Effect of telerehabilitation on motor and functional outcomes in people with spinal cord injuries – a systematic review

Abstract Purpose To summarise the evidence on telerehabilitation for improving motor and functional outcomes in people with Spinal Cord Injuries (SCI). Methods PubMed, Cochrane and Web of Science were searched to identify the eligible studies from October to December 2021. Randomised control trials (RCTs), non-RCTs, and case-control studies were included if they delivered exercises/rehabilitation through synchronous and asynchronous mode of telerehabilitation.. Risk of bias was assessed using Cochrane Risk of Bias Tool for RCTs and ROBINS-I tool for non-RCTs. The included studies were qualitatively synthesised and tabulated to present study characteristics. Result Four articles (190 participants) were included in the present review. Three studies reported significant improvement in motor outcome measures such as Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM) II, Action Research Arm Test (ARAT), ReJoyce Automated Hand Function Test (RAHFT), pinch and grip forces and isometric muscle strength of shoulder muscles. One study reported no difference between the control and experimental groups for the motor outcomes measured using 6-Minute Walk Test (6MWT) and 6-Minute Push Test. Conclusion Telerehabilitation was found to improve motor and functional outcomes in people with SCI and can be considered as a feasible treatment option in rehabilitation after SCI. Prospero registration: CRD42022349245


Introduction
Spinal cord injury (SCI) can result in a severely incapacitating condition that can cause severe personal and economic burdens to the patients and their caregivers [1].Recently, there has been an increase in SCI cases worldwide [2].People with severe spinal cord injury require admission to specialised spinal cord injury rehabilitation units [3].However, there is a lack of enough spinal cord injury units to cater to people with SCI and hence the access to it is limited [2,3].Furthermore, the nature of the condition requiring a longer duration of stay, a limited number of beds and higher cost associated with the admission [3], make admission to spinal cord injury rehabilitation units challenging.
Telerehabilitation can be used as an alternative option to provide continued quality care to the patients with SCI after discharge from the hospital [4].Telemedicine has been in existence since 1960s, and the effectiveness of the telemedicine interventions have been established in specific populations such as people with diabetes mellitus [5,6].More recently, telerehabilitation has been explored as a method to deliver care to the people with SCI.
Telerehabilitation is the provision of rehabilitation services virtually to patients at their home [7].It can be through synchronous (where interactions between the patient and the rehabilitation professional happens in real time) or asynchronous methods (where interactions happen in a non-real time setting) or mixed methods.Synchronous methods include telephonic conversations, video conferencing using virtual platforms and asynchronous methods include messaging (text messages, emails and patient portals), use of websites and wearable devices which collect relevant data and transmit it to the rehabilitation professional [8].Telerehabilitation allows the healthcare provider to monitor the patients' progress, train them, educate them and even treat some conditions [7].Tele-exercise was found to be a safe and feasible way to provide exercise to persons with SCI [9].Utilising tele-exercises for improving muscle strength, range of motion [10] and functional activities might help in improving motor problems in patients with SCI by overcoming non-engagement in exercises due to transportation barriers, inaccessible fitness facilities [11] and expensive gym memberships [4].
Hence, the evidence on the effectiveness of telerehabilitation on motor and functional outcomes in SCI has not been well established in the literature.Therefore, we aimed to identify and summarise evidence on the effectiveness of telerehabilitation in improving motor and functional outcomes when compared to conventional method of rehabilitation in the current systematic review.

Methods
The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.We registered the review in PROSPERO (Registration number: CRD42022349245).

Search strategy
A comprehensive search strategy was conducted utilising the following databases: PubMed, Cochrane Database of Systematic Review and Web of Science.Medical Subject Headings (MeSH) terms included (but were not limited to) spinal cord injuries, telerehabilitation and motor outcomes/mobility and functional outcomes.The list of the search terms is provided in supplementary file 1.The full search strategy is available from AJ.The searches were conducted between October 2021 and December 2021.The bibliography of systematic reviews and included articles were scrutinised for searching further eligible studies.

Procedure
AJ and AM conducted the searches and completed the initial screen of titles and abstracts using Rayyan Software [20].AJ and PK independently reviewed the full text of all potential titles against the inclusion criteria.Any disagreements were resolved by consensus.Potential articles were included using the following selection criteria.
Randomised Controlled Trials (RCTs), non-RCTs and casecontrol studies were eligible if they delivered exercises/rehabilitation through telecommunication or teleconsultation or telemonitoring, used synchronous and asynchronous mode of telerehabilitation, included persons diagnosed with SCI, and focussed on motor and functional outcomes.We considered upper extremity, trunk and lower extremity muscle strength, grip strength, spasticity, balance and coordination as the motor outcomes.Bed mobility, transfers, wheelchair mobility, indoor, outdoor and community ambulation, hand function, ability to carry out ADLs, FIM scores and the SCIM scores were considered as the functional outcomes for the review.Studies were excluded if they were case reports, case series, observational studies, or systematic reviews or published in languages other than English.Studies reporting only cardiovascular fitness or aerobic capacity after SCI with no information about motor outcomes were also excluded.

