A Systematic Review of Clinical Outcomes, Clinical Process, Healthcare Utilization and Costs Associated with Telerehabilitation

Disability and Rehabilitation, 2009; 31(6): 427–447

REVIEW

A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation

DAHLIA KAIRY1,2, PASCALE LEHOUX1,3, CLAUDE VINCENT4,5 & MARTHA VISINTIN2

1Department of Health Administration, University of Montreal, 2Jewish Rehabilitation Hospital, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR) research site, 3Groupe de recherche interdisciplinaire en sante´ (GRIS), 4Department of Rehabilitation, Laval University, and 5Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Canada

Accepted March 2008

Abstract Purpose. To identify clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation for individuals with physical disabilities. Method. Relevant databases were searched for articles on telerehabilitation published until February 2007. Reference lists were examined and key journals were hand searched. Studies that included telerehabilitation for individuals with physical impairments and used experimental or observational study designs were included in the analysis, regardless of the specific clientele or location of services. Data was extracted using a form to record methodological aspects and results relating to clinical, process, healthcare utilization and cost outcomes. Study quality of randomized clinical trials was assessed using the PEDro rating scale. Results. Some 28 articles were analysed. These dealt with rehabilitation of individuals in the community, neurological rehabilitation, cardiac rehabilitation, follow-up of individuals with spinal cord injuries, rehabilitation for speech-language impairments, and rehabilitation for varied clienteles. Clinical outcomes were generally improved following a telerehabilitation intervention and were at least similar to or better than an alternative intervention. Clinical process outcomes, such as attendance and compliance, were high with telerehabilitation although few comparisons are made to alternative interventions. Consultation time tended to be longer with telerehabilitation. Satisfaction with telerehabilitation was consistently high, although it was higher for patients than therapists. Few studies examined healthcare utilization measures and those that did reported mixed findings with respect to adverse events, use of emergency rooms and doctor visits. Only five of the studies examined costs. There is some preliminary evidence of potential cost savings for the healthcare facility. Conclusions. While evidence is mounting concerning the efficacy and effectiveness of telerehabilitation, high-quality evidence regarding impact on resource allocation and costs is still needed to support clinical and policy decision-making.

Keywords: Telemedicine, telehealth, telerehabilitation, videoconference, rehabilitation, outcomes, physical therapy, occupational therapy, speech therapy

advocates promote the use of communication and Introduction information technologies as a way of increasing Current demographic trends, including an ageing accessibility and enhancing continuity of care for population which has tripled over the last 50 years vulnerable populations such as those with disability and an increase in chronic diseases, have put [3–5], as well as a potential time and cost-saving increased pressure on healthcare systems world- strategy [6–10]. wide and their ability to provide quality care [1,2]. Alongside the many branches of telemedicine, the With healthcare resources already scarce, this has number of telerehabilitation programmes has led to a quest for new ways of organizing health been steadily increasing. The use of such technolo- services. Telerehabilitation and telemedicine gies in rehabilitation clearly has many expected

Correspondence: Dahlia Kairy, Jewish Rehabilitation Hospital, 3205 Alton-Goldbloom Place, Chomedey, Laval, Quebec, Canada H7V 1R2. Tel: þ1 450 688 9550. Fax: þ1 450 688 3673. E-mail: [email protected] ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa Healthcare USA, Inc. DOI: 10.1080/09638280802062553 428 D. Kairy et al. and unexpected consequences. In addition, the relevant articles in English or French, starting at technologies involved in the provision of telerehabil- the earliest date available for each database and itation can be quite costly. Prior to implementing ending in February 2007: Medline, CINHAL, new telerehabilitation programmes and in order to EMBASE, Cochrane database for systematic ensure sound clinical and policy decisions, it is reviews, ACP Journal Club, DARE, CCTR, Health therefore essential to understand the consequences And Psychosocial Instruments, PsychInfo, PEDro of its use. (physiotherapy evidence database), and health tech- Systematic reviews can help summarize and nology assessment reports through the Centre for critically synthesize the available body of literature Reviews and Dissemination of the University of and be a useful tool for clinical decision-making and York. The keywords telerehabilitation, teletherapy programme planning [11], especially in a newer and the combination of telehealth or telemedicine research area, where the quality and scope of studies with rehabilitation, were combined with outcome, is very variable. They also help to identify areas in effectiveness, cost or efficacy. As well, the same which research is currently lacking [11–13]. searches were repeated by replacing rehabilitation Although there is a growing body of literature on with physiotherapy/physical therapy, occupational telerehabilitation, there are no systematic reviews in therapy and speech-language pathology. Two main this area. Jennett et al. [14] conducted a systematic journals in telemedicine were also hand searched for review of the socio-economic impact of telehealth. additional relevant references (Journal of Telemedicine However as rehabilitation was one of several areas and Telecare, and Telemedicine Journal and e-Health). they examined, they provide only a very brief Finally, one relevant article was identified overview of the types of socio-economic outcomes among articles previously retrieved by one of the used in the telerehabilitation studies and the number authors which had not been identified through any of of studies demonstrating benefits on those outcomes. the above searches although it should have been Van Dijk and Hermens conducted a review of indexed. Therefore the journal in which the evidence for the use of distance training in restoring article was published was hand searched for addi- motor function [15]. Although their focus was not tional relevant articles, but no new articles solely telerehabilitation programmes, their review were identified. References from all relevant articles included several telerehabilitation studies at that time were checked and potentially relevant articles were in the preliminary stages of development. As well, a retrieved. recent report published by the Agence d’e´valuation des technologies et des modes d’interventions, a Selection criteria health technology assessment agency in Quebec, Canada, identified clinical and technical guidelines Studies published in peer-reviewed journals with a to be applied to telerehabilitation [16]. Its focus telerehabilitation component in a population with however was not the outcomes of telerehabilitation physical deficits were included if: (i) They were programmes nor did it include telerehabilitation in designed as an interventional study (experimental or the patient’s home. This article therefore provides a observational) [17], (ii) they used quantitative or systematic review of the scientific literature in order qualitative approaches, and (iii) they presented to evaluate the efficacy, effectiveness and costs of findings related to outcomes or costs. There were telerehabilitation used for direct patient services. no restrictions for age or care setting (e.g., home, Specifically, this study examined clinical outcomes, community, facility). clinical process and healthcare utilization measures, Studies were excluded if: (i) They dealt with a as well as costs related to telerehabilitation. These population with mental illness only, (ii) they in- outcomes were selected to reflect a common cluded only telephone interventions (unless tele- objective of telerehabilitation programmes, which is phone intervention was one group of the study, with to provide access to quality rehabilitation services a video component in the other, or unless other while maximizing resource allocation and minimiz- technologies were paired up with the use of the ing costs. telephone), (iii) the technology was smart home monitoring devices, (iv) they examined telehome care of patients with chronic disease who received Methods only nursing interventions with no rehabilitation objective, (v) they reported only the development Search strategy phase of the technology (i.e., feasibility of the For the present study, telerehabilitation is defined as technology in a lab setting), (vi) they examined only the use of communication and information technol- the support for caregivers of patients, (vii) they were ogies to provide clinical rehabilitation services from a programme descriptions or reports not designed as distance. The following databases were searched for research studies, and (viii) they were redundant A systematic review of telerehabilitation 429 articles which dealt with the same intervention and the Centre for Evidence-Based Physiotherapy [18], a did not report any new outcomes. Lastly, studies commonly used scale in rehabilitation-related sys- were excluded if they provided insufficient informa- tematic reviews and meta-analyses. One point is tion to allow adequate interpretation of the study attributed to each of 10 items relating to internal design, measures or results or if they were only found validity and statistical information, for a maximum in abstract form or in abstracts or posters from score of 10. Based on the Evidence-Based Review of conference proceedings as these were felt to provide Stroke Rehabilitation [19] scores of 4–5/10 can be insufficient detail. regarded as fair, 6–8/10 as good and 9–10/10 as Potential eligibility of the articles was first deter- excellent RCTs. Trends and gaps in the available mined from the title and abstracts identified from the literature were identified; a combined score for the searches. Full-text articles were then retrieved and strength of the available evidence was not calculated evaluated for relevance. Articles were excluded at as there were wide variations in the studies’ pro- this point if they were not found to meet the above grammes, populations and measures. criteria once the full text was examined (for flow The following types of outcomes reported that chart of article retrieval and reasons for exclusion were of interest for this review were recorded: see Figure 1). A second researcher confirmed the relevance and findings from the selected articles. (1) Clinical measures: Outcome measures re- Twenty-eight articles were retained for analysis using lated to the physical, functional and psycho- the above search strategies. logical capacity that are used to determine the effect of an intervention; (2) Clinical process: Outcomes related to service Data extraction and outcome measures delivery, such as attendance and adherence The articles were reviewed and a data extraction to programmes and recommendations, form was used to include details pertaining to the quantity and frequency of contacts with the study quality such as study design, number of patient, patient accessibility to the pro- subjects, study population, as well as the description gramme, as well as healthcare provider and of the programme and technology used. Study patient satisfaction with the programme; quality was quantified for randomized clinical trials (3) Healthcare utilization: Events that occur (RCT) using the PEDro Rating Scale developed by outside the programme’s scope and that the

