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      Telerehabilitation services for stroke

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          Abstract

          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.

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          Most cited references62

          • Record: found
          • Abstract: found
          • Article: not found

          Global Burden of Stroke.

          On the basis of the GBD (Global Burden of Disease) 2013 Study, this article provides an overview of the global, regional, and country-specific burden of stroke by sex and age groups, including trends in stroke burden from 1990 to 2013, and outlines recommended measures to reduce stroke burden. It shows that although stroke incidence, prevalence, mortality, and disability-adjusted life-years rates tend to decline from 1990 to 2013, the overall stroke burden in terms of absolute number of people affected by, or who remained disabled from, stroke has increased across the globe in both men and women of all ages. This provides a strong argument that "business as usual" for primary stroke prevention is not sufficiently effective. Although prevention of stroke is a complex medical and political issue, there is strong evidence that substantial prevention of stroke is feasible in practice. The need to scale-up the primary prevention actions is urgent.
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            Global stroke statistics.

            Background Up to date data on incidence, mortality, and case-fatality for stroke are important for setting the agenda for prevention and healthcare. Aims and/or hypothesis We aim to update the most current incidence and mortality data on stroke available by country, and to expand the scope to case-fatality and explore how registry data might be complementary. Methods Data were compiled using two approaches: (1) an updated literature review building from our previous review and (2) direct acquisition and analysis of stroke events in the World Health Organization (WHO) mortality database for each country providing these data. To assess new and/or updated data on incidence, we searched multiple databases to identify new original papers and review articles that met ideal criteria for stroke incidence studies and were published between 15 May 2013 and 31 May 2016. For data on case-fatality, we searched between 1980 and 31 May 2016. We further screened reference lists and citation history of papers to identify other studies not obtained from these sources. Mortality codes for ICD-8, ICD-9, and ICD-10 were extracted. Using population denominators provided for each country, we calculated both the crude mortality from stroke and mortality adjusted to the WHO world population. We used only the most recent year reported to the WHO for which both population and mortality data were available. Results Fifty-one countries had data on stroke incidence, some with data over many time periods, and some with data in more than one region. Since our last review, there were new incidence studies from 12 countries, with four meeting pre-determined quality criteria. In these four studies, the incidence of stroke, adjusted to the WHO World standard population, ranged from 76 per 100,000 population per year in Australia (2009-10) up to 119 per 100,000 population per year in New Zealand (2011-12), with the latter being in those aged at least 15 years. Only in Martinique (2011-12) was the incidence of stroke greater in women than men. In countries either lacking or with old data on stroke incidence, eight had national clinical registries of hospital based data. Of the 128 countries reporting mortality data to the WHO, crude mortality was greatest in Kazhakstan (in 2003), Bulgaria, and Greece. Crude mortality and crude incidence of stroke were both positively correlated with the proportion of the population aged ≥ 65 years, but not with time. Data on case-fatality were available in 42 studies in 22 countries, with large variations between regions. Conclusions In this updated review, we describe the current data on stroke incidence, case-fatality and mortality in different countries, and highlight the growing trend for national clinical registries to provide estimates in lieu of community-based incidence studies.
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              • Article: not found

              Telerehabilitation services for stroke

              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.
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                Author and article information

                Journal
                146518
                Cochrane Database of Systematic Reviews
                Wiley
                14651858
                January 31 2020
                Affiliations
                [1 ]Flinders University; Department of Rehabilitation, Aged and Extended Care; Flinders Drive Adelaide South Australia Australia 5041
                [2 ]Southern Adelaide Local Health Network; Division Rehabilitation, Aged Care and Palliative Care; Adelaide Australia
                [3 ]Monash University; Department of Neuroscience, Central Clinical School; Melbourne Australia
                [4 ]The University of Sydney; Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health; PO Box 179 Missenden Road Sydney NSW Australia 2050
                Article
                10.1002/14651858.CD010255.pub3
                6992923
                32002991
                75ed9939-adfc-476e-ab78-64ca6183c326
                © 2020
                Product
                Self URI (article page): http://doi.wiley.com/10.1002/14651858.CD010255.pub3

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