The status of telerehabilitation in neurological applications

Introduction

Telerehabilitation is the provision of rehabilitation services at a distance using telecommunications as the delivery medium. ¹ In a previous review we found that telerehabilitation showed promise in many fields, although strong evidence of benefit was limited, and few studies considered how these approaches might be integrated into health care systems. ² Studies dealing with tele-neurological rehabilitation (TNR) were the most numerous of those we reviewed.

Reviews of telerehabilitation have noted the promise in this field, and the limited available evidence of benefit. Kairy et al. concluded that high-quality evidence regarding the effect of telerehabilitation on resource allocation and costs is still needed to support clinical and policy decision-making. ³ Rogante et al. have referred to a lack of comprehensive studies providing evidence for supporting decision and policy-makers in adopting technologies in clinical practice. ⁴ The theme of promise but limited evidence has also been taken up with respect to TNR in care of stroke survivors. ⁵

The aim of the present study was to obtain an overview of progress in TNR. As in our previous review, our focus was on papers that reported health-related outcomes for patients and/ or caregivers.

Methods

We developed a protocol for the review following approaches taken in previous telemedicine reviews. Initial screening of identified articles was based on the information obtained from their abstracts, which were read independently by at least two reviewers. Further selection of relevant articles was agreed by consensus. When an abstract did not give sufficiently precise information about the study, the article was obtained for further review.

Each full-text article obtained was evaluated independently by at least two reviewers, who reached a consensus on whether an article should be included in the final review. Data were extracted independently from each of the selected publications and any disagreements resolved by consensus. Information extracted included the study objectives, design, type of comparison with the TNR intervention, setting and duration, patient numbers and characteristics, and reported outcomes.

Literature searches were performed using the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL databases to January 2012. There was no language restriction. The complete search strategy is available from the authors.

Articles were selected which described, in a scientifically valid manner, studies reporting clinical or administrative outcomes for patients or caregivers using telerehabilitation applications in the management of neurological disorders. We included articles describing controlled studies in which TNR was compared with a non-TNR alternative, and those on non-controlled series in which there were 20 or more subjects. We excluded studies in which the only outcome measures were related to satisfaction with TNR, reports on technical development or feasibility of a rehabilitation technology and studies identified in the previous review.

Strength of evidence was assessed with an approach used in previous telemedicine reviews that takes account of both study design and study performance. This provides five ratings of study quality and implications for decision makers. ⁶ Study designs included large randomized controlled trials (RCTs) with at least 50 subjects in each arm, smaller RCTs, prospective non-randomized studies, retrospective comparative studies and non-comparative series. For study performance, the areas considered were patient selection, description of the interventions, specification and analysis of the study, patient disposition and reported outcomes. On the basis of scores for study design and performance, each study was assigned to one of five categories to indicate the reliability of its findings (Table 1).

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Table 1.

Study quality and implications for decision making. ⁶

Study quality	Implications for decision making
A. High	High degree of confidence in study findings
B. Good	Some uncertainty regarding study findings
C. Fair to good	Some limitations that should be considered in any implementation of study findings
D. Poor to fair	Substantial limitations in the study, findings should be used cautiously
E. Poor	Unacceptable uncertainty for study findings

Judgements were made on whether the reviewed publications indicated that the TNR applications had been successful. Success was defined in terms of whether the application had performed at least as well as a similar alternative intervention. The principal summary measure was the difference in means of intervention outcomes. For comparative studies, where the interventions in each group were similar, TNR was considered successful when it provided better or equivalent outcomes to those for the comparator. In studies where the TNR intervention included additional resources to those of the comparator intervention, it was considered successful when it provided better outcomes.

For each paper, we judged whether additional data to those reported were needed to establish the TNR method as suitable for routine use. ‘Yes’ indicated substantial limitations in the available evidence. ‘Desirable’ referred to studies of adequate quality, with reasonable evidence of success, where further work was required to confirm the findings. ‘No’ indicated either studies that had provided a strong indication that TNR was suitable for routine use, and for those where an intervention was clearly unsuccessful. Factors considered included the success and clinical significance of the TNR application, its stage of development, the size and composition of the population that was studied and the length of follow up following initiation of rehabilitation.