Figure 1. Flow chart of the results from the literature search. (a) Reasons for exclusion: Programme descriptions only (n ¼ 4); Review articles (n ¼ 2); Feasibility studies (n ¼ 3); Prototype testing (n ¼ 1); No clinical or cost outcomes (n ¼ 1); Descriptive single case study (n ¼ 1); (b) Reasons for exclusion: General programme information (n ¼ 3); Feasibility studies (n ¼ 1); No rehabilitation goals (n ¼ 1); Model for cost- analysis only (n ¼ 1); (c) Reason for exclusion: Insufﬁcient information to interpret methods, measures and results adequately. (n ¼ number of studies). 430 D. Kairy et al.

programme may aim to reduce or increase, Findings relating to clinical outcomes such as hospitalizations, ER admissions and physician visits; Of the 28 studies examined, 82% of them reported (4) Costs: From the patient’s, provider’s or clinical outcomes, with two studies reporting insuffi- organization’s perspective, all costs (savings cient information about the outcome measures used and/or expenses) associated with the use of and results obtained. Of the studies with a control telerehabilitation. group which reported clinical outcomes (n ¼ 8 randomized and n ¼ 5 quasi-experimental studies Studies were then grouped together and outcomes with control group), seven reported improvements of summarized according to the: similar magnitude to a control intervention and six reported greater improvement with telerehabilitation (1) Type of telerehabilitation intervention for a variety of clinical outcomes. These included (Table II): Rehabilitation of community- function in activities of daily living (n ¼ 1) and return dwelling elderly or disabled population to work (n ¼ 2), lower limb range of motion (n ¼ 1), (n ¼ 9), follow-up of patients with spinal cord gait (n ¼ 1), pain (n ¼ 2), exercise capacity (n ¼ 4), injury (n ¼ 3), neurological rehabilitation cognitive tasks (n ¼ 1), speech quality (n ¼ 1), skin (motor retraining n ¼ 3, other n ¼ 3), cardiac integrity (n ¼ 2), falls efficacy (n ¼ 1), quality of life rehabilitation (n ¼ 4), speech-language im- (QOL; n ¼ 4), fatigue (n ¼ 1), anxiety (n ¼ 1) and pairment rehabilitation (n ¼ 2), and consulta- depression (n ¼ 3). No studies reported worse out- tions for varied clientele (n ¼ 3); comes with telerehabilitation than in the control (2) Location of telerehabilitation (Table III): group, although two studies reported smaller gains in Home intervention (n ¼ 22, of which five self-efficacy in the telerehabilitation groups [20,21]. were simulations with the patient and clin- The quasi-experimental studies were well-designed ician in separate rooms in the same health- non-randomized studies, which is similar to the type care facility, and three were virtual groups of study design commonly found in other areas of with each patient in their own home), rehabilitation research. All studies with no control intervention in a group setting in the com- group which examined outcomes pre- and post- munity (n ¼ 2), intervention between health- intervention (n ¼ 9) found greater gains following the care centres (n ¼ 4). telerehabilitation intervention in function in activities of daily living, hand function, cognitive tasks, Grouping the studies in this way then allowed us to balance, gait, pain, speech quality, skin integrity, compare outcomes in programmes with similar falls efficacy, quality of life. characteristics, as discussed in further detail in the In summary, the studies report positive clinical following section. outcomes, with improvement in physical, functional and psychological measures following a telerehabilitation intervention. The evidence consistently de- monstrates that similar outcomes can be obtained Results using telerehabilitation as compared to a face-to-face As Figure 1 indicates, 22 studies were retained after or other control intervention. the initial screening of titles and abstracts and the full-text retrieval of pertinent articles. In addition, six Findings relating to clinical process articles were retrieved from hand searches and reference lists, for a total of 28 studies included in As seen with the clinical outcomes, the process this review, 68% (19/28) of which were published outcomes reported varied between studies. Process after 2003. The search strategy and selection criteria outcomes were reported less frequently than clinical did not limit the type of experimental or observa- measures (68% and 82%, respectively). They were tional design. Among the 28 studies, there were eight least often reported in studies of patients with randomized controlled trials, seven quasi- neurological deficits (n ¼ 1 out of 6 studies) and experimental trials with control groups, nine quasi- spinal cord injury (n ¼ 1 out of 3 studies). Of the experimental pre-post trials without control groups studies that reported these outcomes and that had and four trials with post intervention assessments control groups, four reported similar patient com- only (see Table I for specific study details). pliance and drop-out rates, as well as duration of The results of the clinical outcomes, process consultation and contact time with patients between outcomes, healthcare utilization and costs reported the telerehabilitation intervention and the control in the studies are presented in the following sections. one (three RCTs and one quasi-experimental study These have been summarized in Tables II and III, with control group) and two found better outcomes according to the type of outcome. (two quasi-experimental studies with control group). A systematic review of telerehabilitation 431

Table I. Study characteristics.

