1. Telerehabilitation for motor function: a systematic review A Turolla 1, L Piron 1, T Gasparetto 2, M Agostini 1, HR Jorgensen 3, P Tonin 1, T Larsen 4 1.Laboratory of Kinematics and Robotics, I.R.C.C.S. Fondazione Ospedale San Camillo, Venice, Italy 2.Social and Health Programs, Regione Veneto, Venice, Italy 3.Sygheus Vendsyssel Brønderslev Neurorehabiliteringscenter. Brønderslev, Denmark 4.Southern Denmark University, Centre for Applied Health Services Research and Technology Assessment (CAST). Odense, Denmark

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

3. Implications for research in 2000 Re-consider the focus and scope of telemedicine RCTs of telemedicine applications are feasible and should be carried out. Taking account of changes in distribution and use of telematics in society generally, not just in the health care context. Consider changing patterns of health care needs with emphasis on care for: –people with chronic conditions –the elderly –disease prevention –health promotion Patient-centred approaches. Studies of: –Effectiveness –Efficiency –Appropriateness Formal economic appraisal

4. Framework FP7 - EU HEALTH: INTEGRATED HOME CARE (grant n. 222954) Research for better ways to ensure continuity in clinical care for patients with chronic conditions: –Stroke –Heart failure –COPD WP 5 - Telerehabilitation www.integratedhomecare.eu

5. Broad reviews’ search strategies

6. Inclusion criteriaExclusion criteria 1.Published in English 2.Populations: a)HF b)COPD c)STROKE 3.Age > 18 yrs 4.Home care setting in the intervention 5.Full-text articles in peer- reviewed journals 1.Reviews not addressing patients directly but caregivers or professionals 2.Reviews which did not address telemedicine in: a)HF b)COPD c)STROKE

7. Flow chart of the selected reviews

8. Intervention Telemonitoring (HF, COPD) Telephone follow-up (TFU) Interactive Health Communication Applications (IHCA) Automated telemonitoring of vital signs and symptoms Automated physiologic monitoring Automated computer-based telephone messaging Monitoring of patients carrying implanted electrical devices Telerehabilitation (STROKE) Telephone follow-up (TFU) Remote control and interaction with devices based on position/sensing technologies Remote control and interaction with virtual reality based devices

9. Evidences (4 metanalysis) HFHF & COPDHF & STROKE Telemonitoring reduces: –mortality (RR=0.65, p=0.03) –hospital readmission (21%) Poor reporting: –costs –adherence –acceptability Interactive Health Communication Applications improves: –Knowledge –Social support –Clinical outcomes Case management interventions reduce mortality (OR=0.68, p=0.04) TFU patients show clinically-equivalent results compared to control groups, due to the low methodological quality of the studies

10. Conclusions In stroke patients, should be preferred an on-line interactive device (allowing also videoconference) than a store and forward device to provide telerehabilitation. Hard primary outcomes like: overall mortality hospital admission should also be included to prove efficacy. Secondary outcomes like: QoL, costs, adherence to treatment patient acceptability should be taken into consideration to perform a complete analysis of telerehabilitation.

11. How much broad or narrow should be a systematic review on telerehabilitation?

12. Research methods PubMed = 964 records EMBASE = 328 records The Cochrane Library – CENTRAL=113 records

13. Inclusion criteria Intervention Tele-based therapy programs defined as: 1.provided by means of any kind of technological device which should allow a healthcare professionals/patient on-line interaction; 2.provided by healthcare professionals or individuals under the supervision of healthcare professionals; 3.including at least one or more than one specific intervention targeted to motor function.

14. Inclusion criteria Type of studies RCTs qRCTs CCT First phase of cross over trial

15. Inclusion criteria Comparison Tele-based therapy programs vs. placebo or no intervention Tele-based therapy prograse vs usual care Tele-based therapy programs vs in-presence care Outcome Motor function

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

17. Flowchart of the publications’ selection process Potentially relevant studies identified and screened for retrieval (n=1405) Duplicates (n=199) Studies retrieved (n=1207) Studies included in the metanalysis (n=9) Not meeting inclusion criteria (n=1197)

18. Quality assessment Randomization sequence allocation concealment baseline comparison between groups blinding of outcome assessors ITT Analysis type of study Barnason 2009 ××√××√ Furber 2010 √√√√×√ Hermes 2007 √√√××√ Huijen 2008 √√√××√ Russell, 2011 √√√√√√ Piron 2008 √√√××√ Piron 2009 √√√××√ Dall'Olio, 2008 √√√√×√ Tousignat, 2010 √√√√×√

19. Treated populations

20. Treated patients

21. Telerehabilitation vs usual care Outcome: Motor function

23. Conclusions Little but no significant benefit of telerehabilitation compared to usual care (0.1 SD) If measured, others advantages could sustain the use of telerehabilitation: –Costs –Accessibility –Acceptability A low number of authors have published in the field  No random distribution of bias in different studies Trial sequence analysis  STOP randomization?

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

25. Thanks for your attention! San Marco square looking southeast (1735-40) Gian Antonio Canal called “Canaletto” andrea.turolla@ospedalesancamillo.net