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Telerehabilitation services for stroke

  1. Kate E Laver1,*,
  2. Daniel Schoene2,
  3. Maria Crotty3,
  4. Stacey George4,
  5. Natasha A Lannin5,
  6. Catherine Sherrington6

Editorial Group: Cochrane Stroke Group

Published Online: 16 DEC 2013

Assessed as up-to-date: 12 SEP 2013

DOI: 10.1002/14651858.CD010255.pub2


How to Cite

Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C. Telerehabilitation services for stroke. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD010255. DOI: 10.1002/14651858.CD010255.pub2.

Author Information

  1. 1

    Flinders University, Department of Rehabilitation and Aged Care, Adelaide, Australia

  2. 2

    Neuroscience Research Australia, Falls and Balance Research Group, Sydney, Australia

  3. 3

    Flinders University, Repatriation General Hospital, Department of Rehabilitation and Aged Care, Daw Park, South Australia, Australia

  4. 4

    Flinders University, Department of Rehabilitation, Aged and Extended Care, Daw Park, South Australia, Australia

  5. 5

    Alfred Clinical School, La Trobe University, Faculty of Health Science, Prahran, Victoria, Australia

  6. 6

    The George Institute for Global Health, Sydney Medical School, University of Sydney, Musculoskeletal Division, Sydney, NSW, Australia

*Kate E Laver, Department of Rehabilitation and Aged Care, Flinders University, Repatriation General Hospitals, Daws Road, Daw Park, Adelaide, 5041, Australia. kate.laver@health.sa.gov.au.

Publication History

  1. Publication Status: New
  2. Published Online: 16 DEC 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms
 

Description of the condition

Stroke is one of the most common causes of death and acquired disability worldwide (Donnan 2008). Survivors of stroke commonly experience a range of symptoms affecting motor function, speech, swallowing, vision, sensation and cognition, and recovery can be slow and incomplete (Langhorne 2011). These symptoms often lead to difficulty managing activities and limited participation in home and community activities. Approximately half of stroke survivors access some form of rehabilitation on discharge from acute services (National Institutes of Health 2012; National Stroke Foundation 2011). Rehabilitation programmes are often lengthy and resource intensive (AROC 2011; Canadian Stroke Network 2011). Therefore, determining the most effective and efficient ways to deliver stroke rehabilitation services is a matter of priority (Langhorne 2002). 

 

Description of the intervention

Telerehabilitation is the provision of rehabilitation services to patients at a remote location using information and communication technologies (Brennan 2009). Communication between the patient and the rehabilitation professional may occur through a variety of technologies such as the telephone, Internet-based videoconferencing and sensors (such as pedometers). Virtual reality programmes may also be used as a medium for therapy; the patient completes therapy tasks within a computer-generated virtual environment, and data are transmitted to the therapist (Rogante 2010). Telerehabilitation consultations may include assessment, diagnosis, goal setting, therapy, education and monitoring (Russell 2009).

Stemming from the broader approach of telehealth, telerehabilitation has been described as an alternative method of delivering conventional rehabilitation services rather than a subspecialty (Winters 2002). The approach is relatively new, with the first related literature published in the late 1990s. Increasing interest in the use of telerehabilitation (Brochard 2010) has prompted professional bodies to draft position statements regarding its use (American Speech-Language-Hearing Association 2005; Wakeford 2005). These statements have emphasised the need to ensure that quality, ethical and legal standards are met when treatment is provided remotely rather than in person.

Many examples in the current literature demonstrate the scope of telerehabilitation. For example, home assessments to determine the need for modifications have been completed remotely by occupational therapists using a combination of still photography, telephone calls and videoconferencing technology (Sanford 2004). Physiotherapists have provided a safe and effective therapy programme for people after total knee replacement using videoconferencing (Russell 2004), and speech pathologists have demonstrated the feasibility of assessing motor speech disorders via the Internet (Hill 2006).

 

How the intervention might work

Telerehabilitaton has been described simply as an alternative method of providing rehabilitation. Therefore, in theory, the mechanisms leading to recovery should mirror those associated with conventional rehabilitation programmes. It is now well established that organised, interdisciplinary stroke care reduces the likelihood of institutional care and long-term disability and increases independence in activities of daily living (Kalra 2007). Improvements in function after completion of rehabilitation programmes have been attributed to a combination of physiological recovery, neuroplasticity and compensation (Kwakkel 2004).

One of the key advantages of telerehabilitation is that it provides the opportunity for people who are isolated to access rehabilitation services. This feature is particularly beneficial in vast countries such as Canada and Australia, where many people live long distances away from specialised rehabilitation centres. People in rural and remote areas are unlikely to have access to rehabilitation teams with expertise in stroke, and they may not have access to rehabilitation clinicians at all. Eliminating the need for travel to rehabilitation centres may also benefit people with severely restricted mobility who have difficulty travelling or are unable to travel.

Telerehabilitation services may also be used to complement and enhance the quality of current rehabilitation services. Stroke survivors have expressed concern regarding the lack of available long-term support and ongoing unmet rehabilitation needs (McKevitt 2011). It is possible that the use of telerehabilitation may help to address these gaps by supporting patients as they resume life roles on discharge from inpatient facilities.

Furthermore, the use of telerehabilitation may result in cost savings in various ways. Reduced travel time (for clinicians who visit patients in their own home) may mean that clinicians are able to fit more consultations into a single day. In addition, it may be possible to discharge patients from inpatient rehabilitation facilities earlier and offer telerehabilitation as a way of continuing the rehabilitation programme. Furthermore, telerehabilitation may provide a mechanism for increasing the dose of therapy without an increase in face-to-face supervision.  

Despite its apparent advantages, the challenges associated with telerehabilitation are well documented (Theodoros 2008). One of the key issues facing clinicians is how to conduct assessments or provide interventions that are typically "hands on", for example, assessment of muscle strength. The inability to conduct hands-on assessment or treatment means that therapists need to modify current techniques, for example, by utilising family members or teaching the patient ways to perform the intervention independently (Russell 2009).

Furthermore, clinicians and patients may not possess the technical expertise to establish systems and to troubleshoot information and communication technologies. It has been recommended that service providers ensure that technical requirements are met (such as having adequate bandwidth), provide access to technical support and provide training to all users (clinicians and patients). Concerns have also been raised about the security of data transfer and how patient confidentiality can be maintained (American Telemedicine Association 2010).

 

Why it is important to do this review

Changes in the demographics of the population mean that the burden of stroke is projected to increase (Feigin 2003). New approaches that are demonstrated to be clinically sound and cost-effective will be required. Increasing interest in telerehabilitation suggests that this area will continue to grow (Brochard 2010). Furthermore, clinical guidelines for stroke now recommend telerehabilitation for people without access to centre-based rehabilitation services (Canadian Stroke Network 2006). However, establishment of telerehabilitation services may be expensive because of the costs of equipment, training and ongoing technical support. Therefore, it is important to determine whether telerehabilitation services once established may result in the desired outcomes.

Previous systematic reviews have examined the effectiveness of telerehabilitation after stroke (Johansson 2011; Kairy 2009). Kairy et al reviewed the evidence for telerehabilitation for a range of diagnostic groups (Kairy 2009). The literature search was completed in 2007 and included both experimental and observational studies. Four studies involving participants with stroke were included, all of which were observational. The authors reported that despite positive effects reported by some studies, more research was required to obtain definitive information. A more recent review looked specifically at telerehabilitation after stroke and identified nine relevant studies, of which four were RCTs (Johansson 2011). Once again, the review authors reported that although the approach showed promise and was associated with high levels of participant satisfaction, evidence was insufficient to guide practice, and no evidence regarding the cost-effectiveness of telerehabilitation was found. Several limitations were associated with these reviews, including the use of limited search terms and sources. Given the growth of research in this area and the potential for telerehabilitation to improve access to and quality of rehabilitation services while reducing costs, a review using Cochrane methodology was warranted.  

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms

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.

Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self care and domestic life and improved mobility, health-related quality of life, 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.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included only RCTs. We considered cross-over trials as RCTs in accordance with the guidelines of The Cochrane Collaboration (Higgins 2011). We included studies if they compared telerehabilitation with in-person rehabilitation or no rehabilitation, two different methods of delivering telerehabilitation services, different doses of telerehabilitation or telerehabilitation plus usual care compared with usual care alone.

