Abstract
We conducted a systematic review of telerehabilitation interventions in stroke care. The following databases were searched: Medline, Embase, DARE-NHSEED-HTA (INAHTA) and the Cochrane Library. Nine studies, all published after 2000, were included in the review. A wide variety of telemedicine interventions in post-stroke rehabilitation care was identified. Four studies had been carried out in the USA, two in the Netherlands, two in Italy and one in China. There were four randomized controlled trials and one qualitative analysis. Four studies used an observational study design/case series. Home-based telerehabilitation interventions showed promising results in improving the health of stroke patients and in supporting caregivers. Telemedicine systems based on a virtual environment for upper extremity exercise can improve the physical health of stroke patients. Health professionals and participants reported high levels of satisfaction and acceptance of telerehabilitation interventions. There was no evidence regarding the effects on resource utilization or cost-effectiveness. Most studies showed promising results, although overall, the quality of the evidence on telerehabilitation in post-stroke care was low.
Introduction
Stroke rehabilitation is an important component of post-stroke care and is more effective the sooner it begins. Stroke rehabilitation therapy aims to improve patients physically, cognitively, emotionally and in terms of social wellbeing. 1 Successful rehabilitation depends on stroke severity, rehabilitation team skills, and the co-operation of patients and their families and/or friends. 2 However, many patients have reduced access to care due to limited regional and logistical resources. These patient groups could benefit from a system that allows a health professional to provide rehabilitation services from a remote location. 3
For the purposes of the present review, telerehabilitation was defined as the ability to provide distance support, evaluation and intervention to persons who are disabled via telecommunication.
4
The primary benefit of telemedicine in stroke management is that areas with insufficient neurological services can be supported by stroke experts by telephone, via the Internet or through realtime videoconsulting, which may improve the quality of stroke care. Other putative advantages are a reduction in costs (through the avoidance of patient transport), improvement in stroke education (used in secondary prevention), and better efficiency in the implementation of rehabilitation services.
5,6
We have conducted a systematic review to explore:
The feasibility, effectiveness, cost-effectiveness and quality of telerehabilitation interventions in post-stroke care; The effect of post-stroke telerehabilitation initiatives on health outcomes, health-care processes, the use of health resources, and user/patient satisfaction and acceptance.
Methods
A systematic literature search was conducted in November 2008 (and updated in November 2009) in Ovid Medline, Embase, DARE-NHSEED-HTA (INAHTA) and the Cochrane Library using the MeSh/Emtree terms stroke and telemedicine. The search was limited to the years 1995-2009, and to peer-reviewed journals. Telerehabilitation studies were identified in a broad generic search on telemedicine in stroke care. After the removal of duplicates, 214 hits remained.
Selection criteria
A PICO framework (Population, Intervention, Control, Outcome) was designed and its elements used as selection criteria. Articles were regarded as potentially eligible if they met all of the following criteria: inclusion of stroke patients, evaluation of a telerehabilitation service, and inclusion of original data on health outcomes, health-care processes, or resource utilization. The definition of quality of care was based on Donabedian's model, which considers outcomes, processs and structures of care. 7 The outcome of care indicates the effects of care on individuals. The process of care refers to the characteristics of available services. The structure of care is the facilities, equipment, services and manpower available for care, and the credentials and qualifications of the health-care professionals involved. 8
Selection method
Two reviewers independently screened each title and abstract of a potentially eligible report using Endnote, with the help of a standardised internal manual. Each article was categorized into one of three groups: ‘yes’ (based on abstract, seems to meet inclusion criteria), ‘no’ (does not meet the inclusion criteria) and ‘background’ (useful background material). From the 214 hits, 18 articles were ordered for full text review and of these nine studies were included.
Data extraction
Two standardized extraction tables were created including a set of variables for extracting relevant information on telemedicine technologies in post-stroke rehabilitation care:
General characteristics: author, year, country, study design, objective, settings and funding; Characteristics and outcomes of included studies involving telerehabilitation: intervention, study (intervention) length, population, technology and personal resources, process management, outcome category measured and result.
Results
Nine studies, all published after 2000, were included in the review (Table 1). Four studies had been carried out in the USA, 3,9–11 two in the Netherlands, 12,13 two in Italy 14,15 and one in China. 4 There were four randomized controlled trials 9,12–14 and one qualitative analysis. 10 Four studies had used an observational study design/case series. 3,4,11,15
General characteristics of the studies reviewed
Quality of studies
Study design is crucial in assessments of the quality of evidence. Many studies in the present review had small sample sizes, with almost two-thirds having 25 or fewer participants.