Outcomes and variables reported (Clinical Study outcomes (CO), Process quality outcomes (PO), Healthcare Author Study design (PEDro Description of program utilization measures (year) (sample size) scale/10) Study population Technology used (Tech) (HCU), Costs)

Community-dwelling elderly or individuals with disability Sanford et al. RCT (remote televideo 6 Community-dwelling 4 once-weekly in-home CO: Modified Falls (2006) [20] n ¼ 16; traditional adults of all ages multifactorial OT/PT Efficacy Scale home visit n ¼ 16; with prescription interventions targeting usual care n ¼ 33) for new mobility mobility and transfer tasks aid Control: usual care, no therapy Tech: Mobile wireless televideo system over telephone lines transmits audio and video signal. Have a research assistant in the house to mimic a home health aid. Hoenig et al. Single group post- N/A Community-dwelling 4 once-weekly in-home PO: Adherence to (2006) [24] intervention only adults of all ages multifactorial OT/PT recommendations, (n ¼ 13) with prescription interventions targeting compliance with exercise for new mobility mobility and transfer tasks programme, patient and aid Tech: Mobile wireless televideo therapist satisfaction system over telephone lines transmits audio and video signal. Have a research assistant in the house to mimic a home health aid. Russell et al. Single group post- N/A Patients with total One 45-minute physiotherapy CO: knee flexion range of (2004) [50] intervention only knee replacement session per week for 6 weeks motion and others (n ¼ 31) Tech: PC-based (details not provided, see videoconferencing low- 2003 study) bandwidth using motion- PO: adherence to analysis tools (simulation programme, compliance only of home environment). with exercise programme, patient and therapist satisfaction Russell et al. RCT (face-to-face 6 Patients with total One 45-minute physiotherapy CO: active/passive knee (2003) [27] n ¼ 11; knee replacement session per week for 6 weeks flexion, knee extension, telerehabilitation Tech: PC-based limb girth measurements, n ¼ 10) videoconferencing low- strength on straight leg bandwidth using motion- raise, pain on visual analysis tools (simulation analog scale, WOMAC only of home environment). osteoarthritis index pain and function subscales, Gait Assessment Rating Scale, Patient Specific Functional Scale, Timed Up and Go PO: patient satisfaction Tousignant Quasi-experimental N/A Geriatric patients Physiotherapy programme with CO: Functional Autonomy et al. single group pre-post discharged from exercises for weakness, range Measurement System, (2006) [35] pilot study (n ¼ 4) acute care or of motion, balance, transfers, Berg Balance Scale, geriatric unit walking for 4 weeks, 1 hour Timed Up and Go, 30 discharged home sessions 3 times a week. A sec. chair stand test requiring research assistant was PO: therapist satisfaction rehabilitation present for all sessions HCU: adverse events Tech: Broadband with video Costs: mean duration of transmission. Audio session, mean hourly transmission over hands-free salary of physiotherapist, phone. Software used to travel time of 20 minutes, control cameras and provide cost of internet service e-record. without contract and installation

(continued) 432 D. Kairy et al.

Table I. (Continued).

Wong et al. Quasi-experimental N/A Community-dwelling Once-a-week session for 12 CO: WOMAC (2005) [51] single group pre-post older adults (460 weeks: subjects came to one osteoarthritis index for intervention study yo) with knee pain of two community centres pain, stiffness and (n ¼ 20) affecting function and participated in a group function, Berg Balance exercise and education Scale, Timed Up and programme led by Go, quadriceps strength, physiotherapist though knee range of motion, videoconference. A home SF36, knowledge gained programme was prescribed. PO: Compliance with home Tech: Broadband, with programme, attendance videoconferencing units at to sessions, patient community centre and satisfaction therapist’s site, allowed simultaneous presentation of PowerPoint with DuoVideo. Lai et al. Quasi-experimental N/A People who had a For 8 weeks, once a week for CO: Berg Balance Scale, (2004) [52] single group pre-post stroke at least 6 1.5 hours, seniors come to SF-36, State Self-Esteem intervention study months previously community centre to Scale, stroke knowledge (n ¼ 19) and attend geriatric participate in group exercise test day hospital or and education programme PO: Attendance, patient seniors’ led by physiotherapist satisfaction community centre through videoconference. Tech: Broadband, with videoconferencing units at community centre and therapist’s site. Wu et al. Quasi-experimental N/A Individuals over 65 Group tele-exercise programme CO: Timed Up and Go, (2006) [37] single group pre-post years old, living given for 4 months, using Tai single leg stance, body intervention study and ambulating Chi Quan movements sway in quiet stance, (n ¼ 17) independently, emphasizing balance, SF36, fear of falling who have fallen in strength, ﬂexibility and PO: Compliance with the past year or balance. Given 3 times a week exercise, attendance, have a fear of for one hour, over 15 weeks. patient satisfaction falling Tech: Exercise class taught by Costs: Equipment, internet instructor from a studio, fee, rental of studio and participants in their home, equipment and technical everyone able to communicate support with each other through a videoconference system and video camera linked in the homestoTVsetsand videoconferencing devices with video camera and microphone, connected through broadband Internet connection. Nakamura Quasi-experimental N/A Cases who were Home care or home telecare with CO: Functional et al. pre-post enrolled to get services predetermined by independence measure (1999) [23] (non-randomized) home care, with baseline evaluation: included (FIM) case-control matching varying diagnoses physician, nurse, PT, OT, PO: Person minutes per (home care n ¼ 16; speech therapist, social worker case, total minutes home telecare n ¼ 16) and others. Initial visit was contact, total minutes done in person for both with transportation time, groups. In video group, there number of consultations was a combination of face-to- per week, satisfaction of face and telecare. professionals Tech: Videophones over telephone lines, video camera, codec and monitor over ISDN lines.

(continued) A systematic review of telerehabilitation 433

Table I. (Continued).

Neurological rehabilitation Egner et al. RCT (video group 6 People with advanced Weekly education sessions (30– CO: Quality of Well-Being (2003) [53] n ¼ 9; phone group multiple sclerosis 40 minutes) by rehabilitation Scale, Fatigue Severity n ¼ 11; standard care (EDSS score 7) nurse for 5 weeks, then every Scale, Center for n ¼ 7) with recent two weeks for one month Epidemiologic Stuides exacerbation and Standard care: regular follow- Depression Scale with mobility ups offered by rehab facility (CES-D) restrictions Tech: Video transmitted over POTS. Phone group used telephone with no image. Tam et al. Case series quasi- N/A Traumatic brain Cognitive rehabilitation CO: Performance on (2003) [54] experimental ABA injury patients through 6 individualized cognitive tasks and design (n ¼ 3) occupational therapy perception of users on sessions their performance such as Tech: Over broadband, PC- word recognition, based, with software for memory tasks (tasks training and webcams, used differed according to NetMeeting to have access to patient’s deficits) patient’s screen Man et al. RCT (computer assisted 9 Patients with Cognitive rehabilitation for CO: Analogy problem- (2006) [21] training group n ¼ 30; traumatic brain problem-solving skills using solving skills, Category online interactive injury less than 6 20 weekly 45-minute test for adults, Halstead- computer-assisted months ago with sessions. Reitan training n ¼ 29; cognitive deficits Tech: Therapist can have full Neuropsychological test therapist administered control of patient’s computer battery, Lawton training n ¼ 30; with NetMeeting, also used instrumental ADL scale control group n ¼ 20) Polycom videoconferencing units for audio and video Lum et al. Quasi-experimental N/A Chronic stroke Upper extremity activity CO: Hand function tests (2006) [22] single group pre-post patients training using AutoCite for 3 (Wolf Motor Function intervention study (412 months) hours per day over 10 days in Test, Jebsen-Taylor (n ¼ 7) 2 weeks (intensive training Hand function test, protocol) Motor Activity Log) Tech: AutoCite (automated PO: Contact time with constraint induced trainer), patient with 2 laptops with video camera. Therapist could also see Autocite monitor and adjust it. High speed ethernet connection (higher than in home setting – done in a lab setting in separate rooms to simulate home) Piron et al. Quasi-experimental N/A Chronic stroke One hour of virtual reality CO: Subscore of Fugl- (2002) [55] single group pre-post patients teletherapy for arm Meyer scale for the upper intervention study movement, five days a week extremity, Functional (n ¼ 5) for 6 weeks. Training period Independence Measure of 2 weeks at the hospital with FIM, velocity of arm virtual reality system prior. movement, arm Tech: 2 PC workstations linked trajectories by ISDN, 3-D motion tracking system on patient’s computer to monitor arm movement. Therapist could control patient’s console. Also had videoconference equipment for therapist to monitor whole patient.

