Is telehealth an effective and feasible option for improving falls-related outcomes in community-dwelling adults with neurological conditions? A systematic review and meta-analysis
Restricted accessResearch articleFirst published online January, 2023
Is telehealth an effective and feasible option for improving falls-related outcomes in community-dwelling adults with neurological conditions? A systematic review and meta-analysis
To determine the effectiveness of telehealth interventions in reducing community falls risk or rates compared to equivalent in-person interventions in adults with neurological conditions.
Data Sources
Eight electronic databases, trial registries and search engines were searched for the concepts ‘falls’, ‘neurological conditions’, and ‘telehealth’, limited to English language, from inception until August 2022.
Review methods
Search for original research where the intervention was delivered via synchronous videoconferencing with the aim of reducing falls and falls-related outcomes. Screening and risk of bias assessment were completed by two independent researchers. Outcome data included falls rates, falls-related outcomes, safety, feasibility, and acceptability. Risk of bias was assessed using the ROB-2 and ROBINS-I tools. Quality of evidence was rated with the grading of recommendations, assessment, development and evaluation (GRADE) approach.
Results
Seventeen studies with 581 participants were included; six were randomised controlled trials. Risk of bias ranged from low to high. Only one study (n = 76) reported falls and did not find differences between telehealth and in-person physiotherapy. There was low-quality evidence that telehealth interventions improve balance outcomes more than face-to-face interventions (pooled between-group mean difference 2.48 Berg Balance Scale units, 95%CI 0.77 to 4.20). Fear of falling was not different between intervention delivery modes.
Conclusion
Findings suggest that telehealth delivered falls prevention interventions are safe, feasible and acceptable in community-dwelling adults with neurological conditions, however, data related to effectiveness in reducing falls is limited. Low-quality evidence suggests that telehealth may deliver similar or better outcomes for standing balance in this population.
StolzeHKlebeSZechlinC,et al.Falls in frequent neurological diseases—prevalence, risk factors and aetiology. J Neurol2004; 251: 79–84.
2.
SackleyCBrittleNPatelS, et al.The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke. Stroke2008; 39: 3329–3334.
3.
NilsagårdYGunnHFreemanJ, et al.Falls in people with MS—an individual data meta-analysis from studies from Australia, Sweden, United Kingdom and the United States. Mult Scler2015; 21: 92–100.
4.
PaulSSCanningCGSherringtonC,et al.Three simple clinical tests to accurately predict falls in people with Parkinson's disease. Mov Disord2013; 28: 655–662.
5.
FriedmanJH. Re: practice parameter: assessing patients in a neurology practice for risk of falls (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009; 72: 382.
6.
SaverinoAMoriartyAPlayfordD. The risk of falling in young adults with neurological conditions: a systematic review. Disability & Rehabilitation2014; 36: 963–977.
7.
BoothVLoganPHarwoodR,et al.Falls prevention interventions in older adults with cognitive impairment: a systematic review of reviews. Int J Ther Rehabil2015; 22: 289–296.
8.
AbouLAlluriAFlifletA,et al.Effectiveness of physical therapy interventions in reducing fear of falling among individuals with neurologic diseases: a systematic review and meta-analysis. Arch Phys Med Rehabil2021; 102: 132–154.
9.
O’MalleyNCliffordAMConneelyM,et al.Effectiveness of interventions to prevent falls for people with multiple sclerosis, Parkinson’s disease and stroke: an umbrella review. BMC Neurol2021; 21: 378.
10.
TomlinsonCLPatelSMeekC, et al.Physiotherapy versus placebo or no intervention in Parkinson's disease. Cochrane Database Syst Rev2013; 2013(9): CD002817.
11.
DenissenSStaringWKunkelD, et al.Interventions for preventing falls in people after stroke. Cochrane Database Syst Rev2019; 10: CD008728.
12.