Randomized controlled trials
The quality of the included randomized controlled trials varied. The randomization procedure was not clearly described in the studies, which raises concerns about potential selection bias. However, there were no significant differences in subject characteristics at baseline between the groups. 9,12–14 One randomized controlled trial had a power calculation 12 and another an intention-to-treat analysis. 13 In one study the examining neurologist was blind to the treatments administered to the patients. 14 The other studies lacked adequate blinding procedures. 9,12,13 If outcomes are subjective then their assessment is highly susceptible to bias. 16 No high dropout rates (>20%) or differential dropout rates (>15%) were recorded. 9,12–14
Observational studies
Some of the observational studies could be categorized as experimental or pilot studies. 3,10,15 Observational studies are in many cases graded as low evidence, but can provide important information on safety and feasibility. However, due to the small sample sizes and lack of control groups, the level of evidence provided by the observational studies was very low.
Home-based or community-based telerehabilitation
Eight home-based interventions were identified in the literature. 3,9–15 Two systems used ordinary telephones 9,12 and one system used low bandwidth videophones. 11 Another study used an Internet-based intervention to support and educate caregivers of stroke survivors. 10 Four studies used a virtual environment-based motor telerehabilitation system with an integrated high quality videoconsulting method to exercise the upper extremity. 3,13–15 One study used a realtime videoconsulting system for a community-based stroke rehabilitation programme. 4
Distant care and support
One telephone-based intervention developed a distant care programme for stroke patients discharged home in order to improve quality of care. Telehealth nurses supported patients (with family caregivers) according to their individual needs, e.g. advised them how to solve and cope with problems themselves. The programme consisted of telephone contact and visits to patients' homes. 12 Another telephone intervention aimed to develop and maintain stroke survivors' and their caregivers' social problem-solving skills, in home-based settings. 9 One study aimed to identify factors that influenced the receptiveness, use and acceptance of videophones. The system was used to support caregivers of stroke survivors in their homes. 11 An Internet-based educational intervention aimed to support stroke caregivers living in rural communities. The participants were linked to a customized educational care website giving ‘tips of the month’ and educational information. They also had the possibility of participating in an email consultation with a specialist nurse or rehabilitation team. An email discussion forum, that offered caregivers the opportunity to communicate with each other and exchange personal experiences was established. 10
One study used a realtime videoconsulting system in a community-based stroke rehabilitation programme. The system linked a hospital and a community centre for seniors. A physiotherapist gave educational talks, physical exercises and provided participants with psychological support using the system. 4
Physical therapy/motor function
Four studies aimed to improve stroke survivors' upper extremity function with a virtual environmental-based motor telerehabilitation intervention. Sensors placed either on the upper extremity (arm/hand) or objects, sometimes both, were used to monitor patients' exercises. The patient data were transmitted to a hospital-based server. Two monitors, one for the realtime videoconsultation and one for the virtual environment-based tasks, were used in these systems. Through the videoconsulting system the therapist could provide the patient with different tasks and support the patient when needed. 3,13–15 One system used the ISDN network to link the workstations. 15 In a later publication, an Internet-based broadband connection was used (ADSL). 14 In total, 63 stroke patients (intervention groups with a range from 5–36 patients) were included in the virtual environment-based motor telerehabilitation studies. The length of interventions varied from 4–6 weeks with an one-hour session five days per week. 3,13–15
Outcome categories measured
A broad range of outcome measures was used in the telerehabilitation studies (Table 2). A short description of the instruments is given in Table 3. Different scales for measuring quality of life, health status and depression were used. Among others, the following scales were used to measure dependency and mobility: the Barthel Index (BI), modified Ranking Scale (mRS), Functional Independence Measure (FIM scale) and the Elderly Mobility Scale. Different scales for measuring the burden of caregiving were also used. Six studies reported outcomes on satisfaction with telerehabilitation interventions using a satisfaction questionnaire. 4,9–13
Population, outcome categories measured and results
Outcome measurement instruments
Health outcomes
Distant care and support
In a distant nursing support intervention the primary outcome measures were the SF-36 quality of life score and a satisfaction questionnaire. Stroke patients in the intervention group reported better SF-36 scores than controls, but the difference was not significant. No significant difference was found in satisfaction or in secondary outcome measures such as the Hospital Anxiety and Depression Scale, the BI, the mRS and the use of secondary prevention drugs since discharge. One exception was that intervention patients used fewer rehabilitation services (14%) than controls (20%) and had lower anxiety scores: median 4 (range from 2 to 8) in the intervention group versus 5 (range from 2 to 8) in the control group. 12 One study aimed to improve stroke caregivers' social problem-solving skills through a telephone-based intervention. Caregivers in the intervention group had better problem-solving skills, greater caregiver preparedness and less depression than the control group. The intervention group had significantly better SF-36 scores in vitality, social functioning, and mental health compared to the control group. 9
