Physiotherapy 2.0: Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion Emily Knight, Robert J. Werstine, Diane M. Rasmussen-Pennington, Deborah Fitzsimmons and Robert J. Petrella PHYS THER. Published online March 13, 2014 doi: 10.2522/ptj.20130432

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Running head: Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion

Innovative Technologies Special Issue

Physiotherapy 2.0: Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion

Emily Knight, Robert J. Werstine, Diane M. Rasmussen-Pennington, Deborah Fitzsimmons, Robert J. Petrella

E. Knight, Health & Rehabilitation Sciences, University of Western Ontario, London, Ontario, Canada, 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, University of Western Ontario.

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R.J. Petrella, MD, PhD, Health & Rehabilitation Sciences, University of Western Ontario, and Aging, Rehabilitation & Geriatric Care Research Centre, Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada N6C 5J1. Address all correspondence to Dr Petrella at: [email protected].

[Knight E, Werstine RJ, Rasmussen-Pennington DM, et al. Physiotherapy 2.0: leveraging social media to engage patients in rehabilitation and health promotion. Phys Ther. 2014;94:xxx–xxx.]

© 2014 American Physical Therapy Association

Published Ahead of Print: XXX Accepted: March 9, 2014 Submitted: September 10, 2013

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Abstract Care for chronic conditions and non-communicable diseases are dominating health systems around the globe. For physiotherapists, this presents a substantial opportunity for engaging patients in health promotion and disease management in the years to come. Examples of social media being used to engage consumers in the business landscape are pervasive, and research reports suggest that patients are ready for social media to be incorporated in the way health systems deliver care. We propose that leveraging the power and utility of existing technologies, such as social media, could innovate the way physiotherapists engage patients in rehabilitation and health promotion practices, thus contributing to the evolution of the profession: Physiotherapy 2.0. To continue to be relevant in the community, physiotherapy practice must respond to patients’ needs and expectations. Incorporating social media in how physiotherapists are both designing and delivering care holds potential for enhancing patient engagement in prescribed health behaviors and improving treatment outcomes. This conceptual paper presents the perspective that physiotherapists can utilize social media to enhance care delivery and treatment outcomes.

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INTRODUCTION Life expectancies in developed countries are increasing at a rate of approximately two years every decade, which on a more immediate scale is equivalent to increasing by three months per year or by five hours per day(1-3). While people are, and can continue to expect to be, living longer than previous generations, there is a disparity between longevity and healthy, independent living: adults are living longer, but this is not matched to fewer years of disability and ill health(4). Global health systems are progressively being dominated by care for chronic conditions and non-communicable diseases(5, 6). In the coming decades, it is projected that deaths due to such conditions as cardiovascular disease, cancer, and diabetes will contribute to 70% of all deaths, accounting for 57% of disease burden globally(6). As the number of patients continues to grow and the health care resources continue to strain, the need to engage patients in selfmanagement of these diseases becomes an essential strategy(7, 8). This presents a substantial opportunity for physiotherapists to engage patients in rehabilitation, health promotion 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 treatment regimens that attract and involve patients in the management of their own care(5). The World Health Organization suggests that difficulty 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 physiotherapists engage patients in rehabilitation and health promotion practices.

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Web 2.0 Web 2.0 is a popularized term that began to surface following the dotcom burst in 2001(10). The term describes the evolutionary framework of the Internet with a focus on widespread engagement. Web 2.0 is a dynamic platform where content and applications are 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 treatment outcomes(1). The inherent dynamic and social nature of Web 2.0 supports its potential for engaging patients in prescribed health behaviors to enhance on-going care and selfmanagement(5).

Social media is a broad descriptor, and platforms can be grouped according to common features. Similar to others,(14) we have previously reported five classifications of social media: (1) Blogs, (2) Content Communities (e.g. YouTube, Flickr), (3) Collaborative Projects (e.g. Wikis, consumer review sites), (4) Social Networking Sites (e.g. Facebook, Twitter), (5) Virtual Worlds (e.g. Second Life, World of Warcraft)(5). Like other sectors and industries, health care delivery could improve by leveraging existing and emerging social media platforms. Previously we have explored the evidence base and research opportunities for leveraging these platforms for improved treatment outcomes with patients(5). The perspective explored in this conceptual paper furthers the conversation about engaging patients in prescribed health behaviors using social media by drawing specific attention to the need for research informing best practices to address

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the gap between physiotherapist and patient in health care service delivery, as well as highlighting areas for future research.