(continued) 434 D. Kairy et al.

Table I. (Continued).

Piron et al. Quasi-experimental N/A Chronic stroke One hour of virtual reality CO: Subscore of Fugl- (2004) [56] single group pre-post patients teletherapy for arm movement Meyer scale for the upper intervention study daily, ﬁve days a week for 4 extremity, Functional (n ¼ 5) weeks. Training period of a few Independence Measure hours at the hospital with FIM, velocity and virtual reality system prior. duration of arm Tech: 2 PC workstations linked movement, arm by ISDN, 3-D motion tracking trajectories system on patient’s computer to monitor arm movement. Therapist could control patient’s console. Also had videoconference equipment for therapist to monitor whole patient. Cardiac rehabilitation Giallauria Quasi-experimental N/A Myocardial infarction Control group: 8-week in- CO: Cardiovascular et al. pre-post (non- in the last 8 days hospital cardiac rehab (3X functional capacity (peak (2006) [57] randomized) (control week, exercise was cycling at exercise HR, exercise n ¼ 15; intervention1 75% peak hear rate) duration and peak n ¼ 15; intervention2 Intervention group 1 and 2: exercise workload), n ¼ 15) patients who could not follow SF-36, Beck Depression thein-hospitalprogrammefor Index State anxiety scales logistic reasons had 8-week (STAI-Y1) home based cardiac PO: Patients lost at rehabilitation. Given same follow-up instructions as control group HCU: Hospitalizations andtoldtoexercise36 week on stationary bicycle at 75% peak HR. Had training sessions at predetermined times. Group 1 had telecardiology ECG monitoring. Tech: ECG recording and transmitting device to monitor patients during the home- based exercise programme, connected to call-centre and sent by email to the centre. Ades et al. Quasi-experimental N/A Within 3 months of 3-month, 3 times a week CO: Hemodynamic data (2000) [32] pre-post intervention acute myocardial exercise and education (HR/syst. BP product, study with control infarction programme. Intervention body weight, submax

group (intervention group had monitoring by VO2, Peak VO2, peak n ¼ 83; control phone and ECG transmitter, workload, Borg scale of n ¼ 50) patient was in direct contact perceived exertion, with nurse and up to 4 other Health Status participants during exercise Questionnaire sessions. Trained on PO: Dropout rate stationary bikes. HCU: sessions cancelled Control group was on site with because of symptoms treadmill training. Tech: ECG transmitted over modem (transtelephonic ECG). Also used a headset and voice transmitter (can monitor 5 patients at one time, all patients can speak to each other)

(continued) A systematic review of telerehabilitation 435

Table I. (Continued).

Sparks et al. RCT (control n ¼ 10; 5 Cardiac patients 6- 12 week, 3 times a week for one CO: Exercise capacity (1993) [31] intervention ¼ 10) weeks post- hour, programme of exercise (workload, maximal hospital discharge training with education. oxygen consumption, who were entering Control: hospital-based pressure rate product), a phase II programme return to work rehabilitation Intervention: Home-based PO: Compliance programme programme with monitoring HCU: New arrhythmias and voice transmission, patient in contact with therapist and up to 4 other patients during training Tech: Transmission of ECG and voice over phone lines (can monitor 5 patients at one time, all patients can speak to each other). Kortke et al. Quasi-experimental N/A Patients who just Control group was admitted to CO: Body mass index, (2006) [30] pre-post intervention underwent cardiac rehabilitation hospital for 3- heart rate, SF36 study with control surgery week standardized PO: Number of contacts to group (control n ¼ 70; multidisciplinary cardiac institute for assistance intervention n ¼ 100) rehabilitation (unique to HCU: Adverse events Germany) Costs: Breakdown for home Intervention group received programme: equipment, some training on-site and then setup, consultations, continued up to 3 months at training, transport of home with exercise training on equipment, clinical tests, stationary bike 3 times a week, transportation cost for with transtelephonic patient, hospital costs monitoring and with based on daily rate. reassessments onsite to progress the exercise programme at 3, 6, 9 and 12 weeks. Tech: Cardiovascular function during training at home was monitored using mobile telemedicine unit (ECG with heart rate monitor transmitted telephonically to the institute for applied telemedicine). Follow-up for spinal cord injured patients Vesmarovich Single group post N/A Hospitalized spinal Weekly telerehabilitation CO: pressure ulcers that et al. intervention only cord injured sessions with nurse (initial healed and that required (1999) [58] (n ¼ 8) patients visit in clinic to assess surgery baseline for signs such as PO: number of visits, temperature and odour) patient and nurse Tech: Videophones for audio satisfaction and still images over phone lines. Phillips et al. Quasi-experimental N/A Hospitalized spinal Video and telephone groups: CO: number of pressure (1999) [33] post-intervention cord injury patients weekly interventions for 10– ulcers per year, employed only, case-control 12 weeks, with counselling or returned to work matching (control sessions for video group for PO: Calls to help line n ¼ 10; telephone 6–8 weeks followed by HCU: Annual number of n ¼ 13; video n ¼ 12) telephone only for 4–6 ER visits, of weeks. Telephone group hospitalizations, of received telephone doctor visits counselling only throughout.

(continued) 436 D. Kairy et al.

Table I. (Continued).

Standard care is not described but patients have a scheduled follow-up visit at 2 months, and can contact nurse if issues arise earlier. Tech: Videophones for audio and still images over phone lines. Phillips et al. RCT (video n ¼ 36, 7 Hospitalized spinal Video and telephone groups: CO: depression (CES-D), (2001) [34] phone n ¼ 36, cord injury patients weekly interventions for 5 Quality of Well-Being standard care n ¼ 39) weeks, with individual HCU: Annual days of counselling sessions for video hospitalization, number group then once every two of patients hospitalized weeks for 1 month. Standard care group can call help line if help needed in between the regularly scheduled follow-up at 2 months provided for all groups. Tech: Videophones for audio and still images over phone lines. Rehabilitation for speech-language impairments Sicotte et al. Quasi-experimental N/A Children or Speech-language pathologist CO: patient/parent (2003) [28] Single-group pre-post adolescents with from paediatric tertiary care perception of stuttering, intervention (n ¼ 6) stuttering problem centre provided assessment stuttering frequency and treatment services to PO: Patient attendance, subjects in remote northern child/parent and therapist region, for 12–20 weeks, satisfaction once a week for 1 hour Costs: Personal costs due to sessions with some follow-up work or home related sessions expenses when having to Tech: Videoconferencing units go to treatment in tertiary care centre in urban area and primary care centre in rural area with one TV monitor, via intranet at 768 kbits/s. Mashima RCT (conventional 5 Patients with voice 30 minute speech-therapy CO: Fiber-optic et al. vocal rehabilitation disorders, age sessions, over an average of 9 laryngoscopy by ENT, (2003) [29] n ¼ 28; ranged from 18–85 weeks, with an average of 5.7 voice quality, acoustic videoteleconference with different sessions analysis of voice (jitter, vocal rehabilitation diagnoses (mainly Tech: Voice therapy was given shimmer) n ¼ 23) military personnel) with therapist in adjacent PO: Adherence to room (simulation), using programme, patient video camera and satisfaction microphone and a speech analysis workstation seen by therapist and patient. Consultations for varied clienteles Lemaire et al. Single group post N/A Patients seen at one Consultations between one PO: Time spent on-line and (2001) [59] intervention (n ¼ 47) of the local rural specialized physical off-line for each hospitals for rehabilitation hospital and consultation, patient, communication eight community remote clinician and disorders, foot rehabilitation hospital when specialist satisfaction care, gait expertise is not available,