HayesSGalvinRKennedyC, et al.Interventions for preventing falls in people with multiple sclerosis. Cochrane Database Syst Rev2019; 11: CD012475.
13.
DautzenbergLBeglingerSTsokaniS, et al.Interventions for preventing falls and fall-related fractures in community-dwelling older adults: a systematic review and network meta-analysis. J Am Geriatr Soc2021: 2973–2984.
14.
GillespieLDRobertsonMCGillespieWJ, et al.Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev2012; 2012(9): CD007146.
15.
FosterMAllenSFlemingJ. Unmet health and rehabilitation needs of people with long-term neurological conditions in Queensland, Australia. Health Soc Care Community2015; 23: 292–303.
16.
NicholsonSLDonaghyMJohnstonM, et al.A qualitative theory guided analysis of stroke survivors’ perceived barriers and facilitators to physical activity. Disabil Rehabil2014; 36: 1857–1868.
17.
MarzoliniSBalitskyAJagroopD, et al.Factors affecting attendance at an adapted cardiac rehabilitation exercise program for individuals with mobility deficits poststroke. J Stroke Cerebrovasc Dis2016; 25: 87–94.
18.
GallowayMMarsdenDCallisterR,et al.The feasibility of a telehealth exercise program aimed at increasing cardiorespiratory fitness for people after stroke. Int J Telerehabil2019; 11: 9–28.
19.
Di TellaSPagliariCBlasiV,et al.Integrated telerehabilitation approach in multiple sclerosis: a systematic review and meta-analysis. J Telemed Telecare2020; 26: 385–399.
20.
RamageERFiniNLynchEA, et al.Look before you leap: interventions supervised via telehealth involving activities in weight-bearing or standing positions for people after stroke-a scoping review. Phys Ther2021; 101(6): 103784.
21.
EnglishCCeravoloMGDorschS, et al.Telehealth for rehabilitation and recovery after stroke: State of the evidence and future directions. Int J Stroke2022; 17(5): 487–493.
22.
PageMJMcKenzieJEBossuytPM, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J2021; 372: n71.
23.
SheaBJReevesBCWellsG, et al.AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Br Med J2017; 358: j4008.
24.
GuyattGDrummondRMeadeM,et al.The evidence based medicine working group users’ guides to the medical literature. Essentials of evidence-based clinical practice2008; 284(10): 1290–1296.
HigginsJPSavovićJPageMJ,et al.Assessing risk of bias in a randomized trial. In: Cochrane Handbook for Systematic Reviews of Interventions, 2019: 205–228.
28.
SterneJAHernánMAMcAleenanA,et al.Assessing risk of bias in a non–randomized study. In: Cochrane Handbook for Systematic Reviews of Interventions, 2019: pp.621–641.
29.
McGuinnessLAHigginsJPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods2020: 1–7.
30.
TysonSConnellL. How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions. Clin Rehabil2009; 23: 824–840.
31.
VanicekNKingSAGohilR,et al.Computerized dynamic posturography for postural control assessment in patients with intermittent claudication. J Vis Exp2013; 82: e51077.
32.
GazibaraTKurtagicIKisic-TepavcevicD, et al.Falls, risk factors and fear of falling among persons older than 65 years of age. Psychogeriatrics2017; 17: 215–223.
33.
NilsagardYCarlingAForsbergA. Activities-specific balance confidence in people with multiple sclerosis. Mult Scler Int2012; 2012: 613925.
34.
MakMKPangMY. Balance confidence and functional mobility are independently associated with falls in people with Parkinson's disease. J Neurol2009; 256: 742–749.
35.
ParkEYLeeYJChoiYI. The sensitivity and specificity of the falls efficacy scale and the Activities-specific Balance Confidence Scale for hemiplegic stroke patients. J Phys Ther Sci2018; 30: 741–743.
36.
DykesPCDuckworthMCunninghamS, et al.Pilot testing fall TIPS (tailoring interventions for patient safety): a patient-centered fall prevention toolkit. Jt Comm J Qual Patient Saf2017; 43: 403–413.