Health 2.0 In North America, it has been reported that the majority (ranging between 60-83%) of Internet users seek health information online(12, 15, 16). Health 2.0 is a popularized term representing the presence of health information in Web 2.0(17). It differs from other technological evolutions in health (e.g. eHealth) given its collaborative nature and emphasis on personalized healthcare(18). The large proportion of people seeking health information online necessitates the involvement of health professionals, such a physiotherapists, in the online dialogue. As consumers, individuals have been attracted to, retained and engaged in the commercial landscape using social media(16, 19)

. 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 healthcare delivery(15).

Physiotherapy 2.0 Incorporating social media in the way physiotherapists both design and deliver care holds potential for engaging patients in prescribed health behaviors. Commentaries discussing the application of Web 2.0 in the practice of physical therapy date back to 2008(20). Social media has been described by physiotherapists as a simple medium to reach individuals, answer questions, and educate(21). Building on understandings of Web 2.0 and Health 2.0 we propose that physiotherapists can leverage social media platforms to engage in user-generated dialogues with their patient populations. Thereby enhancing care delivery models and contributing to the evolution of the practice of physiotherapy: Physiotherapy 2.0. By extension of previous 6 Downloaded from http://ptjournal.apta.org/ at Hospital Virgen De La Salud Biblioteca on April 10, 2014

definitions in the Health 2.0 landscape(18), we conceptualize Physiotherapy 2.0 as the use of Web 2.0 tools and platforms by physiotherapists, using principles of user-generated content and collaboration among networks and individuals to personalize health care and promote health education. We consider this approach a means to develop patient engagement in on-going 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 paper was written, of the top 500 websites, social media sites Facebook and YouTube are in the top three –only surpassed by Google(22). Other social sites in the top ten include collaborative sites (e.g. Wikipedia) and consumer-review sites (e.g. Amazon), with various social networking and blog sites (e.g. Twitter, Blogspot.com, and LinkedIn) rounding out the top fifteen(22). These data support the intuitive understanding that social media is pervasive in modern North American culture. Yet the challenge to the health sector is leveraging this popularity to impact health care delivery in a positive and significant way for patients and practitioners.

Based on previous literature, how can a health practitioner engage 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 (i.e. Flickr), there was a statistically significant relationship between highly relevant pictures and both the number of views and number of ‘favorites’ or ‘likes’, which

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suggested a relationship among views, favorites and relevance(23). This information could be extended to suggest that when information is deemed important online (i.e. ranked highly by search engines) there is a strong correlation with it also being viewed and being ‘favorited’ by more site traffic.

Moreover, previous work has also concluded that images displaying positive emotions (i.e. happiness) were more likely to be viewed(23). This finding suggests that positive reinforcement through social media may lead to more views of the content posted (i.e. user engagement with the content). Additionally, it has been demonstrated in the literature that emotions elicited (e.g. happy, funny), impressions aroused (e.g. intense, enjoyable), and perceived utility (e.g. useful to self, network or society) through user-generated content factor into an individual’s decision to share the content with others(24).

This information about relevance, tags, emotion, utility and engagement 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. This in turn may also relate to increased engagement by patients with the content. However, it remains to be established if this increased engagement will lead to better self-management of chronic conditions or improved treatment outcomes for patients.

Examples from the Health Sector Despite the abundance of experience with social media in many industries, evidence reporting its utility in the health landscape is only emerging. Predominantly, the existing evidence base is

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descriptive and observational with fewer examples of interventions using social media(25). In an experiment to influence social health policies, a project from the United Kingdom explored the efficacy of social media tools (e.g. blogs, social networking) in conjunction with ‘viral marketing techniques’ to engage end-users and policy makers in health policy development(26). More specifically, the project used blogs with reader comments, Twitter and online polling to engage the public, and found that social media was a powerful dissemination and discussion forum which may help to enable strategic change in health policies(26). 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 progressively becoming more prevalent in the research landscape. Reports describe available social content for specific conditions and disease states (e.g. concussion, obesity), health promotion practices (e.g. physical activity, smoking behaviors) and communicable disease prevention (e.g. vaccination)(27-31). 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(30). Despite this, healthcare and educational organizations should continue to explore social media platforms for dissemination of evidence-based information and promotion of the health profession(30, 32).

Establishing the credibility of information collated through collaborative sites (e.g. 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 information(5, 33).

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Moreover, it has been reported that patients with chronic conditions are more likely to seek out information through this landscape(12, 33). The ability of patients and physiotherapists to critically appraise user-generated content to discern which information will improve care delivery and patient-important outcomes in an ethical and evidence-based way remains a challenge. Increased involvement of physiotherapists in the social media dialogue may help to populate the landscape with credible information(34). For example, wikis specific to the physiotherapy profession exist, which provide opportunity for collaborative sharing of physiotherapy-related content. While such wikis are promoted as having the potential to improve patient care, contribute to global health, and support the practice of physiotherapy as well as connect practitioners(35), evidence of these outcomes have yet to be reported. The presence of physiotherapy experts in the social media landscape will help to contribute credible, evidence-based information to the online dialogue.