(continued) A systematic review of telerehabilitation 437

Table I. (Continued).

problems, consultations result in orthotics, exercise prescription, prosthetics, arm assistive devices, equipment weakness and adaptation and modiﬁcation wheelchair of the client’s environment prescription Tech: Both sites equipped with PC, video card, NetMeeting, video capture software, speakerphone, camera, gait analysis software, transmitted over 2 phone lines, low bandwidth Guilfoyle Single group cross-over N/A High care residents of Consultations between PO: Time for consultation, et al. design (n ¼ 12) residential aged- metropolitan allied health usefulness of (2003) [25] care facility centres to nursing staff in a videoconference, residential aged-care facility clinician satisfaction in rural area. Same clinician did a face-to-face and a videoconference consultation for each patient. Tech: Videoconferencing unit over ISDN lines set up at both sites Hassall et al. Single group cross-over N/A High care residents of Consultations between Costs: Fixed and variable (2003) [36] design (n ¼ 12) residential aged- metropolitan allied health costs for videoconference care facility centres to nursing staff in a sessions and face-to-face residential aged-care facility sessions (equipment, in rural area. Same clinician lines, training, calls, did a face-to-face and a salaries, travel time, videoconference consultation accommodations), varied for each patient. equipment cost and Tech: Videoconferencing unit intensity of face-to-face over ISDN lines set up at sessions both sites Appel et al. RCT (face to face n ¼ 9; 6 Having pain for more Behavioural interventions by CO: Relaxation Inventory, (2002) [26] speakerphone n ¼ 9; than 6 months clinical psychologist aimed at Behavior Rating Scale, closed-circuit TV from various self-regulation (relaxation analog pain scale, n ¼ 9) conditions and guided imagery) Subjective Unit of (orthopaedic, Tech: TV monitor and camera Discomfort Scale peripheral at patient and psychologist PO: Patient satisfaction neuropathy, ends, not done with lumbar, cervical) videoconferencing equipment or over network, set up in the hospital as a simulation

*PEDro scale: score of 0–10, 10 indicating better quality, only applicable to RCTs (N/A ¼ not applicable); PEDro items include eligibility criteria, random and concealed allocation, similar baseline between groups, blinding of subjects, therapists and assessors, outcome measure reporting with point estimates and variability, intent to treat analysis, between-group statistical comparisons; n: for each study, sample size per group.

Nine of the 11 studies without control groups also or longer times for consultations conducted by reported ﬁndings relating to compliance and dura- telerehabilitation compared to face-to-face, while a tion of consultation but they did not provide any home-intervention study reported greater contact basis for comparison. Studies examining telerehabil- time between the patient and the therapist but overall itation between healthcare facilities found similar shorter duration of sessions with telerehabilitation 438 .Kiye al. et Kairy D. Table II. Main outcomes reported in telerehabilitation studies according to location of intervention.

Location of intervention Group intervention in community setting Home intervention providing group Home intervention one-on-one (n ¼ 19) Intervention between healthcare Outcome (n ¼ 2) [51,52] interaction (n ¼ 3) [31,32,37] [20–24,26,27,29,30,33–35,50,53–58] centres (n ¼ 4) [25,28,36,59]

Clinical Significant improvement post Significant improvement post Most studies report significant One study found reduced outcomes telerehabilitation in functional (balance, telerehabilitation in physical improvement in physical (active/passive stuttering in all subjects but mobility) and psychological outcomes (hemodynamic data), functional ROM, strength, pain, swelling, velocity gains not always maintained (QOL) and in some physical outcomes (exercise capacity, perceived exertion, of movement, body mass index, long term. No other studies (quadriceps strength, not knee range of balance, mobility and return to work) pressure sores, speech quality) examined this type of outcome. motion). and psychological outcomes (QOL and functional (functional autonomy, ADL, No control groups or other data available fear of falling). gait, mobility, balance, hand motor for comparison. 2 studies were controlled trials, and had function, cognitive tasks, exercise similar improvements in capacity, return to work, perception of telerehabilitation and hospital-based pain) and psychological outcomes cardiac rehabilitation programme (distress, falls self-efficacy, depression, anxiety). In studies with control groups, outcomes were similar or better to control group. Some suggestions of decline with long-term follow-up although inconsistent findings. Clinical process Attendance at sessions and adherence to Attendance rates were high and drop out Studies showed high attendance rates High patient attendance. Mixed exercise programmes were high rates low. They were comparable (similar with and without findings relating to time spent although no comparison group between groups in 2 studies with telerehabilitation) and lower drop out for consultations, same as face- available. control groups. High level of rates with telerehabilitation. Contact to-face or longer. High satisfaction in group tele-exercise time with patients was increased with satisfaction, but one study sessions for balance training telerehabilitation. reported higher satisfaction in High satisfaction rates from clients and remote clinicians than specialists therapists, weakest satisfaction for video and one reported higher quality and scheduling of sessions. satisfaction for face-to-face Telerehabilitation seen as valid assessment than for alternative to clinic visits. Study for videoconference, felt behavioural intervention found videoconference care plans were moderate satisfaction for interpersonal incomplete without face-to-face. relationship between therapist and Additional information on patient. underlying reasons for satisfaction obtained from focus groups with therapists.

(continued) Table II. (Continued).

Healthcare Not reported Development of arrhythmias in small Few studies examined this. Not reported utilization number of participants in cardiac Mixed results concerning adverse events. rehabilitation studies that resulted in Two studies of cardiac rehabilitation some change in management programmes found slightly more angina and arrhythmias with ECG monitoring but it may be a positive outcome as it led to change in management; another study found more angina in control group, but no difference for dyspnea. Home physiotherapy in one small study did not lead to any fall or incidents. No signiﬁcant difference in hospitalizations, ER use, doctor visits although trends are variable between studies. Costs Not reported Only one study presents a brief cost Two studies report 18–58% savings with Two studies did cost-analyses and

analysis for tele-exercise intervention telerehabilitation from an assumed equal efﬁcacy. From telerehabilitation of review systematic A from organizational perspective, so no organizational perspective. Insufﬁcient organizational perspective, conclusion can be drawn. evidence to allow conclusions to be breakeven point at 850 sessions drawn regarding cost-effectiveness. per year, decreased if equipment charge decreased or was used for other purposes as well, and depended on intensity of face- to-face intervention. From patient perspective, would cost $20 more per speech therapy session, an amount acceptable to patients.