37.
AngEMordiffiSZWongHB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs2011; 67: 1984–1992.
38.
van GaalBGSchoonhovenLMintjesJA, et al.Fewer adverse events as a result of the SAFE or SORRY? Programme in hospitals and nursing homes. Part I: primary outcome of a cluster randomised trial. Int J Nurs Stud2011; 48: 1040–1048.
39.
WiensCAKolebaTJonesCA,et al.The falls risk awareness questionnaire: development and validation for use with older adults. J Gerontol Nurs2006; 32: 43–50.
40.
HillAMMcPhailSMWaldronN, et al.Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised controlled trial. Lancet2015; 385(9987): 2592–2599.
41.
HillAMMcPhailSHoffmannT, et al.A randomized trial comparing digital video disc with written delivery of falls prevention education for older patients in hospital. J Am Geriatr Soc2009; 57: 1458–1463.
42.
KuhlenschmidtMLReeberCWallaceC,et al.Tailoring education to perceived fall risk in hospitalized patients with cancer: a randomized, controlled trial. Clin J Oncol Nurs2016; 20: 84–89.
43.
PynoosJSteinmanBANguyenAQD,et al.Assessing and adapting the home environment to reduce falls and meet the changing capacity of older adults. J Hous Elderly2012; 26: 137–155.
44.
LettsLMarshallL. Evaluating the validity and consistency of the SAFER tool. Phys Occup Ther Geriatr1996; 13: 49–66.
45.
GagnonMASebiyo BatchoCBirdML,et al.Feasibility of a remotely supervised home-based group eHealth Fitness and Mobility Exercise program for stroke: French-Canadian version preliminary study. Top Stroke Rehabil2022: 1–11.
46.
WanXWangWLiuJ,et al.Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol2014; 14: 135.
47.
LuoDWanXLiuJ,et al.Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res2018; 27: 1785–1805.
Review Manager (RevMan). Version 5.4.1. Copenhagen: The Cochrane Collaboration; 2020.
50.
ChenJJinWDongWS, et al.Effects of home-based telesupervising rehabilitation on physical function for stroke survivors with hemiplegia: a randomized controlled trial. Am J Phys Med Rehabil2017; 96: 152–160.
51.
GandolfiMGeroinCDimitrovaE, et al.Virtual reality telerehabilitation for postural instability in Parkinson's disease: a multicenter, single-blind, randomized, controlled trial. Biomed Res Int2017; 2017: 7962826.
52.
LavoieVBouchardMTurcotteS,et al.Telerehabilitation for individuals with Parkinson's disease and a history of falls: a pilot study. Physiother Can2021; 73: 343–350.
53.
GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University and Evidence Prime Afgo. Available from: URL: Available from gradepro.org.
54.
Ortiz-GutierrezRCano-de-la-CuerdaRGalan-del-RioF, et al.A telerehabilitation program improves postural control in multiple sclerosis patients: a Spanish preliminary study. Int J Environ Res Public Health2013; 10: 5697–5710.
55.
Ortiz-GutiérrezRGalán Del RíoFCano de la CuerdaR,et al.A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation2013; 33: 545–554.
56.
AsanoMTaiBChenC, et al.Home-based tele-rehabilitation presents comparable and positive impact on self-reported functional outcomes as center-based rehabilitation: Singapore tele-technology aided rehabilitation in stroke (STARS) trial. Ann Phys Rehabil Med2018; 61: e22–ee3.
57.
ChenSCLinCHSuSW,et al.Feasibility and effect of interactive telerehabilitation on balance in individuals with chronic stroke: a pilot study. J Neuroeng Rehabil2021; 18: 71.
58.
ChanpimolSBensonKMaloniH,et al.Acceptability and outcomes of an individualized exergaming telePT program for veterans with multiple sclerosis: a pilot study. Arch Physiother2020; 10: 18. –.