 

Types of participants

All study participants had received a clinical diagnosis of stroke as defined by the World Health Organization ("a syndrome of rapidly developing symptoms and signs of focal, and at times global, loss of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin") (WHO 1989). We included people with all types of stroke, at all levels of severity and at all stages poststroke (acute, subacute or chronic). We also included participants with subarachnoid haemorrhage. We excluded studies with participants of mixed aetiology (e.g. stroke and traumatic brain injury) unless data were available for stroke survivors only. We set no age limits; however, we planned to acknowledge the inclusion of any participants who were younger than 18 years of age.

 

Types of interventions

We included Interventions if they matched the following definition of telerehabilitation: "the delivery of rehabilitation services via information and communication technologies" (Brennan 2009). Clinically, this term encompasses a range of rehabilitation services that include assessment, prevention, intervention, supervision, education, consultation and counselling (American Telemedicine Association 2010). Programmes must have lasted longer than one session. Interactive and communication technologies included the telephone, the Internet, virtual reality and monitoring via sensors or wearable devices. We included rehabilitation programmes that used "store and forward" methods of communication, or real-time interaction. Interventions were provided by one or more health disciplines (e.g. we planned to include studies involving only physical therapy). We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation to conduct assessment or intervention, provided that the greater proportion of intervention was provided via telerehabilitation. We did not include the use of telerehabilitation when the purpose was to provide education or support for healthcare professionals rather than participant care.

 

Types of outcome measures

 

Primary outcomes

The primary outcome of interest was independence in activities of daily living. In the review, this encompassed the self care, mobility and domestic life activity and participation domains derived from the International Classification of Functioning, Disability and Health (WHO 2010). Included were assessment tools scored by the healthcare professional, such as the Functional Independence Measure or the Barthel Index, and questionnaires completed by the study participant (e.g. the Nottingham Extended Activities of Daily Living Index).

 

Secondary outcomes

  1. Self care and domestic life.
  2. Mobility (e.g. Timed Up and Go test, walking speed, functional ambulation category).
  3. Participant satisfaction with the intervention.
  4. Self-reported health-related quality of life.
  5. Upper limb function (e.g. Action Research Arm Test, Wolf Motor Function Test, Fugl-Meyer Upper Extremity measure).  
  6. Cognitive function (global measures such as the Mini Mental State Examination, or specific measures such as tests of attention or executive functioning).
  7. Functional communication.
  8. Cost-effectiveness (as measured by comparing the costs and outcomes of each intervention approach).
  9. Adverse events.

We also aimed to provide information on the feasibility of telerehabilitation for use with stroke patients by reporting on participant eligibility criteria and recruitment methods used in the individual studies identified.

 

Search methods for identification of studies

See the 'Specialized register' section in the Cochrane Stroke Group module. We searched for relevant trials in all languages and planned to arrange translation of trial reports published in languages other than English, if necessary.

 

Electronic searches

We searched the Cochrane Stroke Group Trials Register, which was searched by the Managing Editor in November 2012 using the intervention code telerehabilitation, and the Cochrane Effective Practice and Organisation of Care (EPOC) Group Trials Register in November 2012 using the terms (stroke or brain infarc or cerebral infarc or brain stem infarc) AND tele* as well as (stroke OR brain infarc OR cerebral infarc OR brain stem infarc) AND telerehab*. In addition, we searched the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, November 2012), MEDLINE (Ovid, 1950 to November Week 1, 2012) (Appendix 1), EMBASE (Ovid, 1980 to 11 November 2012) (Appendix 2), AMED (Ovid, 1985 to 18 November 2012) (Appendix 3), CINAHL (Ebsco, 1982 to 11 November 2012) (Appendix 4), PsycINFO (Ovid, 1840 to 11 November 2012) (Appendix 5), PsycBITE (Psychological Database for Brain Impairment Treatment Efficacy, www.psycbite.com/ to 8 November 2012), OTseeker (www.otseeker.com to 8 November 2012), Physiotherapy Evidence Database (www.pedro.org.au to 9 November 2012), REHABDATA (www.naric.com/research/rehab/ to 9 November 2012) and the Health Technology Assessment Database (HTA) (www.crd.york.ac.uk/crdweb/ to 9 November 2012). We developed the MEDLINE search strategy with the help of the Cochrane Stroke Group Trials Search Co-ordinator and used a combination of controlled vocabulary and text word terms. We adapted this strategy for use with the other databases. Search words for trial registers and for other Web-based databases included telerehabilitation, telemedicine, telehealth, videoconferencing and stroke.

We also:

  1. searched the following ongoing trials registers: Current Controlled Trials (www.controlled-trials.com), National Institutes of Health Clinical Trials Database (www.clinicaltrials.gov), Stroke Trials Registry (www.strokecenter.org/trials/), EU Clinical Trials Register (www.clinicaltrialsregister.eu), WHO International Clinical Trials Registry Platform (www.who.int/ictrp/en/) and Australian New Zealand Clinical Trials Registry (www.anzctr.org.au/) to 11 November 2012;
  2. used the Cited Reference Search within Science Citation Index (SCI) and Social Science Citation Index (SSCI) to track relevant references;
  3. searched Dissertation Abstracts (to 9 November 2012) and contacted key researchers in the area and international telemedicine organisations;
  4. searched the UK Telemedicine and E-health Information Service (www.teis.port.ac.uk/); and
  5. searched the grey literature using Open Grey (www.opengrey.eu) and Google Scholar (http://scholar.google.com) on 13 November 2012.

 

Searching other resources

To identify further published, unpublished and ongoing trials, we:

  1. scanned the reference lists of all identified studies and reviews;
  2. scanned the abstracts of non–English language studies if they were available in English; and
  3. searched the proceedings of the American Telemedicine Association International Meetings (2005 to 2012) and the International Congress on Telehealth and Telecare (2011 to 2012).

 

Data collection and analysis

 

Selection of studies

Two review authors (KEL and DS) independently reviewed titles and abstracts of the records identified through searches and excluded obviously irrelevant studies. We obtained the full text of the remaining studies, and two review authors (KEL and DS) selected studies for inclusion based on the inclusion criteria of the review. When unsure regarding inclusion of a particular study, a third review author (MC, SG or CS) made the final decision. We contacted trial authors for further details when required and documented the reasons for exclusion.

 

Data extraction and management

Two review authors (KEL and DS) independently extracted study data and recorded information on a predesigned data extraction form. We extracted the following study details.

  1. Citation details: title, authors, source and year of publication.
  2. Participant inclusion and exclusion criteria.
  3. Participant details: age, gender, location of stroke, time since onset of stroke and level of disability.
  4. Recruitment details: numbers of people screened, eligible, recruited and randomly assigned; withdrawals.
  5. Methodological quality: The Cochrane Collaboration's tool for assessing risk of bias.
  6. Intervention details: descriptions of procedures, personnel involved, duration, dose and comparison interventions.
  7. Outcome measures: measures used, by whom, when they were administered and how they were administered (in person or via information and communication technologies).

We contacted trial authors to ask for missing information when required. We resolved differences by discussion or by consultation with a third review author when necessary.

 

Assessment of risk of bias in included studies

Two review authors (KEL and DS) independently assessed the risk of bias of included studies using The Cochrane Collaboration's 'Risk of bias' tool (Higgins 2011). This tool allows assessment of the following possible sources of bias: random sequence generation; allocation concealment; blinding of outcome assessors; incomplete outcome data; selective reporting; and any other potential sources of bias. We did not report on whether studies were able to blind participants or personnel because of the difficulties involved in achieving this in rehabilitation trials. We compared each study against the tool and assessed it as "low risk", "high risk" or "unclear risk" of bias, depending on whether it met the criteria for each aspect of the tool. A third review author resolved any disagreements.   

 

Measures of treatment effect

Two review authors (KEL and DS) independently assigned outcome measures to the domain assessed (activities of daily living, participant satisfaction, health-related quality of life, mobility, upper limb function, cognitive function, functional communication). If more than one outcome measure was used in the same domain from the same study, we included the measure most frequently used across included studies.