Main outcomes identiﬁed in telerehabilitation studies according to location of intervention; n ¼ number of studies included for each location of intervention. 439 440 Table III. Main outcomes reported in telerehabilitation studies according to type of rehabilitation.

Outcome

Type of rehabilitation Clinical outcomes Clinical process Healthcare utilization Costs al. et Kairy D.

Rehabilitation for community- All studies reported significant Adherence to recommendations There were no adverse events such Comparison with theoretical home dwelling individuals with improvement in physical (active/ was moderate following in-home as falls with telephysiotherapy. visit showed 12 sessions of disability (n ¼ 9) passive ROM, strength, pain, multifactorial intervention for As only one study examined this telephysiotherapy to be 17% [20,23,24,27,35,37,50–52] swelling), functional (functional balance (61%). Studies aspect in a small sample, no cheaper. Home teleexercise autonomy, mobility, gait, consistently report moderate to conclusions can be made at this balance programme was balance) and psychological (falls high adherence to exercise time. estimated to cost $2140 per self-efficacy, QOL, self-esteem) programme (478%) and high patient for 45 sessions over 15 outcome measures following compliance with home exercise weeks. Due to lack of evidence, telerehabilitation. Mixed program One study reported a further conclusions cannot be findings in 3 studies with greater number of patient drawn regarding comparison group, two found consultations with cost-effectiveness of greater increase in falls-self- telerehabilitation compared to telerehabilitation. efficacy and functional status traditional home care services. and one reported similar There was a high level of outcomes for lower extremity satisfaction with the usefulness physical and functional of telerehabilitation, lowest measures with in-home satisfaction for visual clarity telerehabilitation Neurological rehabilitation (n ¼ 6) Most studies reported One study reported that 18% of a Not reported. Not reported. [21,22,53–56] improvement in physical (arm 3-hour training session involved movement) and functional (arm communication between the function and cognitive function) therapist and patient who could outcomes. One study reported train independently with improved psychological monitoring. Little data is outcomes (QOL, fatigue available on clinical process depression) in patients with outcomes in neurological multiple sclerosis receiving video rehabilitation so no conclusions interventions compared to can drawn. phone interventions or standard follow-up care. Cardiac rehabilitation (n ¼ 4) All studies examined Attendance and adherence to Adverse events (arrhythmias, One study reported significant [30–32,57] cardiovascular and exercise exercise programme was similar angina) were identified more savings per patient (58%) for capacity and found similar for telerehabilitation and often in transtelephonic groups transtelephonic monitoring significant improvement in hospital based programmes. compared to hospital-based compared to in-patient hospital transtelephonic ECG No satisfaction data is presented in programmes although these rehabilitation programme from monitoring groups and control these studies. were not necessarily attributed the healthcare establishment rehabilitation in hospital. Most to the exercise, or may reflect perspective. studies reported psychological increased monitoring used at measures (QOL, depression, home. anxiety) but findings were mixed, some reporting similar and some better outcomes in

(continued) Table III. (Continued).

Outcome Type of rehabilitation Clinical outcomes Clinical process Healthcare utilization Costs

telerehabilitation group. 2 studies had large sample sizes (n 4 100) and most had rigorous methodology strengthening conclusions. Rehabilitation for spinal cord Findings support equivalence of Insufficient reporting of clinical Mixed results for annual days of Not reported injured patients (n ¼ 3) telerehabilitation home process measures to draw hospitalization in 2 studies from [33,34,58] monitoring and standard follow- conclusions. same author, earlier study with up at 2 months, but only long term assessment found no relevant if programme is in place difference between because of limited accessibility telerehabilitation and standard to follow-up services. care, while later study that did Several studies from the same not include long term outcomes group of authors examined but had larger sample showed pressure ulcer development, decreased hospitalizations. with no significant difference between types of interventions, although trend to more ulcers identified by video. Rehabilitation for speech-language Physical measures of voice quality High patient adherence and high Not reported. One cost analysis from patient impairments (n ¼ 2) [28,29] (jittering, stuttering) satisfaction reported for patients perspective reports additional significantly improved with and therapists, lowest for quality cost of $20 per session to attend remote speech-therapy and to a of video. Identified some clients session at primary care centre.