EVOLVING PHYSIOTHERAPY PRACTICE Establish Best Practices for Incorporating Social Media It has been suggested that the use of social media in professional practice 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 also share credible health information(21). While the article largely focused on fundamentals and how-to cautions for online communication, it also included valuable insights from practitioners currently engaging with various forms of social media in physiotherapy 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 delivery and clinical education as well as contribute to the

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establishment of best practices for incorporating social media.

The Canadian Medical Association reports beginning the process of developing social media practice guidelines for physicians in Canada(36). And while the Canadian health landscape may be playing catch-up, American corporations in the health sector (such as Kaiser Permanente and Mayo Clinic) have already developed social media policies to guide employee best practices. However a challenge remains for implementing 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(37). Moreover, it has been suggested that virtual communication by a health practitioner should mimic that in real clinic settings, for example maintaining patient privacy, confidentiality and best practices for professional conduct(21).

While implementing social media among regulated health professions may have similarities with its use in other industries, inherent, and perhaps unique, challenges also exist. From an interview with a representative of Kaiser Permanente, Blogger daryl_perieira(38) posted suggestions that similarities include taking action when unsatisfied consumers (e.g. patients) voice their concerns online, while challenges to overcome include identifying when action needs to be taken to alert regulating bodies regarding information posted publicly by patients and perhaps practitioners. It has been suggested that when social media platforms are used appropriately, with common sense, and with professional integrity, they may offer many advantages to clinicians(21). Best practice guidelines may help direct health practitioners in ethical and effective ways to engage in the online dialogue.

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Clinician Adoption Similar to the introduction of other ‘new’ information and communications technology systems, the readiness of clinicians to adopt social media practices in the process of delivering routine care may vary among health professions. The Canadian Medical Association reports that among a survey of 600 association members (i.e. physicians), 46% have downloaded an app to use in practice, 49% believe social media will improve their practice by increasing patients’ sense of community, and 30% believe it will facilitate collaborative sharing of information(36). 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(21). This information suggests that some health practitioners are currently adopting various aspects of social media in clinical practice.

Clinician adoption of social media practices may also be limited by factors that commonly arise when considering changes to health service delivery such as legislation, liability, scope of practice, access, safety, privacy and time. These factors should be considered when developing 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 is affordable, accessible and user-friendly, allowing clinicians to utilize existing tools in practice to engage with social media, and existing platforms are generally free. However, the funding model to support the time clinicians are engaged in social media remains to be established. It is not clear if billing platforms for practitioner involvement in the social media landscape will be developed and adopted. We speculate that evidence for cost-savings to payers would need to be demonstrated, for which many research opportunities exist. Alternatively, 12 Downloaded from http://ptjournal.apta.org/ at Hospital Virgen De La Salud Biblioteca on April 10, 2014

social media may find its place under the umbrella of online professionalism, which presents opportunities for continuing education as well as essential competency development for future clinicians (e.g. physical therapy 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 information, and challenges regulating ownership and privacy with the growing body of available information(18). While 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 development of evidence-informed best practices will help to ensure that patient safety and privacy are maintained as clinician practices evolve to meet the new demands of Physiotherapy 2.0. Establishing best practices is required for effective and appropriate integration of social media in current physiotherapy delivery, as well as for the education and training of future clinicians.

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 if engaging in the social dialogue leads to improved treatment outcomes? Three principle constructs have been proposed for developing metrics to analyze effectiveness of social strategies(39): determining (1) what needs to be measured; (2) how to best measure it; and (3) if using these metrics for analysis

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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 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 like video titles, tags (i.e. keywords), text, and viewer comments. Previous research analyzing condition-specific content on YouTube has used metrics such as top five tags, number of views, and months since the video was uploaded(30). Another metric worth considering would be cross-pollination of information: for example amount specific content (e.g. 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(39), we propose that clinicians and researchers consider the following metrics when implementing social media in care delivery: (1) Social Patient Relationship Management, (2) Referred Social Traffic, (3) Social Impressions, and (4) Social Treatment Outcomes. 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 population. This could be achieved by tracking the size of the population 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

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media involvement. This could be achieved by tracking the number of users who accessed a site from a referring social media site (e.g. blogs, social networking, content communities), and this information can be collected using existing analytics tools (e.g. 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 (e.g. clinician’s Twitter feed, professional organization’s YouTube channel) in the greater online social community. Social Treatment Outcomes - This would provide a metric to help determine if social media engagement leads to improved treatment outcomes. This could be achieved by reporting the relationship between a patient’s treatment outcomes and their engagement in care delivery that is augmented with social media.