We intended to conduct separate analyses between short-term (less than three months after intervention) and long-term (three months or longer) outcomes.

We planned to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs), or standardised mean differences (SMDs) and 95% CIs for continuous outcomes, as appropriate.  

 

Unit of analysis issues

The unit of randomisation in these trials was the individual participant. For three-armed trials in which telerehabilitation was compared with in-person or no rehabilitation, we intended to enter half the sample size for the telerehabilitation group. Thus, each alternative intervention would be included in a separate comparison, and the number of participants in the telerehabilitation group would be divided equally between comparisons; the telerehabilitation group mean and standard deviation would remain unchanged.

 

Dealing with missing data

We contacted trial authors to ask for missing data. We planned to convert available data when possible (e.g. when data are reported as standard error) using the procedures detailed in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We intended to deal with missing data as recommended by the Cochrane Handbook for Systematic Reviews of Interventions. When dropouts were clearly identified, we used the denominator of participants contributing data at the relevant outcome assessment.

 

Assessment of heterogeneity

When appropriate, we pooled results to present an estimate of treatment effect using a random-effects model. We assessed heterogeneity by performing visual inspection of the forest plot along with the I2 statistic (Higgins 2011).

 

Assessment of reporting biases

We sought to reduce the impact of publication bias by searching clinical trials registers for studies. In addition, we investigated whether selective reporting occurred by comparing study protocols and the methods sections of papers with the results sections. We intended to assess small sample bias by preparing a funnel plot.

 

Data synthesis

We conducted a meta-analysis based on a random-effects model with 95% CIs using RevMan 5.2 (RevMan 2012). We explored heterogeneity as detailed below.

 

Subgroup analysis and investigation of heterogeneity

If a sufficient number of comparable studies were identified, we planned to perform subgroup analyses to determine whether outcomes varied according to time since onset of stroke, severity of stroke, frequency of the intervention (occasions of service per week), intensity of the intervention (total hours of intervention), intervention approach selected (e.g. speech therapy, upper limb retraining), mode of delivery (e.g. telephone versus videoconferencing, real-time communication versus "store and forward") and whether the intervention was provided by a multidisciplinary team or by members of a single discipline.

 

Sensitivity analysis

We intended to perform sensitivity analyses based on the methodological quality of studies (allocation concealment, blinding of outcome assessor, intention-to-treat analysis) to assess the impact of risk of bias in the included studies. We also planned to conduct a sensitivity analysis to identify differences noted when a fixed-effect versus a random-effects model was used.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

 

Results of the search

We identified 29 studies by searching the Cochrane Stroke Group trials register, 28 studies by searching the Cochrane EPOC Group trials register and 2787 references by searching electronic databases, totaling 2881 references. Of these records, we found 22 on clinical trials registries. We reviewed 160 articles in full text and contacted study authors to request more information when required, excluding articles that did not meet the inclusion criteria. Details of the 16 excluded studies are provided in the 'Characteristics of excluded studies' table. We identified 10 ongoing studies (Characteristics of ongoing studies). Search details are presented in the flow diagram (Figure 1).

 FigureFigure 1. Study flow diagram.

 

Included studies

We included 10 RCTs, with a total of 933 participants, in the review.

 

Sample characteristics

Included studies were conducted in the United States (n = 5), The Netherlands (n = 2), Italy (n = 2) and Canada (n = 1). All studies were published within the previous 10 years (between 2004 and 2012). Sample sizes ranged from 11 to 536; most studies included fewer than 50 participants ( Table 1;  Table 2).

Most participants in the included studies were aged in their 50s, 60s and 70s. Similar numbers of male and female participants were included, with the exception of two studies (Chumbler 2012; Smith 2012), for which only male participants were recruited. Two studies recruited participants in the acute stages poststroke (Boter 2004; Mayo 2008), whereas the rest of the studies involved participants in subacute and chronic stages.

Criteria for participant inclusion and exclusion varied amongst studies. Five studies stated that they excluded participants with significant cognitive impairment (Chumbler 2012; Deng 2012; Huijgen 2008; Piron 2008; Piron 2009), although this condition was defined differently between studies; two studies stated that participants needed to have a caregiver available (Forducey 2012; Smith 2012).

As seen in  Table 1, among 1427 stroke survivors screened across all studies, 860 were recruited, resulting in a participation rate of 60%. This rate varied widely between studies, ranging from 15% (Carey 2007) to 100% (Chumbler 2012).

 

Interventions

All interventions were delivered in the participant's own home.

The primary aim of the intervention varied across the studies. Four studies aimed to improve upper limb function through the use of customised computer-based training programmes (Carey 2007; Huijgen 2008; Piron 2008; Piron 2009). Two studies aimed to improve lower limb function and mobility (Chumbler 2012; Deng 2012); one of these studies delivered exercises using a customised computer-based training programme (Deng 2012), whereas the other involved delivery of an exercise programme based on a combination of technologies to enable communication between the participant and the teletherapist. One study used a combination of occupational therapy and physiotherapy to provide rehabilitation that often focused on remediation of impaired limbs (Forducey 2012), two studies aimed to provide support to the person in the home using a case management intervention consisting of home visits and telephone calls (Boter 2004; Mayo 2008) and the remaining study aimed to support the caregivers of stroke survivors by providing them with education and professional and peer support (Smith 2012).

Several different types of information and communication technologies were used to deliver telerehabilitation interventions. These included the telephone (Boter 2004; Mayo 2008), videoconferencing hardware and software (Carey 2007; Deng 2012; Huijgen 2008; Piron 2008; Piron 2009) and desktop videophones (Forducey 2012). Two studies used a combination of technologies: Chumbler 2012 used a combination of telephone calls, an in-home messaging device and video recordings taken by a research assistant to be reviewed by the teletherapist. Smith 2012 used a combination of email, an online chat programme and an online resource room (a virtual online library) established for caregivers of stroke survivors.

Most interventions were conducted entirely by using information and communication technologies (Carey 2007; Deng 2012; Forducey 2012; Huijgen 2008; Piron 2008; Piron 2009). Two studies used a combination of telephone calls and home visits (Boter 2004; Mayo 2008). The remaining study (Chumbler 2012) used "store and forward" methods in which the research assistant video-recorded the participant in his or her home and transmitted the information to the teletherapist for review.

With regard to the comparison interventions used in the studies, two studies compared different models of telerehabilitation (Carey 2007; Deng 2012), five studies compared telerehabilitation with an alternative intervention (Forducey 2012; Huijgen 2008; Piron 2008; Piron 2009; Smith 2012) and the remaining studies (Boter 2004; Chumbler 2012; Mayo 2008) compared telerehabilitation with usual care, when no specific intervention was provided by the trialists.

A wide range of outcome measures were used to assess the effects of the range of intervention approaches. These included measures of physical function, independence in activities of daily living, quality of life and participant satisfaction. All studies assessed outcome measures postintervention. Several studies included follow-up at one month (Piron 2009; Smith 2012), three months (Carey 2007; Chumbler 2012) or six months (Mayo 2008) after completion of the intervention.

 

Excluded studies

We deemed 16 studies to be ineligible: four because of ineligible populations (e.g. traumatic brain injury or transient ischaemic attack), two because they were not randomised trials and the remaining 10 because the intervention did not meet our definition of telerehabilitation (Characteristics of excluded studies).

 

Risk of bias in included studies

Refer to Figure 2; Figure 3.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
 FigureFigure 3. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

 

Allocation

Allocation concealment was adequate in four studies (Boter 2004; Chumbler 2012; Piron 2009; Smith 2012) but was unclear in the reports of the remaining studies.

 

Blinding

Partial blinding of participants and personnel was performed in one of the studies, in which participants were masked to the study objectives because of postponed informed consent procedures (Boter 2004). It was unclear whether the outcome assessor was blinded to intervention group allocation in three studies (Carey 2007; Forducey 2012; Huijgen 2008). The remaining studies clearly stated that the assessor was blinded to allocation.

 

Incomplete outcome data

Outcome data were incomplete in three studies (Boter 2004; Carey 2007; Forducey 2012). This was deemed adequate in the remaining studies.

 

Selective reporting

One trialist reported study data to be free of selective reporting (Piron 2009). In three studies, selective reporting was identified (Chumbler 2012; Huijgen 2008; Smith 2012). It was unclear whether selective reporting occurred in the remaining studies.