similar extent as with face-to- who may not be suitable for Lack of empirical evidence to telerehabilitation of review systematic A face therapy, but not all gains remote speech-therapy. date limits further conclusions were maintained at 6-month for cost-effectiveness of remote follow-up. Strength of speech therapy. conclusions limited by small number of studies in this area and larger control trial used a simulated environment in the hospital as proof-of-concept. Rehabilitation for multiple Findings limited to one study of Moderate satisfaction, lower for Not reported Only reported in one study of clienteles (n ¼ 4) [25,26,36,59] behavioural intervention, found specialist than clinician at local consultations to residential no significant difference in hospital or residential facility, facility. Found breakeven point relaxation and pain between higher satisfaction for face-to- for cost of video conference or face-to-face and video face than video conference face-to-face consultation of 850 conference. Study done in sessions. Mixed findings relating sessions per year, which varied clinical setting with therapist and to time spent face-to-face versus depending on intensity of face- patient in separate rooms. video conference sessions. to-face intervention and equipment cost. 441 Main outcomes reported in telerehabilitation studies according to type of rehabilitation; n ¼ number of studies included in each type of rehabilitation. 442 D. Kairy et al. compared to an in-person home-visit [23]. Comple- was a positive outcome suggesting better monitoring teness of care plans was addressed in only one study, with the telerehabilitation home intervention. Similar using a single-group cross-over design with each conflicting results are reported by Phillips et al. participant having a face-to-face and a videoconfer- [33,34], where in a quasi-experimental study, the ence consultation. The authors found that care plans authors report a trend for higher use of health were incomplete after having only a videoconference services in the telephone and video intervention consultation but not after having only an in-person groups, whereas a later RCT found lower hospitali- consultation [25]. zation rates in the video group. Finally, one before- In summary, there are fewer studies that examined and-after study reported no falls in patients receiving process outcomes as compared to clinical outcomes. home physiotherapy. In summary, due to the low Nevertheless there is a trend from one fair quality number of studies measuring and reporting these RCT and six quasi-experimental studies with and outcomes, and with some conflicting findings emer- without control groups of good attendance at ging, the literature available does not yet allow us to programmes and good compliance with recommen- draw any clear conclusions regarding the effect of dations when a programme is offered by telerehabil- telerehabilitation on healthcare utilization. itation. Findings relating to costs Findings relating to satisfaction Finally, only five studies (19%) presented some type With respect to perception of and satisfaction with of cost analysis of the telerehabilitation intervention, services, 11 studies (39%) report patient satisfaction two in studies dealing with community-dwelling findings, seven (25%) report the clinicians’ perspec- individuals, one in cardiac rehabilitation, one ad- tive and only four of these studies examine both dressing speech impairments and one regarding perspectives. Overall the findings are very encoura- consultations for multiple clienteles. None of the ging, with patients and therapists reporting positive studies calculated costs using the same elements. perceived benefits, convenience and usefulness of the In conducting cost analyses, it is crucial to identify telerehabilitation program. The only study to report from which perspective the analysis is being con- any problematic area from the patient’s point of view ducted; in other words, who is defraying the costs or found moderate satisfaction with the interpersonal achieving the savings, be it the patient, caregiver, relationship between patient and therapist [26]. clinician, healthcare establishment or organization, Main complaints from therapists were related to healthcare system, reimbursement agency, society the quality of video transmission [24,27,28], sche- and so on. Four studies reported cost analyses from duling issues [24], and difficulties in using the an organizational perspective. Tousignant et al. [35] technology with certain clienteles such as active or calculated costs using duration of sessions, hourly shy children [28]. In one study, remote therapists salaries of therapists, travel time and cost of internet tended to be more satisfied than the consulted with installation, and estimated that it would be 17% specialists [25]. Except for two studies [25,29], the or $100 cheaper per patient for 12 sessions of remaining studies that report satisfaction with tele- telephysiotherapy in the home compared to a rehabilitation do not provide any comparison even programme of theoretical home visits. Kortke et al. when a control group is available. [30] reported differences of a greater magnitude, with costs that would be 58% lower for a 3-month home cardiac rehabilitation programme with trans- Findings relating to healthcare utilization telephonic monitoring of ECG signals as compared Some 26% of studies (n ¼ 7) report healthcare to the 3-week in-hospital rehabilitation programme utilization outcomes. The most commonly reported currently offered. The basis for their cost estimate outcomes include adverse events such as falls, included the costs for the home programme includ- arrhythmias, angina and dyspnea (n ¼ 4), number ing equipment, setup, consultations, training, trans- and days of hospitalizations (n ¼ 3), visits to the portation of equipment, clinical tests, and emergency room (n ¼ 1) and doctor visits (n ¼ 1). transportation cost for the patient, as well as hospital With respect to cardiorespiratory events, findings costs for the control group based on the daily rate. were conflicting, with two quasi-experimental cardi- Hassal et al. [36] based their cost estimate on the ac rehabilitation studies reporting significantly more equipment and internet lines required, staff training, angina [30] and more hospitalizations in the control calls made, salaries, travel time and accommodations groups compared to the transtelephonic groups, for face-to-face assessments. They found a breakeven while two others identified slightly more adverse point of 850 sessions per year for videoconferencing events in the telerehabilitation group [31,32]. How- compared to a typical face-to-face assessment of ever, it was argued by the latter two authors that this elderly people in a residential facility; interestingly A systematic review of telerehabilitation 443 they showed how this could change if equipment intervention, which was in some cases the standard costs changed or if the face-to-face option differed. care, while 10 used face-to-face comparisons. In two While Wu et al. [37] did not provide any basis for studies, the between-group statistical tests were not comparison, they calculated that it would cost $2140 robust as multiple t-tests were conducted comparing per patient at risk of falling or with a history of falls to multiple pairs of groups (e.g., telerehabilitation participate in a group balance tele-exercise pro- intervention compared to control, telerehabilitation gramme from home for four months. They estimated intervention compared to telephone only and tele- the costs based on the equipment used, the internet phone only compared to control) at each evaluation fees, rental of the studio and equipment and time (pre and post-intervention), increasing the technical support. Only one study examined costs chance of finding a significant difference when one from the patient’s perspective. Sicotte et al. [28] is not present. They did not adjust for the numerous reported that patients incurred a maximum of $20 tests or apply ANOVAs or regression models. per session, based on personal costs (e.g., work time Slightly more than half the studies (n ¼ 15/28) lost) related to having to attend videoconference used a single-group design and the authors often cite speech therapy sessions at their primary care centre this as a limitation of their study that should be in a rural area, given by a speech-language pathol- addressed in future studies as they cannot exclude ogist at an urban tertiary care centre. natural evolution. Many of the studies used con- In summary, there are two quasi-experimental venience samples based on geographical location of studies with control groups and two small pre-post patients or patient preference, clearly introducing the studies that found lower costs for the healthcare possibility of selection bias. None of the studies used facility when using telerehabilitation. While the multiple time series analyses, with repeated pre- and evidence is gradually emerging, the lack of studies post-intervention assessments that would allow an providing cost analyses from similar perspectives and analysis of trends even with no control group and accounting for similar costs prevents us from strengthen the conclusions about the role of the drawing any definite conclusions about the cost- telerehabilitation programme in the observed effectiveness of telerehabilitation. The same is true in changes. Finally, a few studies (n ¼ 6) presented many areas of rehabilitation research. only outcomes in a single group of patients at post- intervention only, which compromised the strength of conclusions derived from these studies about the Overall findings related to study methodology effect of the telerehabilitation intervention as there There was an impressive proportion (n ¼ 13/28) of was no basis for comparison either between groups well conducted RCTs and quasi-experimental de- or before and after the intervention. signs with control groups, particularly for studies Close to 40% (n ¼ 11) of studies had sample sizes reporting clinical measures. It is generally accepted of fewer than 20 subjects, and none of the studies in meta-analyses and systematic reviews that clinical provided power calculations. Small sample sizes can trials, particularly RCTs and other quasi-experimen- lead authors to conclude that no significant differ- tal designs, are best suited for assessing the efficacy ence exists between groups, i.e., a Type II error, and cost-effectiveness of an intervention, and whereas in reality the study had insufficient power to thus provide stronger evidence on which to base identify a significant difference [39,47]. Several conclusions. larger non-randomized controlled trials were con- There was heterogeneity in the scientific quality of ducted in the area of cardiac rehabilitation. For the studies reviewed. The eight RCTs had PEDro example, Ades et al. [32] and Kortke et al. [30] had scores ranging from 5–9 out of 10, as reported in 133 participants and 170 participants, respectively, Table I. Common methodological weaknesses in divided into two groups. This may be a reflection of these studies included lack of blinding of therapists, the longer history of telerehabilitation in that area patients or assessors. While in telerehabilitation it is [48] and may partly explain the more widespread use not always feasible to design studies with patients and acceptability of the transtelephonic ECG mon- and therapists who are not aware of group assign- itoring systems technology, and thus facilitate access ment, the use of outside assessors reduces the to a larger study population. As