In the community-based videoconsulting intervention participants presented better scores after the programme compared to the initial phase. The Berg Balance Scale improved from 42 to 49, the State Self-Esteem Scale and knowledge test from 65 to 80. Scores on all subscales of the SF-36 also improved. 4
Physical therapy/motor function
In a motor arm telerehabilitation intervention no significant differences were found in the Action Research Arm Test and the Nine-Hole Peg Test, when comparing the intervention group and control group. These results suggest that upper extremity exercise via telerehabilitation in home-based settings is feasible. 13 In another study based on a 3-D motion tracking system, patients' arm disability reduced significantly. The Fugl-Meyer mean score improved from 51 to 57. No difference was seen in the FIM scale scores. 15 A recently published article on the 3-D motor tracking system reported significant improvements in the Fugl-Meyer Upper Extremity scale when comparing the intervention group (54) and control group (50). No differences were found in the ABILHAND scale and Ashworth scale. At one month follow-up both groups maintained the benefits achieved. 14
In a case series study significant improvements in upper extremity functions were registered using the Fugl-Meyer test of motor recovery, Wolf motor test and shoulder strength test. Grip strength showed an improving trend. At four months follow-up the following improvements were maintained: Fugl-Meyer test (+7.6), Wolf motor test (−18.4 s), shoulder strength (+169%) and grip strength (+53%). 3
Satisfaction and acceptance
Six studies reported user and patient satisfaction of telemedicine interventions in stroke rehabilitation settings. Overall, participants, caregivers and health professionals were satisfied and accepted the use of telerehabilitation services. 4,9–13
In the community-based videoconsulting rehabilitation programme all participants reported a high level of acceptance and satisfaction. Patients rated the intervention as good in 63% of cases and excellent in 36% of cases. 4 In the ‘problem-solving skills telephone partnerships intervention’, satisfaction with health-care services decreased over time in the control group while remaining similar in the intervention group. 9 All participants in the educational Internet-based intervention stated that they were satisfied with the service. 10 Overall, patients and therapists were satisfied with the virtual environmental-based motor telerehabilitation service. 13
Cost and utilization
No study reported information on cost-effectiveness or on resource utilization. Some studies mentioned investment costs. 3,10,11
Discussion
Many patients released from acute inpatient rehabilitation have limited access to outpatient rehabilitation, especially those who live in rural areas. 3 A wide variety of telemedicine interventions in post-stroke rehabilitation care were identified and most of them showed promising results. Using telerehabilitation systems it is possible to provide rehabilitation services in patients' homes or in community-based settings. This allows health professionals to monitor patients' health status and to identify conditions that need improvement before an adverse effect occurs. Telerehabilitation interventions in stroke care can also be used for educational purposes and to support caregivers of stroke survivors living at home.
Speech-language pathology evaluation via videoconsulting as opposed to face-to-face evaluation has been shown to be feasible, 17–19 although no study included in the present review explored this intervention. Speech-language pathology therapies via telemedicine seem to be a promising research area for stroke patients with speech disorders.
Health professionals and participants reported high levels of satisfaction and acceptance of telerehabilitation interventions in stroke care, although few studies explored this outcome extensively. Satisfaction studies tend to generate positive results. This can be misleading, as patient satisfaction measures often fail to discount first impressions and explore what happened to patient satisfaction over time. 20
Overall, the studies included in the present review involved small populations and only four studies had a control group, thus making it difficult to reach any definite conclusions about the effectiveness of telerehabilitation interventions in post-stroke care. Patients included in telerehabilitation interventions generally suffered from mild impairment after stroke and were living in home settings. Whether telerehabilitation interventions are suitable for patients with heavier impairments is still to be investigated. Most studies showed improvements in the outcome measures used, but failed to explain the clinical relevance of these results.
Finally, the present review has at least one limitation: the reports on telerehabilitation were identified in a broad generic search strategy, which focused on telemedicine and stroke care.
In summary, the few telerehabilitation studies on post-stroke care reviewed showed promising results in improving stroke survivors' and caregivers' health. Health professionals and participants reported high levels of satisfaction and acceptance of telerehabilitation interventions. Virtual environmental-based motor systems upper extremity exercise using telemedicine can improve stroke patients' physical health. Nevertheless, the overall quality of the evidence on telerehabilitation in post-stroke care is low. More research is required to determine its effect on effectiveness and costs, and the utilization of telerehabilitation services in stroke care.
Footnotes
Acknowledgements
We are grateful to Prof Dr Gunther Ladurner, at the Christian-Doppler-Clinic Salzburg, Paracelsus Medical Private University for support and advice in preparing the manuscript. The Ludwig Boltzmann Institute of Health Technology Assessment is funded by national research funds (60%) and partner institutions (40%) interested in translational research, e.g. regional hospital cooperation.