CRD summary

The authors concluded that positive physical, functional and psychological outcomes were achievable following a tele-rehabilitation intervention. There was conflicting evidence with regard to the effect on healthcare utilisation. This review contained potential limitations in search strategy, study quality assessment and reporting of the review process. The reliability of the authors' conclusions is unclear.

Authors' objectives

To evaluate the effectiveness of tele-rehabilitation interventions on clinical outcomes and healthcare utilisation in individuals with physical disabilities.

Searching

MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), ACP Journal Club, DARE, Health and Psychological Instruments, PsycINFO, PEDro and Health Technology Assessment Reports were searched for articles published in English and French from the earliest data available to February 2007. Search terms were reported. The Journal of Telemedicine and Telecare, and Telemedicine Journal and e-Health were handsearched. Reference lists of all relevant articles were searched for further studies. Abstracts and conference proceedings were excluded.

Study selection

All studies of tele-rehabilitation in participants of any age with physical impairment and in any setting were eligible for inclusion in the review. Tele-rehabilitation was defined as the use of communication and information technologies to provide clinical rehabilitation services from a distance. Included participants comprised those exposed to a variety of rehabilitation and control interventions connected to neurological or cardiac events, spinal cord injury, speech-language impairment and other conditions. Clinical outcomes and healthcare utilisation measures were the outcomes of interest. Outcomes included in the review related to physical, functional and psychological capacity, and hospitalisation, emergency room admissions and physician visits. Clinical process outcomes were reported, but did not form part of this abstract. Studies were excluded if they dealt only with mental illness, included telephone-only interventions or smart home monitoring devices or evaluated only support for caregivers of participants.

Studies were selected by one reviewer. Studies' relevance to the review was confirmed by a second reviewer.

Assessment of study quality

The quality of randomised controlled trials (RCTs) was assessed using the 10-item PEDro scale. Studies with scores of 4 or 5 were rated as fair, from six to eight as good and nine or 10 were rated as excellent.

The authors did not state how many reviewers performed the quality assessment.

Data extraction

The authors stated neither how the data were extracted for the review nor how many reviewers performed the data extraction.

Methods of synthesis

Data were synthesised narratively and grouped according to type and location of the tele-rehabilitation intervention. The authors highlighted the results of better quality studies in the text.

Results of the review

Twenty-eight studies were included in the review. There were eight RCTs (n=431) and five controlled quasi-experimental studies (n=415). Single RCTs scored 9 and 7, four scored 6 and two scored 5 on the PEDro quality assessment scale. The remaining 15 studies were single-group studies with pre-post or crossover measurements (n=209). Eleven studies contained sample sizes of less than 20.

In the 13 controlled studies, tele-rehabilitation produced similar or greater improvements on the following outcomes: function in activities of daily living (one study); return to work (two studies); lower limb range of motion (one study); gait (one study); pain (two studies); exercise capacity (four studies); cognitive tasks (one study); speech quality (one study); skin integrity (two studies); falls efficacy (one study); quality of life (four studies); fatigue (one study); anxiety (one study) and depression (three studies).

Findings that related to healthcare utilisation were conflicting (seven studies).

Cost information

Two controlled quasi-experimental studies and two small pre-post design studies reported lower costs for healthcare arising from tele-rehabilitation interventions. One study had no comparator.

Authors' conclusions

Positive physical, functional and psychological outcomes are achievable following a tele-rehabilitation intervention. There was conflicting evidence with regard to the effect on healthcare utilisation.

CRD commentary

The review question was supported by broad inclusion criteria for study design, participants, interventions and outcomes. The search strategy included a number of relevant sources. However, the restriction to published studies in two languages means that relevant studies may have been missed and publication and language biases were possible. There was insufficient indication that the review process was conducted with full attempt to minimise error and bias; the study selection process reported only a partial demonstration of this. Quality assessment was carried out using a recognised tool for RCTs; the quality of the other included studies was unclear. Study characteristics were presented in detail, but the results were grouped in a way that made the separation of RCT data difficult. Wide variation amongst the included studies meant that the chosen method of synthesis was appropriate. Given the various potential reporting and methodological limitations identified above, the extent to which the authors' conclusion is reliable is unclear.

Implications of the review for practice and research

Practice: The authors stated that clinical and policy decision makers should combine any research developments with a greater understanding of the underlying changes (and factors that influenced sustainability) of tele-rehabilitation programmes.

Research: The authors stated that more methodologically robust studies that investigated resource allocation and costs and incorporated patient focus and clinical process measurements were required in this topic area.

Funding

Doctoral fellowship: Fonds de la Recherche en Sante du Quebec (FRSQ); Analyse et Evaluation des Interventions en Sante (AnEIS) programme.

Bibliographic details

Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation 2009; 31(6): 427-447. [PubMed: 18720118]

Original Paper URL

http://informahealthcare.com/doi/abs/10.1080/09638280802062553

Indexing Status

Subject indexing assigned by NLM

MeSH

Health Services /utilization; Outcome and Process Assessment (Health Care); Patient Satisfaction; Rehabilitation /economics /methods; Telemedicine /economics

AccessionNumber

12009106045

Database entry date

20/01/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.