well, a large RCT potential for evaluation bias. Although seven of was conducted by Man et al. [21], examining tele- the 13 studies with controls did not randomly cognitive rehabilitation in patients with traumatic allocate patients, five of the studies demonstrated brain injury in 103 patients divided into three baseline group equivalence for some clinical and intervention groups and one control group. The socio-demographic parameters. There was variability authors were able to design the study despite the in the type of control intervention used as a heterogeneous nature of traumatic brain injuries. comparison to the telerehabilitation intervention, Nevertheless, larger studies often remain challenging five of the studies using no therapy as the control to carry out, as many of the programmes are still in 444 D. Kairy et al. their pilot phases and there is often limited avail- reasons for satisfaction or dissatisfaction therefore ability of the patient population concerned. While remain unclear. All except two studies [25,29] report small sample size is often identified by authors as a satisfaction only in the telerehabilitation group, even limitation, smaller studies are essential as long as when a control group is available. A few studies they are conducted in a scientifically sound manner report some qualitative data from interviews; and provide contextualized outcomes or some basis however, description of data collection methods for comparison that allow a better analysis of the and results are generally too brief to draw any overall results; however results should be interpreted cau- conclusions. The findings in this review are similar to tiously. the conclusions arrived at by Mair and Whitten [42] These methodological issues are not isolated to as well as Williams et al. [43] in their systematic telerehabilitation research. They are common to reviews of studies reporting patient satisfaction with many rehabilitation research fields, particularly when telemedicine. Continuing to measure user satisfac- patient populations are small and interventions are tion in the current manner will simply confirm not widely accepted or easily available. previous findings of acceptability of the technology, but will not increase the understanding of the underlying processes of telerehabilitation use. A Discussion better understanding of satisfaction therefore re- mains an important area for future research in Outcomes of telerehabilitation telerehabilitation. The findings from the current systematic review are in part supported by those reported by other Limitations of cost analyses telemedicine systematic reviews not related to rehabilitation. These reviews consistently report that Few of the studies reported here examined any costs there are a few areas of telemedicine, such as aspects (19%, n ¼ 5). However, reduced costs or teledermatology, teleradiology, telemental health better resource utilization is often cited as one of the and home telecare for some chronic conditions, main goals of telerehabilitation. While the studies where there is emerging evidence for the efficacy of presented here included calculations of costs in- telemedicine, but few studies supporting the cost curred or saved from an organizational or patient benefits of telemedicine, and no evidence of the long perspective, the costs were not related to the other term outcomes of telemedicine (e.g., [38–41]). More clinical, process or healthcare utilization outcomes. If specifically, our systematic review of telerehabilita- outcomes are similar between a telerehabilitation tion showed that although there is heterogeneity programme and an alternative programme, then between studies in terms of study designs, clienteles, cost-minimization, or the cheapest of the two settings and outcomes measured, there is a consis- interventions is an appropriate measure of costs. If tent trend in the literature supporting the efficacy outcomes are different, then it is more relevant to and effectiveness of telerehabilitation. Many good identify how much more or less a telerehabilitation quality studies, including 13 studies with control programme costs compared to an alternative, taking groups, report similar or better clinical outcomes into account the change in clinical outcomes of each when compared to conventional interventions. A program. Cost differentials such as the incremental smaller number of studies examining process mea- cost-effectiveness ratio can be useful in this case. It sures indicate a trend towards the positive impact of may also be pertinent to examine whether certain telerehabilitation on process outcomes, particularly resources or programmes will no longer be available adherence and compliance. if a telerehabilitation programme is introduced, Overall, satisfaction ratings regarding the use of particularly in a context of limited public healthcare telerehabilitation were very high from both patients funding. As well, it may be appropriate to relate the and therapists, regardless of the patient population, cost difference to the impact on services offered. For setting or study design. However, certain measure- example, the number of patients who can receive the ment issues limit the usefulness of the reported data. telerehabilitation service may change due to the costs For example, the tools used to measure satisfaction saved or incurred, an important factor for a decision- are for the most part poorly described and not maker to take into account. Furthermore, and standardized. The underlying satisfaction concept is certain authors alluded to this, in longer term cost often vague and therefore the interpretation of the analyses, the value of the technology needs to be satisfaction findings is unsatisfactory. In addition, accrued over time. Costs may also change over time they are generally limited to satisfaction with the as the technology becomes increasingly used for technology and with the service received/given, and similar or other activities or as therapists gain do not specify any aspects of the service delivery or experience with the technology for example. It may their experience in the program. The underlying therefore be appropriate to conduct sensitivity A systematic review of telerehabilitation 445 analyses by adjusting some of these parameters, as It is well documented that there is a publication bias were calculated by Hassal et al. [36]. Finally, it is towards studies that have positive findings [49]. essential to identify whether the program’s goal is in Therefore, studies that do not demonstrate any effect fact direct cost savings. It may be more appropriate or report a negative effect of telerehabilitation may to examine whether it allows for better utilization of not carry as much weight in the synthesis of the data scarce resources, as often promoted by champions of because they were not identified through the search. telemedicine [44]. It is also important to remember Moreover, this study did not include studies looking that with the introduction of a telerehabilitation at patient assessment as the focus of this review was programme, costs may be redistributed to a different on intervention programmes. This was a first attempt level of care [44], such as from a home care service to to identify scientifically sound evidence of telereh- a rehabilitation centre, emphasizing the importance abilitation intervention programmes and synthesize of the perspective of the cost analysis. and critically appraise the published literature in this area. In part this also helps identify areas of weakness and possible directions for future studies. Issues relating to study design Future reviews could extend the scope of this Health technology assessments (HTA), the model analysis. often followed by telemedicine evaluations, generally In addition, there is an inevitable time lag between adhere to the normative approach favouring findings the conducting of studies and their publication [49]. from RCTs. But as many of the systematic reviews of A further delay is added with the synthesis of these telemedicine have reported, and as found in this findings. Reporting and synthesizing findings in a review of telerehabilitation, many studies have timely manner is crucial, particularly in a field where trouble fitting into the HTA mould. This is in part the technology is evolving so fast. Studies identified due to some of the intrinsic limitations of the in this review ranged from 1993–2006, the majority technology such as small groups of patients who being published after 2003. While some of the use the technology, rapidly evolving technology studies may have published their results after a limiting long term evaluations and the difficulty in longer delay than others, this suggests that the obtaining a valid control group [45]. Therefore, in findings are probably generalizable to the technolo- order to develop an evidence base that is useful for gies currently in use. Furthermore, a description of decision-making, it is essential to pursue research the technologies used by the studies has been that gives us a better understanding of the underlying provided in order to assess the relevance to current processes when they are implemented in a real telerehabilitation programmes. context. Studies using research methodologies that allow the processes to be examined, such as through Conclusion case studies [46] combining qualitative and quantitative data, can provide essential information for the This systematic review of telerehabilitation pro- integration of telerehabilitation into organization of grammes identified a substantial amount of scien- services. For example, in a recent in-depth study of tific literature in the relatively new area of three telehomecare evaluation projects, Gagnon et al. telerehabilitation. The results of this study indicate identified different types of evaluation models (e.g., that telerehabilitation can lead to similar clinical process evaluation, economic evaluation, rando- outcomes compared to traditional rehabilitation mized controlled trial) that can be applied depending programmes, with possible positive impacts on on the type of telehomecare programme, size of some areas of healthcare utilization. There is overall patient population and objective of the evalua- high acceptance from both patients and therapists tion [44]. although we have very little understanding of the As noted previously, four of the studies examining underlying factors that lead to the perceptions and the benefit of a home telerehabilitation programme acceptance. To date, there is insufficient evidence did so using a simulated environment in a hospital to confirm that telerehabilitation is a cost-saving or setting. Clearly the generalizability of such findings cost-effective solution. Further research in the area to home telerehabilitation is limited as there are of telerehabilitation, with methodologically sounder numerous context-related factors that may affect the studies examining healthcare utilization and costs in quality of the telerehabilitation sessions, and accept- greater depth is essential. In addition, for this ability and ease of use within the home may differ. research to be useful to clinical and policy decision makers, it must be combined with a more com- plete understanding of the underlying changes Limitations of this systematic review involved in telerehabilitation and of the factors One of the limitations of this systematic review is that influencing the sustainability of telerehabilitation it uses studies published in a peer-reviewed journal. programmes. 446 D. Kairy et al.

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