These four metrics, for example, may be tracked, which would facilitate comparison of care delivery within clinics, across treatment conditions, 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(21). To determine if including social media in care delivery is beneficial, physiotherapists not only need to track involvement and online presence, but also collect patient-centered outcome measures to evaluate whether this strategy improves treatment outcomes.

Implementation in Practice For practitioners, researchers, and regulating bodies there are many opportunities to implement

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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 five categories based on the platform(5), each of which presents opportunities for research and care delivery. (1) 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. Blogs 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 wishing 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 recommended that bloggers consider establishing a regular timeframe for contributing to their blog (e.g. weekly, monthly, etc) and post this information so that users can set expectations for their own engagement with the blog. (2) Content Community platforms like YouTube and Flickr offer opportunities to share images and audio with the greater professional network. Posted content may be used to help patients remember proper 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. (3) Collaborative Projects like wikis and consumer review sites hold much potential for physiotherapy. In addition to profession-specific wikis (e.g. Physiopedia), clinicians, researchers and professional associations can contribute to more general wikis to enhance the profession’s online credibility and brand identity by posting evidence-based information. Moreover, engaging

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in this practice will help to ensure that the information accessed by lay-users (e.g. patients) is more likely to be credible. Utilizing user-generated reviews (e.g. patients reviews) on practice websites could help to ensure that the practice is responsive to its patient population, and may also help to generate increased business by allowing new potential patients to learn about the experiences of current and past patients. (4) Social Networking Sites like Twitter and Facebook offer the opportunity to collaborate with users in real-time. Clinicians, researchers and regulating bodies can use social networking sites to update patients and practitioners by sharing announcements for administrative updates (e.g. hours of operation, equipment, or services provided) practice updates (e.g. treatment guidelines, emerging evidence) as well as professional and research opportunities (e.g. funding, training, employment). Moreover, private social networking sites in the health landscape (e.g. 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. (5) Virtual Worlds require the establishment of a virtual environment and persona (e.g. avatar), and may also 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 a patient’s 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. While limited research exists demonstrating the utility of virtual worlds for improving health(5), more research is needed to establish the evidence base for employing them within the practice of physiotherapy.

The ideas above for implementation are intended to incite and enhance the use of social media

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both in practice and research. In the absence of best practice guidelines for the evidence-based implementation of social media in the practice of physiotherapy, 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.

CONCLUSION Augmenting, Not Replacing, Existing Patient Care As presented previously, the statistics indicate that the majority of Internet 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 hesitant to engage in rehabilitation and health promotion care programs that involve social media. Moreover, regulating bodies (e.g. professional healthcare licensing colleges and other government agencies) have yet to engage in the discussion of Health 2.0(40). Lack of regulation may limit a health professional’s willingness to engage in the social media dialogue, and limit a user’s ability or confidence in determining both the accuracy and applicability of information on Web 2.0 platforms to their personal health(30). 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 replace existing 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.

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Build the Evidence Base Social media is pervasive in our daily lives and research investigating its clinical utility is crucial so that physiotherapy can respond to, not avoid, this reality. The engagement of physiotherapists 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. Physiotherapy 2.0 involves participants (e.g. clinicians, patients, regulating bodies) interacting collaboratively to impact practice, healthcare service delivery, and both clinician and patient education. This conceptual paper presents our perspective that physiotherapists 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 in clinical practice remains sparse. To help build the evidence, clinicians should continue to explore social media in their physiotherapy practices and report its utility and feasibility for engaging patients in prescribed health behaviors. To inform the development of best practices, it is suggested that metrics are identified and reported to help determine if incorporating social media does, in fact, lead to improved treatment outcomes and cost-savings.

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Ms Knight, Mr Werstine, Dr Rasmussen-Pennington, and Dr Petrella provided concept/idea/research design. All authors provided writing. Dr Petrella provided data analysis, study participants, and facilities/equipment. Ms Knight provided project management and clerical support. Ms Knight and Dr Petrella provided institutional liaisons. Ms Knight, Mr Werstine, and Dr Rasmussen-Pennington provided consultation (including review of manuscript before submission).

Ms Knight is supported by a Doctoral Research Award from the Canadian Institutes of Health Research/Canadian Physiotherapy Association/Physiotherapy Foundation of Canada.

DOI: 10.2522/ptj.20130432

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Physiotherapy 2.0: Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion Emily Knight, Robert J. Werstine, Diane M. Rasmussen-Pennington, Deborah Fitzsimmons and Robert J. Petrella PHYS THER. Published online March 13, 2014 doi: 10.2522/ptj.20130432

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