 

Other potential sources of bias

Several studies were identified as being at risk of bias because of small sample sizes or differences between groups at baseline, or both (Carey 2007; Deng 2012; Forducey 2012; Huijgen 2008; Piron 2008). It was unclear whether other studies were at risk of other sources of bias.

 

Effects of interventions

 

Primary outcome

Four studies presented outcomes for the primary outcome: independence in activities of daily living (Boter 2004; Chumbler 2012; Forducey 2012; Mayo 2008). Significant clinical heterogeneity between studies was noted with regard to the purpose of the intervention and the comparison intervention (described below). Two studies were similar enough to indicate that pooling was appropriate (Boter 2004; Mayo 2008).

 

Comparison 1.1. Independence in activities of daily living

Two studies (Boter 2004; Mayo 2008) including 661 participants used a case management approach after discharge, provided via a combination of telephone calls and home visits. The control group received usual care, in which the trialists did not provide intervention; however, participants may or may not have received follow-up from other sources. The estimated effect of telerehabilitation on activities of daily living as measured by the Barthel Index was SMD 0.00, 95% CI -0.15 to 0.15 ( Analysis 1.1).

One study (Forducey 2012) compared a telerehabilitation intervention delivered by physiotherapists and occupational therapists, in which the primary aim was restoration of physical function, versus a more conventional rehabilitation approach delivered face-to-face. Both groups received the same dose of therapy. Participants receiving telerehabilitation communicated with the therapist via a desktop videophone connected to a standard home telephone line. The authors reported that both telerehabilitation and control groups showed statistically significant improvement in activities of daily living. No significant differences in improvement were noted between groups.

Another study (Chumbler 2012) compared a combination of technologies (video recordings, in-home messaging and phone calls) in an intervention designed to improve functional mobility versus usual care and reported no statistically significant differences between groups after the intervention was provided.

 

Secondary outcomes  

 

Mobility

One study, which was designed primarily to provide case management intervention (Mayo 2008), assessed mobility postintervention using the Timed Up and Go test and reported no significant differences between groups postintervention or at follow-up six months after stroke.

 

Participant satisfaction with the intervention

Three studies reported outcomes related to participant satisfaction with the intervention using different scales (Boter 2004; Huijgen 2008; Piron 2008). Two of these studies (Huijgen 2008; Piron 2008) compared upper limb therapy delivered via customised computer programmes and telerehabilitation versus therapy provided in-person or for self-completion. We were unable to obtain the data required to pool these studies; however, both studies reported that participants in the intervention and control groups had high levels of satisfaction with the intervention. The remaining study (Boter 2004), which compared case management provided for up to six months postdischarge versus usual care, also reported no significant differences in satisfaction with care between intervention and control groups.

 

Self-reported health-related quality of life

Three studies reported outcomes for health-related quality of life (Boter 2004; Forducey 2012; Mayo 2008). It was inappropriate to pool results because of clinical heterogeneity between studies and the ways in which outcome measures were reported. One of the studies, which provided a case management intervention (Boter 2004), reported that participants in the intervention group had better scores in the domain of 'role limitations due to emotional health' on the Short Form (SF)-36; however, no other significant differences were noted between groups. Another study, which also provided case management intervention (Mayo 2008), reported that people in the intervention group were more likely to respond to one or more of the outcomes within the SF-36 subscales (odds ratio (OR) 1.41, 95% CI 1.11 to 1.79). The remaining study involved a programme of physiotherapy and occupational therapy (Forducey 2012), and investigators reported that although both groups reported improvement in health-related quality of life, no differences between groups were evident after the intervention was provided.

 

Upper limb function

 
Comparison 2.1. Upper limb function

We pooled two studies conducted by the same research team (Piron 2008; Piron 2009), which consisted of 46 participants and used a computer software programme to retrain upper limb function. One of the studies compared the intervention versus the same intervention delivered in person (Piron 2008), and the other study (Piron 2009) compared use of a virtual reality programme provided via telerehabilitation versus conventional therapy delivered in person. Participants in both studies were assessed with the Fugl-Meyer Upper Extremity Scale postintervention. The impact of telerehabilitation on upper limb function was not significantly different from the impact of the control intervention: MD 3.65, 95% CI -0.26 to 7.57 ( Analysis 2.1).

An additional study, for which we were unable to obtain the data required for pooling (Huijgen 2008), reported that no significant differences were observed between groups on the Action Research Arm Test or the Nine-Hole Peg Test after intervention.

 

Other secondary outcomes

No studies reported on outcomes in the categories of self care and domestic life, cognitive function, functional communication or cost-effectiveness. No studies reported on the presence of adverse events during completion of the studies.  

 

Studies comparing two different telerehabilitation interventions

Two studies included in the review compared different forms of telerehabilitation (Carey 2007; Deng 2012). Although the main aim of the studies was different, with one study (Carey 2007) aiming to improve finger and wrist movement and the other study (Deng 2012) aiming to improve ankle movement, these studies were similar with regard to the method of intervention and the comparison and were conducted by the same research group. Both studies compared a computer programme that provided feedback on movement and accuracy versus a programme that provided less feedback. Teleconferencing was used in both studies to enable communication with the therapist. Carey 2007 found that both groups improved on measures of hand function after intervention, with no clear difference noted between the groups. The other study (Deng 2012) reported that after intervention, both groups exhibited an increase in dorsiflexion during gait; this was significantly greater in the group that received more feedback.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms
 

Summary of main results

We found 10 studies (with 933 participants) that were eligible for inclusion in this review. Because of clinical heterogeneity between studies, it was inappropriate to pool data in most cases.

 

Independence in activities of daily living

We pooled data from two trials with 661 participants that compared a case management intervention including telephone calls after discharge from hospital versus usual care. Data from these trials showed no evidence of a beneficial effect of telerehabilitation when compared with usual care. However, the strength of the evidence justifies further research in this area.

Two additional studies (Chumbler 2012; Forducey 2012) assessed independence in activities of daily living after telerehabilitation intervention; one compared telerehabilitation versus face-to-face therapy, and the other compared telerehabilitation versus usual care, which may or may not have included any intervention. Both studies failed to find any significant differences in outcomes between the groups postintervention.

 

Secondary outcomes

We pooled two trials (Piron 2008; Piron 2009) with 46 participants that aimed to retrain upper limb function using a computer programme administered via telerehabilitation. These studies were small; thus evidence was insufficient to allow conclusions on whether the intervention was more effective than the comparison upper limb therapy programme.

It was inappropriate to conduct further analyses because of heterogeneity between studies. Limited information and insufficient evidence prevented conclusions regarding the effects of telerehabilitation on mobility, participant satisfaction and health-related quality of life.

We were unable to find any data related to our other secondary outcomes of self care and domestic life, cognitive function, functional communication and cost-effectiveness.

 

Overall completeness and applicability of evidence

Despite our extensive search strategy, we were able to find few RCTs that were eligible for inclusion in this review. Furthermore, significant heterogeneity was noted between the included studies with regard to the intervention used, the information and communication technologies involved and the comparison intervention and outcomes assessed. Most studies involved small sample sizes. All studies were published over the past 10 years, demonstrating that this approach is relatively new in rehabilitation. However, our review of the 10 trials provides information about the current state of telerehabilitation research; we also identified 10 ongoing studies, which suggests that research in this area is increasing.

Several studies evaluated interventions involving specialised software and hardware programmes (Carey 2007; Deng 2012; Huijgen 2008; Piron 2008; Piron 2009). Although these studies provide important information regarding the effects of novel technologies, these intervention programmes are not readily accessible to clinicians. Two other studies evaluated interventions that provided case management using a combination of home visits and phone calls (Boter 2004; Mayo 2008). These studies appear to have been designed to evaluate the effectiveness of the case management intervention rather than telerehabilitation per se. However, they met our inclusion criteria and therefore were included in this review. Another study was directed at supporting caregivers of people with stroke using a combination of online resources, online peer support and a facilitator (Smith 2012). Therefore, only the two remaining studies were primarily designed to evaluate the delivery of common rehabilitation interventions to stroke survivors via telerehabilitation (Chumbler 2012; Forducey 2012). More research is required to investigate whether telerehabilitation can be used as an alternative or as a supplement to conventional therapy that is delivered face-to-face. Furthermore, although telerehabilitation is purported to reduce the cost of administering an intervention, none of the studies included in this review reported on cost-effectiveness.

