Telerehabilitation services for stroke

Why is this review important?
Stroke is one of the most common causes of acquired disability worldwide, leading to difficulties in managing and participating in home and/or community activities. Rehabilitation is often lengthy and expensive. About half of stroke survivors access rehabilitation directly from acute services.
Telerehabilitation (telerehab) is a way for professionals to deliver rehabilitation to patients using information and communication technologies. Communication may happen through telephone, videoconferencing (internet-based), and wearable devices (sensors such as pedometers, potentiometers/encoders, myographic, etc.). It may also include virtual reality programmes that generate data and transmit the data to the therapist from a remote location. Telerehab consultations may include assessment, diagnosis, goal-setting, therapy, education, counselling, supervision, and monitoring.
Recently there has been extensive research and implementation of telerehab considering accessibility, affordability, service quality, real-time monitoring, and client-centric approaches in healthcare. Moreover the COVID-19 pandemic has created a sense of urgency to evaluate the effectiveness of telerehab. 
This review aims to determine whether telerehab can improve the ability to perform daily living activities, mobility, balance, self-care independence, domestic life and health-related quality of life, depression, cognitive function, or communication. It aims also to analyse its cost-effectiveness, feasibility, user-satisfaction, and adverse events.

Who is interested in this review?
Patients with stroke, loved ones / caregivers of stroke survivors, health professionals dealing with stroke, telerehab professionals, researchers, general practitioners, and policymakers.

What does this review talk about?
This review is an update of a previous review published in November 2012. It included 1,937 people of both genders from 22 randomized control trials, published or ongoing as of June 2019. These studies were conducted in the U.S., Canada, the Netherlands, Italy, Germany, China, Taiwan, Spain, and Slovenia. The objective was to gather evidence for effectiveness of telerehab after stroke, comparing it with therapy delivered face-to-face and with no therapy (usual care).

What did the evidence from the review tell us?
The overall effect was rarely determined, as the studies included were very different. The authors found moderate-quality evidence of no difference in activities of daily living, health-related quality of life, and depressive symptoms when comparing telerehab with conventional interventions. There is a low quality of evidence of no difference in effects on activities of daily living, balance outcomes, and upper limb function comparing telerehab to in-person physical therapy programmes. There was a lack of information about cost-effectiveness of telerehab, and no conclusion was drawn on the effect of telerehab on mobility and participant satisfaction. Two trials reported no adverse events related to telerehab. Thus, the quality of evidence for each outcome was limited due to small numbers of study participants in each trial and poor reporting of study details.

Author’s conclusion of the review
The finding for low or moderate-quality evidence suggests that further research could change the estimate of the effect. However, telerehab services have clear advantages as a way of offering intervention, facilitating access to services, and reducing costs related to rehabilitation programmes. The author’s findings suggest that telerehab may not be inferior to in-person therapy and, therefore, appears to be considered as a reasonable model of service delivery for people after stroke who require rehabilitation beyond the acute or subacute phase.
What should be done next?
Telerehab has potential advantages to facilitate access and affordability, but more high-quality randomised controlled trials are required to address the remaining gaps detailed in this review. These studies should be compliant with CONSORT guidelines and should compare telerehab with in-person conventional therapy and combination therapies (telerehab plus conventional); moreover, further studies should evaluate (i) cost-effectiveness, (ii) technologies-usability or user-friendliness, (iii) participant satisfaction, (iv) disability at discharge, (v) disability duration and severity, and (vi) rehabilitation-duration challenges associated with recruitment of participants. Finally, telerehab may provide different kinds of activities, and healthcare professionals may incur difficulties adopting it.