Critical appraisal
Risk of bias was assessed using Cochrane Risk of Bias Tool [21] for RCTs and assessment of non-RCTs were done using ROBINS-I tool [22].Two independent reviewers (AM and PN) assessed the risk of bias of each individual study and any disagreements between the two reviewers were resolved by a third reviewer (PK).

Data extraction and analyses
Data were extracted from all included studies by one reviewer (PK) and checked for accuracy by a second person (AJ).Extracted data included information about study design, participants' characteristics, mode of telerehabilitation, intervention program, results and statistics.The extracted data were narratively synthesised and summarised in as shown in the results section.

Results
Out of 143 records identified, we included 4 studies for the narrative synthesis.The process of screening and selecting studies for inclusion is shown in Figure 1.The selected articles were published over a period of years from 1999 to 2021.

Study design
Three of the four included studies were RCTs [4, 17,19] and one was a pre-post trial with three measurement points [18].Table 1 provides summary of the included articles.

Participants
A total of 190 participants were included in the review.The mean age of the participants ranged from 41.75 ± 4.6 years.The average time duration since SCI ranged from 13 to 16 years.The characteristics of the participants are given in Table 2.

Tele-rehabilitation intervention
Tele-rehabilitation intervention was comprised of specific patient mobility recommendations for transfer from bed to wheelchair, use of aids, prostheses and use of remote controls for electronic devices [4]; individualised online exercise programmes consisting of aerobic, strengthening, stretching and balance exercises were provided using the website which had information related to exercise, exercise diary, advice and education [19]; strengthening exercises for serratus anterior, scapular retractors and depressors and glenohumeral external rotators were given along with anterior chest 'open book' stretch [18].Kowalczewski et al. delivered Functional Electrical Stimulation combined with exercise therapy (FES-ET) to the intervention group in which custom computer games were prescribed and monitored by a telesupervisor [17].The duration of tele rehabilitation intervention ranged from 8 to 24 weeks [4, [17][18][19] The frequency of the interventions were two to three sessions per week [4, 18,19] or five to eight weekly sessions [17,19] and each session lasted for 30-60 min [4,19].The intervention group received specific exercises with exercise progression [18,19].Exercises progression included changing the resistance band, progressing the position to sitting, changing the number of sets or the plane of movement [18,19].
Clinical Physiotherapist reviewed the online exercise diary [19], or exercises were performed under the supervision [17,18] and progress was updated [19].Included studies used both synchronous interventions [4,17,18] and asynchronous methods for providing the interventions [19].A questionnaire was used to evaluate the satisfaction with care [4,19] along with telephonic interview [19] and telerehabilitation group showed a significantly higher satisfaction [4]; all the participants were satisfied with the web-based physiotherapy intervention and rated it either good or excellent [19].

Control group
The control group received usual care, self-management, nursing or unspecialised hospital care [4,19], asked to maintain an exercise log if they were exercising at home [19], or were provided with an individualised exercise plan [17].Exercises in intervention group were made more challenging by progression whereas in the control group participants were informed about self-management and asked to continue the usual care [14].Kowalczewski et al. delivered conventional exercise therapy to the control group that comprised strength training, computer games played with a trackball and therapeutic electrical stimulation [17].

Risk of biases in included studies
Cochrane risk of bias tool [21] was used to measure risk of bias of the RCTs [4, 17,19] and ROBINS-I tool [22] was used to measure the risk of bias of a pre-post trial.Overall, included RCTs [4, 17,19] had low risk of biases as shown in Figure 2. Random sequence generation and allocation concealment obtained low risk in two studies [4,19] and unclear risk in one study [17].Blinding of participants was graded unclear risk for all studies.Blinding of outcome assessor had low risk in one study [17], high risk in another [19] and unclear risk in remaining one RCT [4].All the three RCTs studies obtained low risk in incomplete outcome data and selective reporting.
Other bias such as sample size calculation and attrition rates were graded low risk in two studies [4,17] and unclear risk in one RCT [19].One pre-post trial [18] was assessed using ROBINS-I tool of risk of bias [22].Overall quality of pre-post trial [18] was graded as serious risk of bias.In the pre-post trial confounding, selection of participants, and measurement of outcomes were graded as serious Insufficient information was available to judge the bias for deviations from the intended interventions.Classification of interventions and selection of reported results were graded as low risk.

