Rehabilitación y capacidad funcional en la salud del siglo XXI Translated title: Rehabilitation and functional capacity in the health of the 21st century

Summary Background Rehabilitation has often been seen as a disability-specific service needed by only few of the population. Despite its individual and societal benefits, rehabilitation has not been prioritised in countries and is under-resourced. We present global, regional, and country data for the number of people who would benefit from rehabilitation at least once during the course of their disabling illness or injury. Methods To estimate the need for rehabilitation, data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were used to calculate the prevalence and years of life lived with disability (YLDs) of 25 diseases, impairments, or bespoke aggregations of sequelae that were selected as amenable to rehabilitation. All analyses were done at the country level and then aggregated to seven regions: World Bank high-income countries and the six WHO regions (ie, Africa, the Americas, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific). Findings Globally, in 2019, 2·41 billion (95% uncertainty interval 2·34–2·50) individuals had conditions that would benefit from rehabilitation, contributing to 310 million [235–392] YLDs. This number had increased by 63% from 1990 to 2019. Regionally, the Western Pacific had the highest need of rehabilitation services (610 million people [588–636] and 83 million YLDs [62–106]). The disease area that contributed most to prevalence was musculoskeletal disorders (1·71 billion people [1·68–1·80]), with low back pain being the most prevalent condition in 134 of the 204 countries analysed. Interpretation To our knowledge, this is the first study to produce a global estimate of the need for rehabilitation services and to show that at least one in every three people in the world needs rehabilitation at some point in the course of their illness or injury. This number counters the common view of rehabilitation as a service required by only few people. We argue that rehabilitation needs to be brought close to communities as an integral part of primary health care to reach more people in need. Funding Bill & Melinda Gates Foundation.

Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face‐to‐face or when added to usual care. To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in‐person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face‐to‐face); or (2) no rehabilitation or usual care. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self‐care and domestic life and improved mobility, balance, health‐related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in‐person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost‐effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions. We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library , Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists. Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in‐person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in‐person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation. Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings. We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies . Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post‐hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post‐stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke. Primary outcome: we found moderate‐quality evidence that there was no difference in activities of daily living between people who received a post‐hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) ‐0.00, 95% confidence interval (CI) ‐0.15 to 0.15)). We found low‐quality evidence of no difference in effects on activities of daily living between telerehabilitation and in‐person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI ‐0.43 to 0.48). Secondary outcomes: we found a low quality of evidence that there was no difference between telerehabilitation and in‐person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI ‐0.30 to 0.46). Pooling of three studies with 569 participants showed moderate‐quality evidence that there was no difference between those who received post‐discharge support interventions and those who received usual care on health‐related quality of life (SMD 0.03, 95% CI ‐0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate‐quality evidence that there was no difference in depressive symptoms when comparing post‐discharge tele‐support programs with usual care (SMD ‐0.04, 95% CI ‐0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI ‐2.17 to 4.64, low‐quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in‐person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost‐effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial‐related adverse events were reported. While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate‐level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short‐term post‐hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in‐person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost‐effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes. Telerehabilitation services for stroke Review question 
 This review aimed to gather evidence for the use of telerehabilitation after stroke. We aimed to compare telerehabilitation with therapy delivered face‐to‐face and with no therapy (usual care). Background 
 Stroke is a common cause of disability in adults. After a stroke, it is common for the individual to have difficulty managing everyday activities such as walking, showering, dressing, and participating in community activities. Many people need rehabilitation after stroke; this is usually provided by healthcare professionals in a hospital or clinic setting. Recent studies have investigated whether it is possible to use technologies such as the telephone or the Internet to help people communicate with healthcare professionals without having to leave their home. This approach, which is called telerehabilitation, may be a more convenient and less expensive way of providing rehabilitation. Telerehabilitation may be used to improve a range of outcomes including physical functioning and mood. Study characteristics 
 We searched for studies in June 2019 and identified 22 studies involving 1937 people after stroke. The studies used a wide range of treatments, including therapy programmes designed to improve arm function and ability to walk and programmes designed to provide counselling and support for people upon leaving hospital after stroke. Key results 
 As the studies were very different, it was rarely appropriate to combine results to determine overall effect. We found that people who received telerehabilitation had similar outcomes for activities of daily living function to those that received face‐to‐face therapy and those that received no therapy (usual care). At this point, not enough research has been done to show whether telerehabilitation is a more effective way to provide rehabilitation. Some studies report that telerehabilitation is less expensive to provide but information is lacking about cost‐effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. Further trials are required. Quality of the evidence 
 The quality of the evidence was generally of low or moderate quality. The quality of the evidence for each outcome was limited due to small numbers of study participants and poor reporting of study details.

Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.