In addition, little information is currently available on the usability of information and communication technologies that are used to deliver telerehabilitation. Most studies used simple telephone or videoconferencing equipment, and few examples were provided of more complex technologies such as wearable sensors or remote monitoring or combinations of technology.

Participants in these studies tended to be aged in their 50s, 60s or 70s, whereas the average age of stroke is one to two decades older. Older people are frequently considered to be less confident in using new technologies and may prefer to participate in face-to-face therapy. Some studies excluded patients with cognitive impairment, which may limit the transferability of this approach. None of the studies reported on participants' level of confidence or familiarity with technologies. Furthermore, more information is needed regarding the support required to administer telerehabilitation: whether a caregiver is required to assist, how much technology support is required and whether the person needs to have a certain infrastructure in place (such as a high-speed Internet connection). Studies rarely reported on these factors or how investigators dealt with issues of privacy and protection of data.

The use of technology to facilitate communication may lead to miscommunication. For example, the healthcare professional may make errors in assessment of the patient, or the patient may misunderstand advice or instructions provided by the healthcare professional. We were unable to identify any information in the included trials regarding harms associated with telerehabilitation.

 

Quality of the evidence

Many studies involved small sample sizes; larger, more adequately powered studies are required to provide more conclusive evidence. The reporting of many studies was not consistent with the CONSORT guidelines (Schulz 2010), and it was unclear in many cases whether studies were at risk of bias because of poor reporting and lack of clarification from study authors. In particular, in some cases, we were unable to determine whether the outcome assessor was blinded to the intervention, or whether allocation was concealed. Selective outcome reporting was apparent in several studies.

 

Potential biases in the review process

Our search strategy was comprehensive and included searches of clinical trial registers and the grey literature. However, it is possible that we missed studies. Although we contacted the authors of included and ongoing studies, not all authors responded. Therefore, the methodology of some studies was unclear, and we were unable to obtain some data for analyses.

 

Agreements and disagreements with other studies or reviews

This review identified a greater number of randomised trials than were described in previous reviews. However, our conclusions are similar: Despite the theoretical advantages of telerehabilitation, evidence is currently insufficient to allow conclusions on its effects.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms

 

Implications for practice

Evidence is currently insufficient to guide practice.

 
Implications for research

The potential advantages of telerehabilitation are clear and have the potential to facilitate access to services (thereby improving equity) and reduce costs associated with providing rehabilitation programmes. Therefore, more research in the form of adequately powered high-quality randomised controlled trials (RCTs) is urgently required. In addition, given that several RCTs are under way, we plan to update this review once the results of these trials become available. Researchers in this area should familiarise themselves with the ongoing studies identified within this review and should address the remaining gaps, which are substantial.

Although a growing body of pilot and feasibility studies has been identified, additional RCTs are required to determine the effectiveness of the intervention. Researchers should ensure that studies are adequately powered, are of high methodological quality and are reported in compliance with CONSORT guidelines (Schulz 2010).

Telerehabilitation offers great potential as a replacement for, or as an addition to, current therapies. In the first instance, it is important to understand whether differences have been identified in delivery of the same therapy programme in-person or via information and communication technologies. Therefore, of interest to clinicians are studies that compare telerehabilitation versus conventional therapy, that is, treatment delivered face-to-face, or studies that provide telerehabilitation in addition to conventional therapy.

Evaluation of cost-effectiveness should be prioritised and incorporated into future studies. Furthermore, the use of mixed methods research is valuable in uncovering further information about the usability of telerehabilitation technologies, participant satisfaction with the intervention and challenges associated with recruitment of participants.

It is currently unclear which patient groups are most likely to benefit from telerehabilitation, for example, whether people living in remote areas may benefit and whether people that require enhanced support or rehabilitation on discharge or those many years poststroke would benefit from a short-term programme of rehabilitation.

It is also unclear which types of therapies are best suited to telerehabilitation. Clinicians may find it difficult to adapt their practice to provide services via information and communication technologies, particularly when "hands-on" assessment or treatment is typically involved. It may be that some therapies that do not typically involve "hands-on" assessment (such as speech therapy or counselling) are best suited to this method of delivery.

The studies in this review identified a wide range of outcome measures. It is worth noting that trials do not necessarily have to demonstrate that telerehabilitation services result in superior outcomes in contrast to face-to-face therapy but rather that they result in equal outcomes.

The use of telerehabilitation has only recently emerged and is likely to become increasingly viable as information and communication technologies become more sophisticated and user friendly. It is important that therapists consider how their practice may be adapted so that services can be delivered remotely.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms

The authors wish to thank Brenda Thomas for her assistance in designing the search strategy. We would also like to thank Cochrane editors Peter Langhorne and Alex Pollock and external peer reviewer Paul Davies.

We wish to thank Andrea Turolla, Nancy Mayo, Greg Smith and Han Boter, who generously provided additional details and analyses from their trials to assist us with preparation of the review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms
Download statistical data

 
Comparison 1. Independence in activities of daily living: postintervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Independence in activities of daily living2661Std. Mean Difference (IV, Random, 95% CI)-6.58 [-0.15, 0.15]

 
Comparison 2. Upper limb function: postintervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Upper limb function246Mean Difference (IV, Random, 95% CI)3.65 [-0.26, 7.57]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms
 

Appendix 1. MEDLINE (Ovid) search strategy

1. cerebrovascular disorders/ or exp basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp intracranial arteriovenous malformations/ or exp “intracranial embolism and thrombosis”/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/
2. brain injuries/ or brain injury, chronic/
3. (stroke$ or cva or poststroke or post-stroke or cerebrovasc$ or cerebral vascular).tw
4. ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
5. ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
6. exp hemiplegia/ or exp paresis/
7. (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
8. Gait Disorders, Neurologic/
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. telemedicine/ or telemetry/ or exp videoconferencing/ or telecommunications/ or computer communication networks/ or remote consultation/ or remote sensing technology/ or exp telephone/ or electronic mail/ or internet/
11. (telemedicine or telemetry or telerehabilitation or tele-rehabilitation or telerehab or telehealth or tele-health or telehomecare or tele-homecare or telecoaching or tele-coaching or telecommunication$ or videoconference$ or video-conferenc$ or videoconsultation or video-consultation or telestroke or teleconference$ or tele-conference$ or teleconsultation or tele-consultation or telecare or ehealth or e-health).tw
12. (telespeech or tele-speech or teleOT or tele-OT or telepractice or teletherap$).tw.
13. ((rehabilitation or therap$ or treatment or communication or consultation) adj5 (telephone$ or phone$ or video$ or internet$ or computer$ or sensor$ or modem or webcam or website$ or email)).tw.
14. ((remote$ or distance$ or distant) adj5 (rehabilitation or therap$ or treatment or physio$ or occupational therap$ or communication or consultation or care or specialist$ or monitor$ or virtual reality or virtual environment$ or technolog$)).tw.
15. (tele adj3 (game$ or game$ or exergame$ or virtual reality$)).tw.
16. 10 or 11 or 12 or 13 or 14 or 15
17. Randomized Controlled Trials as Topic/
18. random allocation/
19. Controlled Clinical Trials as Topic/
20. control groups/
21. clinical trials as topic/
22. double-blind method/ or single-blind method/
23. Placebos/
24. placebo effect/
25. cross-over studies/
26. Multicenter Studies as Topic/
27. Therapies, Investigational/
28. Research Design/
29. Program Evaluation/
30. evaluation studies as topic/
31. randomized controlled trial.pt.
32. controlled clinical trial.pt.
33. clinical trial.pt.
34. multicenter study.pt.
35. (evaluation studies or comparative study).pt.
36. random$.tw.
37. (controlled adj5 (trial$ or stud$)).tw.
38. (clinical$ adj5 trial$).tw.
39. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
40. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
41. ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
42. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
43. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
44. (coin adj5 (flip or flipped or toss$)).tw.
45. latin square.tw.
46. versus.tw.
47. (cross-over or cross over or crossover).tw.
48. placebo$.tw.
49. sham.tw.
50. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
51. controls.tw.
52. (treatment$ adj6 order).tw.
53. or/17-52
54. 9 and 16 and 53
55.  exp animals/ not humans.sh
56 54 not 55

