"I'm Just Overwhelmed": Investigating Physical Therapy Accessibility and Technology Interventions for People with Disabilities and/or Chronic Conditions
Momona Yamagami, Kelly Mack, Jennifer Mankoff, Katherine M. Steele · 2022 · ACM Transactions on Accessible Computing · doi:10.1145/3563396
Summary
This interview study examines physical therapy (PT) accessibility for people with disabilities and/or chronic conditions (da/cc), investigating both the barriers they face and opportunities for technology to help. The researchers conducted hour-long semi-structured interviews with 12 US-based participants who perform PT exercises either with a physical therapist or at home. Participants had diverse conditions including Ehlers-Danlos syndrome, POTS, fibromyalgia, chronic pain, depression, epilepsy, and mobility impairments—with 10 of 12 having multiple conditions. The study applies a "post-modern model of disability" that considers both social barriers (transportation, insurance, ableism) and physiological barriers (pain, fatigue, fluctuating symptoms) as interconnected factors affecting PT access. This framing challenges the common assumption that PT non-adherence represents individual failure, instead revealing how systemic barriers and symptom variability make prescribed routines difficult or impossible to complete. The interview protocol explored three areas: participants' motivations for doing PT, barriers they encounter, and their ideas for technology that could support at-home PT. Participants were asked about potential sensor-based systems, tracking, rewards, and notifications. The research was conducted during COVID-19 (December 2020–March 2021), which heightened awareness of in-person PT inaccessibility and increased reliance on at-home exercises.
Key findings
In-person PT was often inaccessible due to insufficient insurance coverage (limited sessions per year, high copays, coverage gaps), lack of transportation, and pandemic-related infection risks. Participants frequently had to choose between unaffordable PT and exacerbating their symptoms. Transportation barriers were compounded by physiological factors—feeling too symptomatic to drive on the day of an appointment. At-home PT introduced different barriers: fluctuating symptoms made it difficult to complete prescribed exercises on "bad days," there was no feedback on movement quality or safety, exercises felt monotonous without variety, and the cognitive burden of adapting exercises to current symptoms was exhausting. One participant captured the feeling: "I'm just overwhelmed...it's an endless list of things to do." Participants suggested seven technology features: customizable exercise presentation (choosing exercises based on daily symptoms), movement tracking (for quality and safety), technology rewards (unlocking apps or content), personalized notifications (with easy dismissal options), hardware that accommodates da/cc needs (wearables that don't cause chafing), data security (critical concern about insurance misuse), and progress sharing with physical therapists. A major tension emerged around insurance: while participants valued tracking for motivation and safety, they feared that data showing missed exercises or symptom fluctuations could be "abused by insurance companies" to deny coverage. This concern was so significant that some participants were reluctant to use tracking technology despite seeing its benefits.
Relevance
This research reframes PT adherence as an accessibility issue rather than a compliance problem. For practitioners developing health and rehabilitation technology, the key insight is that systems must accommodate daily symptom fluctuation—a user's abilities on Monday may differ dramatically from Tuesday. The design recommendation of "adaptability" means allowing users to select exercises appropriate for their current state, adjust repetition counts, and receive alternative exercises when standard ones are inaccessible. The study offers three design principles and one critical tension: (1) adaptability to fluctuating symptoms, (2) movement tracking for quality and safety without therapist supervision, (3) community-building features for peer support and motivation, and (4) the insurance tension—technology must be designed with data privacy as a first-class concern, as health data could be weaponized against users. For the broader accessibility field, this paper demonstrates how healthcare is an underexplored domain where social and physiological barriers interact in complex ways. The finding that five participants avoided using technology due to accessibility barriers (hand fatigue, motion sickness, chafing from wearables) reminds us that PT technology must itself be accessible. The paper calls for HCI researchers to "thoughtfully consider the nuanced inter-relation between physiological and social access needs," particularly when studying people with chronic conditions whose experiences don't fit neatly into either medical or social models of disability.
Tags: physical therapy · chronic conditions · healthcare accessibility · telerehabilitation · wearable technology · symptom fluctuation · insurance barriers · at-home exercise