extended to other areas. However,
some of them thought it was impossible to implement this kind of programme due to
the economical or structural issues of the public health system. These participants also
expressed consciousness of the current financial problems, reduction in health investments
and deficit of healthcare professionals in the public health system that would make it very
difficult to implement telerehabilitation programmes, despite their known benefits.

6. Discussion
The COVID-19 pandemic has had a massive impact on health care systems worldwide,
forcing health professionals to rapidly adapt to the circumstances. During this situation,
telerehabilitation has been widely proposed as an exciting way to provide health services
and many studies have been published regarding physical therapy implementation during
the COVID-19 pandemic [26–28]. However, few studies have been documented pertaining
to the physical therapy management of COVID-19 patients with telerehabilitation [20]. To
our knowledge, this is the first qualitative study describing the opinions and feelings of
confined patients with COVID-19 enrolled in a telerehabilitation exercise programme [19].
It has been published that different populations have found the implementation of tel-
erehabilitation programmes to be helpful and they have reported positive experiences
with these methods [29,30]. Our results align with these findings in that the participants
were generally satisfied with their participation and stated they would participate again.
This great acceptability could be related to the fact that patients felt that they took part
in their recovery; in that sense, self-efficacy has been very important in managing differ-
ent conditions [31,32]. Enrolling patients in their treatments is becoming more important
nowadays and exercise through telerehabilitation seems an interesting intervention for
this purpose. However, to make this achievement possible, new technologies and com-
munication must function correctly. In that sense, our study subjects reflected that no
critical problems were found using technologies and contact was qualified as outstanding.
Communication is a crucial aspect of health treatments [33,34] and many professionals
believe that telerehabilitation could fail in this aspect. However, as it has been shown, this
was not the case in the programme developed.
Another critical point of our programme was exercise planning and its adaptability
to patients according to perceived effort. In that sense, some subjects pointed out that the
programme’s adaptation throughout the 14 days of intervention was beneficial. Adapting
the exercise volume according to health status allowed patients in a worse initial state to
progress alongside the intervention. There was, however, a negative impact of this action;
due to the different clinical pictures in patients with COVID-19 [2], subjects with less
COVID-19 severity argued that they would increase the volume/intensity of the exercise
programme since it was very easy for them, since the first day. Therefore, individualisation
Int. J. Environ. Res. Public Health 2021, 18, 7845 7 of 12

seems crucial for the implementation of these clinical practice interventions, as has been
previously argued [35].
In our study, subjects facing the challenge of being part of their recovery and per-
forming exercise for improvement have been described as helping to endure their disease.
Despite clinical improvements in respiratory and physical measures, the participants also
indicated that they also benefitted from their emotional well-being. We find this point very
important since it has been argued in many studies that confinement leads to worsening
mental health status in different populations [14,36]. Therefore, our findings highlight
that this kind of intervention could help patients managed their disease conditions and
prevent worsening mental health. In that sense, many patients have considered that they
obtained psychological benefits from this intervention. Emotionally, they highlighted that
confinement was not enjoyable and being busy helps to manage this situation. Moreover,
the confidence of having a healthcare provider that pays attention to them has been pointed
out as very important by many of the participants. Thus, telerehabilitation programmes for
COVID-19 patients could improve health status and provide a therapeutic alliance between
patients and physical therapists.
In addition, engagement in this programme has increased motivation in patients,
which should be an objective of every health intervention. The diary follow-up imple-
mented in this programme contributed to motivating patients to be empowered in manag-
ing their diseases.
Patients also described that the feeling of having someone care for them and following
their clinical status and evolution was a positive factor in this programme. In their opinion,
it was crucial to have the ability to directly ask about any doubt through digital services, if
necessary. They argued that public health systems lacked proper follow-up since doctors
did not monitor patient evolution in many cases. This point becomes very relevant since
health assistance could be improved by using these methods, especially in a confined
population, such as COVID-19 patients.
All of the enrolled patients found it indispensable to promote the implementation of
telerehabilitation in the public health system, not only for COVID-19 patients, but also
for other populations, such as patients with difficulties to displace to patients in health
centres, at which effectiveness have already been demonstrated [37–39]. Nonetheless, in
this situation of uncertainty and reduction of investments in the public health system, it was
discovered to be non-viable in the short-term. Increasing the number of physical therapists
enrolled in the public system could facilitate the implementation of telerehabilitation
methods. However, although desirable, it seems unlikely that this could happen in the
short term in the current situation.
Among the limitations, due to the pandemic situation, interviews were conducted
by telephone, which may have reduced personal interaction between the participants
and researchers; therefore, extracted information could be reduced. Moreover, due to
its qualitative design and small sample size, these results cannot be extrapolated to all
patients with COVID-19. Readers should consider that this study analyses the experience
and feelings of 25% of patients included in our randomised controlled trial. Thus, our
conclusions must be taken with care, since although the redundant information extracted
from the interviews was achieved, obtaining speeches was very similar. Another issue
that we should point out is that we obtained extremely positive results. This finding leads
to doubt of the findings themselves. We hypothesise that the subjects’ insecurities due to
isolation, disease and fear may have led to very positive feelings about our programme
and the perceived attention, avoiding, in a certain way, possible negative aspects about the
intervention. However, our findings may assist in the understanding of patients’ feelings
regarding their enrolment in a telerehabilitation programme during COVID-19 confinement
and their opinions and emotions related to isolation. Moreover, variability in health status
due to COVID-19 has been shown to improve our programme. Since patients present
symptoms differently, our programme was not demanding for some of them. Therefore,
Int. J. Environ. Res. Public Health 2021, 18, 7845 8 of 12