 

Appendix 2. EMBASE (Ovid) search strategy

1. exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp intracranial arteriovenous malformations/ or exp intracranial embolism/) and thrombosis/) or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/
2 brain injuries/ or brain injury, chronic/
3 (stroke$ or cva or poststroke or post-stroke or cerebrovasc$ or cerebral vascular).tw.
4 ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$
or thrombo$ or emboli$ or apoplexy)).tw.
5 ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
6 exp hemiplegia/ or exp paresis/
7 (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
8 Gait Disorders, Neurologic/
9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10 telemedicine/ or telemetry/ or exp videoconferencing/ or telecommunications/ or computer communication networks/ or remote consultation/ or remote sensing technology/ or exp telephone/ or electronic mail/ or internet/
11 (telemedicine or telemetry or telerehabilitation or tele-rehabilitation or telerehab or telehealth or tele-health or telehomecare or tele-homecare or telecoaching or telecoaching or telecommunication$ or videoconference$ or video-conferenc$ or videoconsultation or video-consultation or telestroke or teleconference$ or teleconference$ or teleconsultation or tele-consultation or telecare or ehealth or ehealth).tw.
12 (telespeech or tele-speech or teleOT or tele-OT or telepractice or teletherap$).tw.
13 ((rehabilitation or therap$ or treatment or communication or consultation) adj5 (telephone$ or phone$ or video$ or internet$ or computer$ or sensor$ or modem or webcam or website$ or email)).tw.
14 ((remote$ or distance$ or distant) adj5 (rehabilitation or therap$ or treatment or physio$ or occupational therap$ or communication or consultation or care or specialist$ or monitor$ or virtual reality or virtual environment$ or technolog$)).tw.
15 (tele adj3 (game$ or game$ or exergame$ or virtual reality$)).tw.
16 10 or 11 or 12 or 13 or 14 or 15
17 Randomized Controlled Trials as Topic/
18 random allocation/
19 Controlled Clinical Trials as Topic/
20 control groups/
21 clinical trials as topic/
22 double-blind method/ or single-blind method/
23 Placebos/
24 placebo effect/
25 cross-over studies/
26 Multicenter studies as Topic/
27 Therapies, Investigational/
28 Research Design/
29 Program Evaluation/
30 evaluation studies as topic/
31 random$.tw.
32 (controlled adj5 (trial$ or stud$)).tw.
33 (clinical$ adj5 trial$).tw.
34 ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
35 (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
36 ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
37 ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
38 ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
39 (coin adj5 (flip or flipped or toss$)).tw.
40 latin square.tw.
41 versus.tw.
42 (cross-over or cross over or crossover).tw.
43 placebo$.tw.
44 sham.tw.
45 (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
46 controls.tw.
47 (treatment$ adj6 order).tw.
48 or/17-47
49 9 and 16 and 48
50 exp animals/ not humans.sh.
51 49 not 50

 

Appendix 3. AMED search strategy

1 ((cerebrovascular disorders/ or exp basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp intracranial arteriovenous malformations/ or exp intracranial embolism/) and thrombosis/) or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/
2 brain injuries/ or brain injury, chronic/
3 (stroke$ or cva or poststroke or post-stroke or cerebrovasc$ or cerebral vascular).tw.
4 ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
5 ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
6 exp hemiplegia/ or exp paresis/
7 (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
8 Gait Disorders, Neurologic/
9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10 telemedicine/ or telemetry/ or exp videoconferencing/ or telecommunications/ or computer communication networks/ or remote consultation/ or remote sensing technology/ or exp telephone/ or electronic mail/ or internet/
11 (telemedicine or telemetry or telerehabilitation or tele-rehabilitation or telerehab or telehealth or tele-health or telehomecare or tele-homecare or telecoaching or tele-coaching or telecommunication$ or videoconference$ or video-conferenc$ or videoconsultation or video-consultation or telestroke or teleconference$ or tele-conference$ or teleconsultation or tele-consultation or telecare or ehealth or e-health).tw.
12 (telespeech or tele-speech or teleOT or tele-OT or telepractice or teletherap$).tw.
13 ((rehabilitation or therap$ or treatment or communication or consultation) adj5 (telephone$ or phone$ or video$ or internet$ or computer$ or sensor$ or modem or webcam or website$ or email)).tw.
14 ((remote$ or distance$ or distant) adj5 (rehabilitation or therap$ or treatment or physio$ or occupational therap$ or communication or consultation or care or specialist$ or monitor$ or virtual reality or virtual environment$ or technolog$)).tw.
15 (tele adj3 (game$ or game$ or exergame$ or virtual reality$)).tw.
16 10 or 11 or 12 or 13 or 14 or 15
17 random allocation/
18 double-blind method/ or single-blind method/
19 Placebos/
20 Research Design/
21 Program Evaluation/
22 randomized controlled trial.pt.
23 controlled clinical trial.pt.
24 clinical trial.pt.
25 multicenter study.pt.
26 (evaluation studies or comparative study).pt.
27 random$.tw.
28 (controlled adj5 (trial$ or stud$)).tw.
29 (clinical$ adj5 trial$).tw.
30 ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
31 (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
32 ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
33 ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
34 ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
35 (coin adj5 (flip or flipped or toss$)).tw.
36 latin square.tw.
37 versus.tw.
38 (cross-over or cross over or crossover).tw.
39 placebo$.tw.
40 sham.tw.
41 (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
42 controls.tw.
43 (treatment$ adj6 order).tw.
44 or/17-43
45 9 and 16 and 44
46 exp animals/ not humans.sh.
47 45 not 46

 

Appendix 4. CINAHL search strategy

1. MH Cerebrovascular disorders
2. MH Basal Ganglia Cerebrovascular Disease
3. MH Cerebral ischemia
4. MH Carotid Artery Diseases
5. MH Intracranial Arterial Diseases
6. MH Arteriovenous Malformations
7. MH Intracranial Embolism and Thrombosis
8. MH Intracranial Hemorrhage
9. MH Stroke
10. AB brain infarction
11. MH Brain Injuries
12. MH Brain Damage, Chronic
13. TX stroke$ OR TX cva OR TX poststroke OR TX post-stroke
14. TX cerebrovasc$ OR TX cerebral vascular
15. TX cerebral OR TX cerebellar OR TX brain$ OR TX verterbrobasilar
16. TX infarct$ OR TX isch?emi$ OR TX thrombo$ OR TX emboli$ OR TX apoplexy
17. S15 and S16
18. TX cerebral OR TX brain OR TX subarachnoid
19. TX haemorrhage OR TX hemorrhage OR TX haematoma OR TX hematoma OR TX bleed
20. S18 and S19
21. MH hemiplegia
22. TX paresis
23. TX hemipar$ OR TX hemipleg$ OR TX paresis OR TX paretic AND TX brain injur$
24. MH Gait Disorders, Neurologic
25. S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24
26. MH telemedicine
27. MH telehealth
28. MH videoconferencing OR MH teleconferencing
29. MH remote consultation
30. TX telemedicine OR TX telerehabilitation OR TX tele-rehabilitation OR TX tele-rehab OR TX telehealth OR TX tele-health
31. TX tele-coaching OR TX telecoaching OR TX telecommunication$ OR tele-consultation
32. TX telespeech OR TX tele-speech OR TX teleOT OR TX tele-OT OR TX telepractice OR TX teletherap$
33. S26 or S27 or S28 or S29 or S30 or S31 or S32
34. S25 and S33
35. MH randomized controlled trials
36. AB random allocation
37. AB control group$
38. MH Clinical trials
39. TX double-blind OR TX single-blind
40. TX placebo OR TX cross-over OR TX crossover
41. MH Program evaluation
42. PT randomized controlled trial
43. TX random OR TX (controlled N5 trial$) OR (controlled N5 stud$)
44. S35 or S36 or S37 or S38 or S39 or S40 or S41 or S42 or S43
45. S34 and S44

 