59.
BernocchiPVanoglioFBarattiD, et al.Home-based telesurveillance and rehabilitation after stroke: a real-life study. Top Stroke Rehabil2016; 23: 106–115.
60.
Fjeldstad-PardoCThiessenAPardoG. Telerehabilitation in multiple sclerosis: results of a randomized feasibility and efficacy pilot study. Int J Telerehabil2018; 10: 55–64.
61.
HuijbregtsMPMcEwenSTaylorD. Exploring the feasibility and efficacy of a telehealth stroke self-management programme: a pilot study. Physiother Can2009; 61: 210–220.
62.
HuzmeliEDDumanTYildirimH. Efficacy of telerehabilitation in patients with stroke in Turkey: a pilot study. Turk J Neurol2017; 23: 21–25.
63.
KahramanTSavciSOzdogarAT,et al.Physical, cognitive and psychosocial effects of telerehabilitation-based motor imagery training in people with multiple sclerosis: a randomized controlled pilot trial. J Telemed Telecare2020; 26: 251–260.
64.
LaiJCKWooJHuiE,et al.Telerehabilitation—a new model for community-based stroke rehabilitation. J Telemed Telecare2004; 10: 199–205.
65.
RendaMLapeJE. Feasibility and effectiveness of telehealth occupational therapy home modification interventions. Int J Telerehabil2018; 10: 3–14.
66.
SeidlerKJDuncanRPMcNeelyME,et al.Feasibility and preliminary efficacy of a telehealth approach to group tango instruction for people with Parkinson's disease. Mov Disord2016; 31: S673–S6S4.
67.
WuZSXuJJYueCX,et al.Collaborative care model based telerehabilitation exercise training program for acute stroke patients in China: a randomized controlled trial. J Stroke & Cerebrovasc Dis2020; 29: 105328.
68.
GervasoniEJonsdottirJMontesanoA,et al.Minimal clinically important difference of berg balance scale in people with multiple sclerosis. Arch Phys Med Rehabil2017; 98: 337–340. e2.
69.
TamuraSMiyataKKobayashiS,et al.The minimal clinically important difference in Berg Balance Scale scores among patients with early subacute stroke: a multicenter, retrospective, observational study. Top Stroke Rehabil2021; 29(6): 423.
70.
MaldanerNSosnovaMZigaM, et al.External validation of the minimum clinically important difference in the timed-up-and-go test after surgery for lumbar degenerative disc disease. Spine (Phila Pa 1976)2022; 47: 337–342.
71.
GautschiOPStienenMNCorniolaMV, et al.Assessment of the minimum clinically important difference in the timed up and go test after surgery for lumbar degenerative disc disease. Neurosurgery2017; 80: 380–385.
72.
SherringtonCFairhallNKwokW, et al.Evidence on physical activity and falls prevention for people aged 65 + years: systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act2020; 17: 144.
73.
BernocchiPGiordanoAPintavalleG, et al.Feasibility and clinical efficacy of a multidisciplinary home-telehealth program to prevent falls in older adults: a randomized controlled trial. J Am Med Dir Assoc2019; 20: 340–346.
74.
ChanJKYKlainin-YobasPChiY,et al.The effectiveness of e-interventions on fall, neuromuscular functions and quality of life in community-dwelling older adults: a systematic review and meta-analysis. Int J Nurs Stud2021; 113: 103784.
JanssonMMRantalaAMiettunenJ,et al.The effects and safety of telerehabilitation in patients with lower-limb joint replacement: a systematic review and narrative synthesis. J Telemed Telecare2022; 28: 96–114.
78.
RhonDIFritzJMKernsRD, et al.TIDieR-telehealth: precision in reporting of telehealth interventions used in clinical trials - unique considerations for the Template for the Intervention Description and Replication (TIDieR) checklistBMC Med Res Methodol2022; 22: 161.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