future studies could adapt exercise volume/intensity with more significant variability of
series/repetitions.

7. Conclusions
The semi-structured interviews performed during this study show that the tele-
rehabilitation programme implemented in patients confined by COVID-19 under detailed
methods generated significant reception. This result was without considerable technical
difficulties in this size study and generated, in the subjects’ opinions, improvements in
their physical condition, psychological status, confidence and motivation during the isola-
tion process. The interviewed patients considered it essential to implement this type of
assistance in public health systems. Despite these findings, our results should be confirmed
with other studies performed with higher sample sizes.

Author Contributions: Conceptualization, E.A.-L. and C.B.-U.; methodology, C.B.-U. and L.F.-B.;
software, C.R.-B. and J.J.G.-G.; validation, E.D.-L.-B.-A. and M.S.-H.; formal analysis, C.R.-B. and
C.B.-U.; investigation, L.F.-B. and E.D.-L.-B.-A.; resources, J.J.G.-G. and M.S.-H.; data curation, C.B.-U.
and M.A.S.-F.; writing—original draft preparation, C.B.-U. and E.A.-L.; writing—review and editing,
C.B.-U. and E.A.-L.; visualization, C.B.-U.; supervision, C.R.-B. and M.A.S.-F.; project administration,
J.J.G.-G. and M.S.-H. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Ethics Committee of University Hospitals Virgen del
Rocio-Macarena (protocol code 1465-N-20 and date of approval 29 September 2020).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data are not publicly available due to privacy and ethicals reasons.
Conflicts of Interest: The authors declare no conflict of interest.

Appendix A. Interview Questions

• What is your opinion about the telerehabilitation programme in which you were involved?
• How did you feel physically during the telerehabilitation programme?
• How did you feel emotionally during the telerehabilitation programme?
• Did you find impediments to perform the telerehabilitation programme?
• What opinion do you have about the physiotherapeutic approach of your disease
through telerehabilitation?
Int. J. Environ. Res. Public Health 2021, 18, 7845 9 of 12

Appendix B

Table A1. Most Highlighted Answers.

Interview Comments
Technical Aspects
“Everything worked perfectly: I could check exercises when I wanted, I performed exercises with the physical therapist that called me . . . perfect.
And I think that it is convenient and easy to be followed. They can call you if any doubts; I think it is good. I looked for them, (laughs) since they
always called me at the same hour, I was looking for them.”
“When the effort test was performed, the APP to count steps did not work; we could not continue this day.”
Communication
“Sincerely, really good, since the first moment communication worked very well; the health system should go forward in this way.”
“Fantastic. Displacement was not required, and this was especially important in a sick person. With video calls, everything was straightforward
to be understood.”
“I felt communication was adequate; I was confident since both therapists who contacted me were very nice.”
“Although it was through video calls, the relationship with therapists was very close and direct.”
Exercise Planning
“No trouble with exercises. Doubts were immediately solved.”
“At first, I felt both in the respiratory and physical field that I was a bit limited. Later, I started becoming stronger, and I could perform exercises
with less difficulty.”
“At the beginning, it was like a triathlon. Later, the programme was bearable, and exercises were adapted according to my capacities.”
Aspects to Improve
“Exercises that I performed were too easy and quiet. They were good for me, but I think that, depending on the grade of severity of COVID-19,
exercises volume and intensity should be adapted.”
“I would increase the duration of the programme since 15 days go very fast when you are in this situation.”
“Measuring pulsations, instead of how you feel, could become a more objective value, improving the adaptation of exercises.”
“Maybe the elderly, or other people who do not control new technologies, are at risk of exclusion in this kind of programmes.”
“Sincerely, I don’t know how the programme could be improved. As I told you, I feel pleased about having participated in the study, can’t find
anything to improve. I think that it has been very well prepared since the first movement, and execution, at least in my case, has been excellent.”
Perception of Clinical Benefit
“Especially the respiratory aspect- excellent . . . I thought: well, my cough has increased, but I feel like I’m removing and cleaning what I have
in there.”
“Truthfully, I improved m respiratory capacity. I improved since I started doing the exercises because I was vexed . . . ”
“Truly, I felt my confidence increased, and yes, I’ve felt better. First days, I felt pain in my muscles, and it was tough for me, but later I improved,
and I did not feel that way. And, of course, it has influenced my recovery.”
“One of the most significant symptoms I had, I felt pain in my chest, and I felt charged. For me, it was challenging to go up and down in steps.
When I was physically well prepared, I started to sweat the situation, and I felt exhausted. In that situation, performing the exercises
undoubtedly helped me, also to understand that I did not have important sequelae, that I could go ahead, and it did not affect me very much.”
“As I told you, the most important aspect for me was the psychological . . . Facing a challenge daily, being sure that exercises would help in my
recovery and feel better, professionals were guiding me . . . I was sure that the day after, I was going to feel better. I trusted very much, and then,
although I did not find a huge change in the physical aspect, I’m sure that in the psychological aspect, it helped me.”
“I imagine that I had a clinical benefit, but I don’t know. I felt I had positive benefits in my physical reconditioning.”
Psychological Aspects
“Well, isolation is not enjoyable. Being busy helped me to get over the process. If you are active, your mood improves.”
“It has positively influenced me because I knew I had someone who took care of me, a professional with studies and knowledge, and I did not feel
alone. It has been conducive for me; confinement implies loneliness, and if there is someone who calls you and your family, it is good, great.”
“ . . . Yes, sure, psychologically, it helps you because I knew that there was a professional who was there, who was paying attention to me and
my situation.”
“ . . . it was like I was a bit calmer about the follow-up, about the fact that there were some people who are involved in my recovery and how they
could help me to improve and get over the disease. Some days I felt alone, but I felt that actually, some people were there to take care of me.”
“Well, look, it has been very beneficial regarding my mood. I felt with little energy, I felt weakness in my mood, and after performing the exercises,
I felt better. This was the main benefit I felt.”
Int. J. Environ. Res. Public Health 2021, 18, 7845 10 of 12