Appendix 5. PsycINFO search strategy

1 ((cerebrovascular disorders/ or exp basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp intracranial arteriovenous malformations/ or exp intracranial embolism/) and thrombosis/) or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/
2 brain injuries/ or brain injury, chronic/
3 (stroke$ or cva or poststroke or post-stroke or cerebrovasc$ or cerebral vascular).tw.
4 ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
5 ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
6 exp hemiplegia/ or exp paresis/
7 (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
8 Gait Disorders, Neurologic/
9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 (41110)
10 telemedicine/ or telemetry/ or exp videoconferencing/ or telecommunications/ or computer communication networks/ or remote consultation/ or remote sensing technology/ or exp telephone/ or electronic mail/ or internet/
11 (telemedicine or telemetry or telerehabilitation or tele-rehabilitation or telerehab or telehealth or tele-health or telehomecare or tele-homecare or telecoaching or tele-coaching or telecommunication$ or videoconference$ or video-conferenc$ or videoconsultation or video-consultation or telestroke or teleconference$ or tele-conference$ or teleconsultation or tele-consultation or telecare or ehealth or e-health).tw.
12 (telespeech or tele-speech or teleOT or tele-OT or telepractice or teletherap$).tw.
13 ((rehabilitation or therap$ or treatment or communication or consultation) adj5 (telephone$ or phone$ or video$ or internet$ or computer$ or sensor$ or modem or webcam or website$ or email)).tw.
14 ((remote$ or distance$ or distant) adj5 (rehabilitation or therap$ or treatment or physio$ or occupational therap$ or communication or consultation or care or specialist$ or monitor$ or virtual reality or virtual environment$ or technolog$)).tw.
15 (tele adj3 (game$ or game$ or exergame$ or virtual reality$)).tw.
16 10 or 11 or 12 or 13 or 14 or 15
17 control groups/
18 clinical trials.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures]
19 cross-over studies.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, tests & measures]
20 Research Design/
21 Program Evaluation/
22 (evaluation studies or comparative study).pt.
23 random$.tw.
24 (controlled adj5 (trial$ or stud$)).tw.
25 (clinical$ adj5 trial$).tw.
26 ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
27 (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
28 ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
29 ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
30 ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
31 (coin adj5 (flip or flipped or toss$)).tw.
32 latin square.tw.
33 versus.tw.
34 (cross-over or cross over or crossover).tw.
35 placebo$.tw.
36 sham.tw.
37 (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
38 controls.tw.
39 (treatment$ adj6 order).tw.
40 or/17-39
41 9 and 16 and 40
42 exp animals/ not humans.sh.
43 41 not 42

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms

Kate E Laver is the guarantor of the review. Contributions included co-ordinating the review, drafting the protocol, developing the search strategy, searching for trials, obtaining copies of the trials, selecting which trials to include, extracting data from the trials, entering data, carrying out the analysis, interpreting the analysis and drafting the final review.

Daniel Schoene was involved in drafting the protocol, searching for trials, selecting which trials to include, extracting data from trials, interpreting the analysis and drafting the final review.

Maria Crotty was involved in drafting the protocol, selecting which trials to include (arbiter), interpreting the analysis and drafting the final review.

Stacey George was involved in drafting the protocol, selecting which trials to include (arbiter), interpreting the analysis and drafting the final review.

Natasha A Lannin was involved in drafting the protocol, carrying out the analysis, interpreting the analysis and drafting the final review.

Catherine Sherrington was involved in drafting the protocol, guiding and interpreting the analysis and drafting the final review.

All authors will be responsible for updating the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Index terms

None known.

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Characteristics of studies
  15. References to studies included in this review
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
Boter 2004 {published data only}
  • Boter H, for the HESTIA Study Group. Multicenter randomized controlled trial of an outreach nursing support program for recently discharged stroke patients. Stroke 2004;35:2867-72.
Carey 2007 {published data only}
  • Carey J, Durfee W, Bhatt E, Nagpal A, Weinstein S, Anderson K, et al. Comparison of finger tracking versus simple movement training via telerehabilitation to alter hand function and cortical reorganization after stroke. Neurorehabilitation and Neural Repair 2007;21(3):216-32.
Chumbler 2012 {published data only}
  • Chumbler N, Quigley P, Li X, Morey M, Rose D, Sanford J, et al. Effects of telerehabilitation on physical function and disability for stroke patients. Stroke 2012;43:2168-74.
Deng 2012 {published data only}
  • Deng H, Durfee W, Nuckley D, Rheude B, Severson A, Skluzacek K, et al. Complex versus simple ankle movement training in stroke using telerehabilitation: a randomized controlled trial. Physical Therapy 2012;92(2):197-209.
Forducey 2012 {published data only}
  • Forducey P, Glueckauf R, Bergquist T, Maheu M, Yutsis M. Telehealth for persons with severe functional disabilities and their caregivers: facilitating self-care management in the home setting. Psychological Services 2012;9(2):144-62.
Huijgen 2008 {published data only}
  • Huijgen B, Vollenbroek-Hutton M, Zampolini M, Opisso E, Bernabeu M, Van Nieuwenhoven J, et al. Feasibility of a home based telerehabilitation system compared to usual care: arm/hand function in patients with stroke, traumatic brain injury and multiple sclerosis. Journal of Telemedicine and Telecare 2008;14:249-56.
Mayo 2008 {published data only}
  • Mayo N, Nadeau L, Ahmed S, White C, Grad R, Huang A, et al. Bridging the gap: the effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of stroke. Age and Ageing 2008;37:32-8.
Piron 2008 {published data only}
  • Piron L, Turolla A, Tonin P, Piccione F, Lain L, Dam M. Satisfaction with care in post-stroke patients undergoing a telerehabilitation programme at home. Journal of Telemedicine and Telecare 2008;14:257-60.
Piron 2009 {published data only}
  • Piron L, Turolla A, Agostini M, Zucconi C, Cortese F, Zampolini M, et al. Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach. Journal of Rehabilitation Medicine 2009;41:1016-20.
Smith 2012 {published data only}
  • Smith G, Egbert N, Palmieri P, Dellman-Jenkins M, Nanna K. Reducing depression in stroke survivors and their informal caregivers: a randomized clinical trial of a web-based intervention. Rehabilitation Psychology 2012;57(3):196-206.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Characteristics of studies
  15. References to studies included in this review
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
Adie 2010 {published data only}
Bergquist 2012 {published data only}
  • Bergquist T, Yutsis M. The effect of cognitive rehabilitation delivered via instant messaging on functional independence in persons with ABI. Brain Injury 2012;26(4-5):700-1.
Burton 2005 {published data only}
Eide 2012 {published data only}
  • Eide L, Schanke A. Examining computerized working memory training as a supplement to cognitive rehabilitation for patients with an acquired brain injury. Brain Injury 2012;26(4-5):749-50.
Gillham 2010 {published data only}
  • Gillham S, Endacott R. Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomized controlled trial. Clinical Rehabilitation 2010;24(9):822-30.
Hoffman 2010 {published data only}
  • Hoffman T, Worrall L, Eames S. Measuring outcomes in people who have had a stroke and their carers: can the telephone be used?. Topics in Stroke Rehabilitation 2010;17(2):119-27.
Huijbregts 2010 {published data only}
  • Huijbregts M, Cameron J, Taylor D, McEwen S, Kagan A, Streiner D. Videoconference delivery of a stroke self-management program: a mixed methods waiting list randomized controlled trial. Stroke 2010;41:e357.
Jackson 2010 {published data only}
  • Jackson D, Elsom S, Joubert L, Joubert J. An exploration of the role of the nursing coordinator in a telemedicine based stroke secondary prevention model. International Journal of Stroke 2010;5(1):1.
Joubert 2006 {published data only}
  • Joubert J, Reid C, Joubert L, Barton D, Ruth D, Jackson D, et al. Risk factor management and depression post stroke: the value of an integrated model of care. Journal of Clinical Neuroscience 2006;13:84-90.
Joubert 2009 {published data only}
  • Joubert J, Reid C, Barton D, Cumming T, McLean A, Joubert L, et al. Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model. Journal of Neurology, Neurosurgery and Psychiatry 2009;80:279-84.
Kerry 2010 {published data only}
  • Kerry S, Cloud G, Markus H, Khong T, Oakeshott P. Does self monitoring improve blood pressure control in hypertensive stroke patients—first results of a randomised trial. International Journal of Stroke 2010;5(Suppl 3):6.
Mclaughlin 2010 {published data only}
  • Mclaughlin M, Nam Y, Sanders S, Yeh S, Chang C, Kennedy B, et al. Virtual environments for stroke recovery: pilot clinical trials for user-centric patient/clinician distribution platform with tele-rehabilitation application using haptic devices. International Journal of Stroke 2010;5:66.
Palmer 2011 {published data only}
  • Palmer R, Enderby P, Mortley J, Cooper C, Dixon S, Julious S, et al. Cost effectiveness of aphasia computer therapy compared with usual stimulation for people with long standing aphasia (CACTUS). Results of a pilot study. International Journal of Stroke 2011;5:4.
Redzuan 2012 {published data only}
  • Redzuan N, Engkasan J, Mazlan M, Abdullah S. Effectiveness of a video-based therapy program at home after acute stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2012;93:2177-83.
Song 2010 {published data only}
  • Song C, Seo S, Lee G. Video game based exercise for upper extremity function rehabilitation of chronic stroke patients. Results from a randomized controlled single blind trial. International Journal of Stroke 2010;5:304.
Zucconi 2012 {published data only}
  • Zucconi C, Valt V, Agostini M, Turolla A, Tonin P, Piron L. Assessment of a virtual teacher feedback for the recovery of the upper limb after stroke. Neurorehabilitation and Neural Repair 2012;26:4.