Results

From 1850 publications identified in the literature search, 693 had been considered in the previous review ² and included the articles on TNR that were identified in that work; these were not considered in the present study. Of the remainder, 106 were retrieved for closer inspection. Nineteen papers that were not in the previous review met the selection criteria and were included in the review.^7–25 Sixteen of the studies (84%) were of high or good quality and three were fair to good (Table 2).

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Table 2.

Study design, quality and outcome status.

Authors	Condition or symptom	Study design and quality *	Successful?	Further study?
Chumbler et al., 2012 7	Stroke	RCT, A	Yes	Desirable
Pierce et al., 2009 8	RCT, B	Yes	No - established
Bell et al., 2011 9	Brain injury	RCT, A	No	No – not effective
Fish et al., 2007 10	Within-subject comparison, B	Yes	Yes
Soong et al., 2005 11	RCT, C	No	Yes
Bombardier et al., 2008 12	Multiple sclerosis	RCT, A	Yes	Yes
Mohr et al., 2007 13	RCT, A	Yes	Desirable
Motl et al., 2011 14	RCT, A	Yes	Yes
Kowalczewski et al., 2011 15	Spinal cord injury	RCT crossover, A	Yes	Yes
Gitlin et al., 2010 16	Dementia	RCT, A	Yes	No - established
Andersson et al., 2003 17	Headache	RCT, B	No	No-not effective
Dilorio et al., 2009 18	Epilepsy	Observational, B	Unclear	Yes
Constantinescu et al., 2011 19	Speech disorder	RCT, A	Yes	Desirable
Carey et al., 2010 20	RCT, A	Yes	No - established
Kosterink et al., 2010 21	Neck and shoulder pain	RCT, C	Yes	Yes
Knoop et al., 2008 22	Fatigue	RCT, A	Yes	Desirable
Ghahari et al., 2010 23	RCT, C	No	No – not effective
Vitacca et al., 2010 24	Amyotrophic lateral sclerosis	Observational, B	Yes	Desirable
Maher et al., 2010 25	Cerebral palsy	RCT, B	Unclear	Yes

An overview of judgements for the reviewed TNR studies is also given in Table 2. Thirteen of the applications were successful, for two the status was unclear and four were unsuccessful. Further study was judged to be required for eight of the TNR applications and desirable for five. For three applications further study was not needed as there was sufficiently strong supporting evidence. For another three, additional research appeared unnecessary as the interventions were clearly not effective.

Further details of the reviewed studies are given in Table 3 (see online archive). Most of them reported clinical outcomes, including physical improvement, mental health and social measures. Three studies were concerned with influence on the use of health services, and two studies included a focus on caregivers. Telephone based applications were considered in 47% of the studies. Two of the Internet-based interventions used specialised functional electrical stimulation and myofeedback approaches.

Discussion

Our previous review included 18 TNR studies on management of stroke, brain injury and multiple sclerosis. ² Using broad selection criteria, which included all types of study design, we located 19 more recent studies on all areas of TNR, which dealt with 13 different conditions. Thus the database for studies that provide useful information on clinical outcomes is still small. As found in our previous review, telephone-based interventions were used in many of the studies that were identified, most of the rest using the Internet. Use of virtual reality approaches may be an important future development in TNR. We identified several studies on the use of virtual reality in neurorehabilitation, but none of these were in a telemedicine context, with remote diagnosis or treatment of patients by means of telecommunications technology.

In most of the comparative studies the intervention provided through TNR was more elaborate than that in the comparator. Typically, patients were contacted more frequently or provided with additional services. Such studies may demonstrate benefits that are related to use of a more elaborate intervention, rather than to the method of delivery.

Overall, we judged that TNR had been shown to be successful in 13 (68%) of the studies. Further work would be needed for eight of the applications to establish their suitability for routine use, and would be desirable for a further five.

The recent literature provides further support for tele-neurorehabilitation applications, showing the promise of this field in a number of areas. Additional, good quality longer term studies are needed to establish the performance of TNR methods in routine practice and provide a stronger information base for providers and funders of rehabilitation services.