Telerehabilitation for motor function:a systematic review

A Turolla1, L Piron1, T Gasparetto2, M Agostini1, HR Jorgensen3, P Tonin1, T Larsen4

1. Laboratory of Kinematics and Robotics, I.R.C.C.S. Fondazione Ospedale San Camillo, Venice, Italy2. Social and Health Programs, Regione Veneto, Venice, Italy3. Sygheus Vendsyssel Brønderslev Neurorehabiliteringscenter. Brønderslev, Denmark4. Southern Denmark University, Centre for Applied Health Services Research and Technology Assessment

(CAST). Odense, Denmark

Background definitionTELEMEDICINE / TELECARE / TELEREHABILITATION

“…care given using telecommunications technologies, in which at least two communication media are used interactively (e.g. video consultation between hospital consultant and general practitioner).”

Implications for research in 2000

• Re-consider the focus and scope of telemedicine

• RCTs of telemedicine applications are feasible and should be carried out.

• Taking account of changes in distribution and use of telematics in society generally, not just in the health care context.

• Consider changing patterns of health care needs with emphasis on care for:– people with chronic conditions– the elderly– disease prevention– health promotion

• Patient-centred approaches.

• Studies of:– Effectiveness– Efficiency– Appropriateness

• Formal economic appraisal

Framework• FP7 - EU HEALTH:

INTEGRATED HOME CARE(grant n. 222954)

• Research for better ways to ensure continuity in clinical care for patients with chronic conditions:– Stroke– Heart failure– COPD

• WP 5 - Telerehabilitation

www.integratedhomecare.eu

Broad reviews’ search strategies

Inclusion criteria Exclusion criteria

1. Published in English

2. Populations:a) HF

b) COPD

c) STROKE

3. Age > 18 yrs

4. Home care setting in the intervention

5. Full-text articles in peer-reviewed journals

1. Reviews not addressing patients directly but caregivers or professionals

2. Reviews which did not address telemedicine in:

a) HF

b) COPD

c) STROKE

Flow chart of the selected reviews

InterventionTelemonitoring (HF, COPD)

• Telephone follow-up (TFU) • Interactive Health Communication Applications (IHCA) • Automated telemonitoring of vital signs and symptoms • Automated physiologic monitoring• Automated computer-based telephone messaging • Monitoring of patients carrying implanted electrical devices

Telerehabilitation (STROKE)

• Telephone follow-up (TFU) • Remote control and interaction with devices based on position/sensing

technologies• Remote control and interaction with virtual reality based devices

Evidences(4 metanalysis)

HF HF & COPD HF & STROKE

•Telemonitoring reduces:–mortality (RR=0.65, p=0.03)–hospital readmission (21%)

•Poor reporting:–costs–adherence–acceptability

•Interactive Health Communication Applications improves:

–Knowledge–Social support–Clinical outcomes

•Case management interventions reduce mortality (OR=0.68, p=0.04)

•TFU patients show clinically-equivalent results compared to control groups, due to the low methodological quality of the studies

ConclusionsIn stroke patients, should be preferred an on-line interactive device (allowing

also videoconference) than a store and forward device to provide telerehabilitation.

Hard primary outcomes like:• overall mortality• hospital admissionshould also be included to prove efficacy.

Secondary outcomes like:• QoL,• costs,• adherence to treatment• patient acceptabilityshould be taken into consideration to perform a complete analysis of

telerehabilitation.

How much broad or narrow should be a

systematic review on telerehabilitation?

Research methods

• PubMed = 964 records

• EMBASE = 328 records

• The Cochrane Library – CENTRAL=113 records

Inclusion criteria

InterventionTele-based therapy programs defined as:1. provided by means of any kind of technological

device which should allow a healthcare professionals/patient on-line interaction;

2. provided by healthcare professionals or individuals under the supervision of healthcare professionals;

3. including at least one or more than one specific intervention targeted to motor function.

Inclusion criteria

Type of studies• RCTs• qRCTs• CCT• First phase of cross over trial

Inclusion criteria

Comparison

• Tele-based therapy programs vs. placebo or no intervention

• Tele-based therapy prograse vs usual care

• Tele-based therapy programs vs in-presence care

Outcome

• Motor function

Quality assessment

Items:1. generation of randomization sequence;2. allocation concealment;3. baseline comparison between groups;4. blinding of outcome assessors;5. intention-to-treat analysis;6. type of study.

Flowchart of the publications’ selection process

Potentially relevant studies identified and screened for retrieval (n=1405)

Duplicates (n=199)

Studies retrieved (n=1207)

Studies included in the metanalysis (n=9)

Not meeting inclusion criteria (n=1197)

Quality assessment

Randomization

sequence allocation

concealment

baseline comparison

between groups

blinding of outcome

assessors

ITT

Analysistype of study

Barnason 2009 × × √ × × √Furber 2010 √ √ √ √ × √Hermes 2007 √ √ √ × × √Huijen 2008 √ √ √ × × √Russell, 2011 √ √ √ √ √ √Piron 2008 √ √ √ × × √Piron 2009 √ √ √ × × √Dall'Olio, 2008 √ √ √ √ × √Tousignat, 2010 √ √ √ √ × √

Treated populations

trials/population

0

1

2

3

4

5

6

Neurological Post surgery Heart Failure

trial

Treated patients

patients/population

168150

97

126 166

107

0

50

100

150

200

250

300

350

Neurological Post surgery Heart Failure

CTRL

EXP

Telerehabilitation vs usual careOutcome: Motor function

Telerehabilitation vs usual careOutcome: Motor function

Conclusions• Little but no significant benefit of telerehabilitation compared

to usual care (0.1 SD)

• If measured, others advantages could sustain the use of telerehabilitation:– Costs– Accessibility– Acceptability

• A low number of authors have published in the field No random distribution of bias in different studies

• Trial sequence analysis STOP randomization?

“You can discover more about a person in a hour of play, than in a life of conversation”

Plato

Thanks for your attention!

San Marco square looking southeast (1735-40)Gian Antonio Canal called “Canaletto”

andrea.turolla@ospedalesancamillo.net