References to ongoing studies

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Characteristics of studies
  15. References to studies included in this review
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
Eames 2011 {published data only}
  • Eames S, Hoffman T, Worrall L, Read S, Wong A. Randomised controlled trial of a post-discharge education and support package for clients with stroke and their carers. International Journal of Stroke 2011;6(Suppl 1):8.
Graven 2012 {published data only}
  • Graven C, Brock K, Hill K, Cotton S, Joubert L. Does a focus on participation and personal goal achievement have an impact on depression in the first year after stroke?. Neurorehabilitation and Neural Repair 2012;26:755.
Miller 2010 {published data only}
  • Miller I, Bishop D, Epstein-Lubow G. Reduction in post-stroke depressive symptoms among patients and caregivers: theFITT study. American Journal of Geriatric Psychiatry 2010;18(3(Suppl 1)):S61-2.
NCT01144715 {published data only}
  • Alberts J, Wolf S. Rehabilitation of the stroke hand at home (HAPPI). ClinicalTrials.gov (http://clinicaltrials.gov/show/NCT01144715) 2010.
NCT01157195 {published data only}
  • Uswatte G. Home-based automated therapy of arm function after stroke via tele-rehabilitation. ClinicalTrials.gov (clinicaltrials.gov/ct2/results?term=NCT01157195) 2010.
NCT01350453 {published data only}
  • Burridge J. Development and pilot evaluation of a web-supported programme of constraint induced movement therapy following stroke (LifeCIT). ClinicalTrials.gov (http://clinicaltrials.gov/ct2/results?term=NCT01350453) 2011.
NCT01655264 {published data only}
  • Weiss P. Evaluation of the Gertner Tele-Motion-Rehabilitation System for stroke rehabilitation. ClinicalTrials.gov (clinicaltrials.gov/ct2/results?term=NCT01655264) 2012.
Nguyen 2011 {published data only}
  • Nguyen V, Poon J, Tokuda L, Sayers J, Wallis R, Dergalust S. Pharmacist telephone interventions improve adherence to stroke preventative medications and reduce stroke risk factors: a randomized controlled trial. Stroke 2011;42(3):e244.
Rochette 2010 {published data only}
  • Rochette A, Korner Bitensky N, Bishop D, Teasell R, White C, Bravo G, et al. Study protocol of the YOU CALL-WE CALL trial: impact of a multimodal support intervention after a "mild" stroke. BMC Neurology 2010; Vol. 10, issue 3.
Taylor 2012 {published data only}
  • Taylor D. Telerehabilitation to improve outcomes for people with stroke: the ACTIV trial. Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/) 2012.

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Characteristics of studies
  15. References to studies included in this review
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
American Speech-Language-Hearing Association 2005
  • American Speech-Language-Hearing Association. Speech-language pathologists providing clinical services via telepractice: position statement. www.asha.org/policy 2005.
American Telemedicine Association 2010
  • American Telemedicine Association. A blueprint for telerehabilitation guidelines. Telemedicine and e-Health 2011;17:662-5.
AROC 2011
  • Australasian Rehabilitation Outcomes Centre. The AROC Annual Report: the state of rehabilitation in Australia in 2010. http://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@aroc/documents/doc/uow106153.pdf.
Brennan 2009
  • Brennan D, Mawson S, Brownsell S. Telerehabilitation: enabling the remote delivery of healthcare, rehabilitation and self management. In: Gaggioli A editor(s). Advanced Technologies in Rehabilitation. Amsterdam: IOS Press, 2009:231-48.
Brochard 2010
  • Brochard S, Robertson J, Medee B, Remy-Neris O. What's new in new technologies for upper extremity rehabilitation?. Current Opinion in Neurology 2010;23:683-7.
Canadian Stroke Network 2006
  • Canadian Stroke Network. Canadian best practice recommendations for stroke care 2006. www.canadianstrokenetwork.ca.
Canadian Stroke Network 2011
  • Canadian Stroke Network. The quality of stroke care in Canada. http://www.canadianstrokenetwork.ca 2011.
Donnan 2008
Feigin 2003
  • Feigin V, Lawes M, Bennett D, Anderson C. Stroke epidemiology: a review of population based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurology 2003;2:43-53.
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. www.cochrane-handbook.org.
Hill 2006
  • Hill A, Theodoros D, Russell T, Cahill L. An Internet-based telerehabilitation system for the assessment of motor speech disorders: a pilot. American Journal of Speech-Language Pathology 2006;15:45-56.
Johansson 2011
Kairy 2009
  • Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilisation and costs associated with telerehabilitation. Disability and Rehabilitation 2009;31:427-47.
Kalra 2007
Kwakkel 2004
  • Kwakkel G, Kollen B, LIndeman E. Understanding the pattern of functional recovery after stroke: facts and theories. Restorative Neurology and Neuroscience 2004;22:281-99.
Langhorne 2002
Langhorne 2011
  • Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet 2011;377:1693-702.
McKevitt 2011
National Institutes of Health 2012
  • National Institute of Neurological Disorders and Stroke. Post stroke rehabilitation fact sheet 2012. http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm.
National Stroke Foundation 2011
  • National Stroke Foundation. National Stroke Audit- Acute Services Clinical Audit Report. Melbourne, Australia 2011.
RevMan 2012
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
Rogante 2010
  • Rogante M, Grigioni M, Cordella D, Giacomozzi C. Ten years of telerehabilitation: a literature overview of technologies and clinical applications. NeuroRehabilitation 2010;27:287-304.
Russell 2004
  • Russell T, Buttrum P, Wootton R, Jull G. Rehabilitation after total knee replacement via low-bandwidth telemedicine: the patient and therapist experience. Journal of Telemedicine and Telecare 2004;10(Suppl 1):85-7.
Russell 2009
  • Russell T. Telerehabilitation: a coming of age. Australian Journal of Physiotherapy 2009;55:5-6.
Sanford 2004
  • Sanford J, Jones M, Daviou P, Grogg K, Butterfield T. Using telerehabilitation to identify home modification needs. Assistive Technology 2004;16:43-53.
Schulz 2010
  • Schulz K, Altman D, Moher D for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332.
Theodoros 2008
Wakeford 2005
  • Wakeford L, Wittman P, White M, Schmeler M. Telerehabilitation position paper. American Journal of Occupational Therapy 2005;59:656-60.
WHO 1989
  • World Health Organization Task Force on Stroke and Other Cerebrovascular Disorders. Recommendations on stroke prevention, diagnosis, and therapy: report of the WHO Task Force on stroke and other cerebrovascular disorders. Stroke 1989;20:1407-31.
WHO 2010
  • World Health Organization. International classification of functioning, disability and health. http://www.who.int/classifications/icf/en/ 2010.
Winters 2002