Table A1. Cont.

Interview Comments
Motivation
“ . . . I was very unmotivated. I felt generalised weakness, not only back pain but like if I had low energy. Then, it has been beneficial for
motivating me to perform exercises and, after doing exercises, I felt better, more encouraged.”
“ . . . it was like my daily sport because although it was not purely sport, I had not enough strength to do something hard. Therefore, I thought:
come, I’m going to perform my respiratory exercises, and I finished my day.”
“Yes, I saw like I was feeling better, and thus, I felt more motivated. Moreover, indeed, I still perform the exercises sometimes . . . ”
“Especially in the second or third session, I felt the improvement because the first day I was awful . . . I could not walk much time, I felt tired, and
I could not perform exercises properly, and this situation overwhelmed me. Later, I started to perform exercises better, and I noticed that I was
doing faster . . . Not only that, I felt better, but I was performing the exercises with fewer difficulties.”
“Depending on the day, there were some days that I felt exhausted, and it was difficult to start, but talking to the therapist indeed gave me
confidence and courage to perform exercises.”
“Yes, some days I felt worse. I did not want to do exercises, but as I know I was going to be contacted to ask me how it had gone, this obligated me
to perform the exercises.”
Level of Health Assistance
“Well, the follow-up, attention, kindness of people who took care of me, and how they adapted to my circumstances . . . the attention
was extraordinary.”
“Attention has been perfect, and I felt safeguarded. I always had the faculty of asking them in case of any doubt. When I started the programme, I
started feeling new things, weird feelings, and having their support in any moment was good.”
“The direct attention, it is imperative that we had a telephone to consult. Health assistance is very deficient in this situation, and this programme
offered us new possibilities.”
“I had feared to die daily, and they told you that they are going to call you, but . . . they don’t call you. However, with this programme, I had the
security that they were going to contact me. I was pleased about that.”
Applicability to the public health system
“I think that it should arrive. Not only for patients with COVID-19, but also when COVID-19 disappears, these programmes should stay and
they should be developed because, with a good explanation and two video calls, it is sufficient.”
“It is weird that it does not exist. I do not understand why it is not implemented frequently.”
“I understand that this is new, that it is not still implemented, but is important and necessary for some patients that could have complications
with the facility.”
“Not only now because of COVID-19, but generally, it should be adopted in the management of patients with mobility problems, difficulties in
moving around, people with respiratory issues, in-bed patients . . . I think it is crucial. Besides, it is not simply a conversation, but it has an
objective, a daily programme with a specific aim.”
“It could be feasible if there were more physiotherapists and they could spend more time with patients.”
“I think it is not feasible, and it would be complicated. I would like not to say that, but it is complicated. Taking into account that right now is a
delicate situation of uncertainty.”
“I don’t think that the public health system could assume the costs currently. With cuts that the health system is suffering, it would be advisable,
but I don’t know if it could be implemented. The public health system does not work well, and I don’t think it would be feasible.”

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