Discussion
This review evaluates the effectiveness of telerehabilitation on motor and functional outcomes in people with spinal cord injuries.Out of the included studies three studies reported improvement in motor outcomes such as FIM scores, SCIM II scores [4], Action Research Arm Test (ARAT) scores, RAHFT scores, pinch and grip forces [17] and isometric muscle strength of shoulder muscles [18], whereas one study reported no difference between the control and experimental groups for the motor outcomes measured through 6-Minute Walk Test (6MWT) and 6-Minute Push Test [19].The findings of our review are in line with the three previous reviews in spinal cord injury that examined the effectiveness of telerehabilitation in SCI [23][24][25].A narrative review examining the published literature on telerehabilitation in SCI concluded that telerehabilitation can be used for examination and guiding purposes but further research is needed on methodology and efficacy of telerehabilitation in SCI [23].Solomon et al. systematically reviewed the evidence for the use of telerehabilitation for people with SCI in lowand-middle income countries (LMICs) and reported significant improvement in quality of life, pressure ulcer management and some improvement in functional ability of the individuals with SCI.They reported insufficient evidence for the use of telerehabilitation in LMICs [25].According to the recent (fiscal year 2023) World Bank Classification, countries with Gross National Income between US$1085 to US$13205 are categorised as LMICs.This category constitutes 136 countries and represents 63% of the total countries in the world [26].Lee et al. investigated the effectiveness of telerehabilitation in 43 different outcomes and reported positive changes among 34 outcomes [24].However, authors reported heterogeneity among the included studies and recommended further studies to substantiate the results [24].Therefore, in the present review we summarised the evidence of telerehabilitation on motor outcomes in individuals with SCI.difference in FIM scores of the experimental group at six months was 7.55.The change observed was greater than the standard error margin of 4.4 for FIM [27], indicating a true improvement in the FIM scores.The study was conducted in central and Southern Italy, where there are few spinal cord units for consultation and rehabilitation of SCI patients.Hence, authors propose that the availability of specialists trained in spinal cord injury care through telemedicine consultations would have facilitated greater improvements in the telemedicine group [4].Even though number of readmissions were much lesser in the telemedicine group (one) compared to the control group (five), the study was underpowered to draw a conclusion on the efficacy of telemedicine on hospital readmissions.Also, authors report no significant difference between the groups for number and type of complications post SCI, small sample size could have also contributed to these findings.Kowalscezki et al. reported significant improvements in the action research arm test, Rejoyce automated hand function test, grasp and pinch forces in the FES assisted Rejoyce Exercise therapy delivered through a telerehabilitation among C5-C7 tetraplegia patients [17].Inclusion of task oriented training, which is proven effective in improving UE function [17] along with functional electrical stimulation [28] could have led to better improvements in the FES assisted Rejoyce Exercise therapy.Van Straaten et al. reported significant reduction in shoulder pain and improvement in arm function [18].Also, there was significant improvement in the strength of serratus anterior and scapular retractors.The type of intervention program incorporated in the study that included lighter resistance and higher number of repetitions, would have facilitated the reduction in pain and improved arm function [29].Some muscle groups such as external rotators did not show significant improvement in the muscle strength which could be because of the nature of program that focussed on muscular endurance training than muscular strength training [18,30].
Even though Coulter et al. [19] reported no statistically significant improvement in 6-Minute Push Test and 6MWT.Their telerehabilitation group had greater improvement in walking distance (57.8 m) than minimal detectable change (45.8 m) [27] for the 6MWT in people with SCI indicating a clinical change.Lower sample size would have resulted in statistical non significance.Majority of the included studies reported improved patient and caregiver satisfaction with the telerehabilitation [4, 17,19].One of the included studies did not assess patient satisfaction [18].Patients were willing to continue participation in telerehabilitation, and the compliance rate to the intervention was higher.Also, they reported website was easy to use, fun and enjoyable to follow, and beneficial for health and well-being [19] indicating telerehabilitation is a potentially effective and acceptable option to improve motor and functional outcomes in individuals with SCI.

Quality of evidence
In the present review, most of the information was obtained from studies that were at low risk of bias or unclear risk of bias indicating moderate quality of evidence.Selection bias (random sequence generation and allocation concealment) and other biases were low in two studies and were unclear in two.Blinding of the participant was unclear among all the studies and risk of bias for blinding of the outcome assessor was low in one study, high in another and unclear in the remaining two studies.Reporting bias was low among all the included studies.Quality of the pre-post study was judged as having serious risk of bias, indicating the study has some important problems, nevertheless study is not too problematic to provide useful information [22] therefore it was included in the narrative synthesis.

Limitations
There are several limitations to our review.Firstly, we did not include unpublished literature in the current review which could have led to missing out of some relevant unpublished information.Secondly, we could include only four studies in the review out of which one was a pre post trial.Due to limited research in this area, we aimed to summarise all the pertinent information on telerehabilitation after SCI and included both RCTs and non RCTs, which could have lowered the quality of evidence.Additionally, very few motor and functional outcomes were assessed in the included studies, restricting the generalisability of our findings to other motor and functional outcomes mentioned in our inclusion criteria.Lastly, there was heterogeneity in the selection criteria of the included studies as the authors recruited participants with both complete and incomplete spinal cord injuries and varying levels of injury ranging from C1-C4 to T1-S5.Therefore, our findings may not be applicable to specific level of SCI.

Conclusion
The evidence of telerehabilitation in SCI is limited due to very few trials.However, the findings of this review show that telerehabilitation might be effective in improving motor and functional outcomes and is found to be acceptable in people with SCI.Further RCTs with higher sample size and longer follow up is necessary to substantiate the evidence on telerehabilitation and its effect after SCI.

Table 1 .
Characteristics of included studies.

Table 1 .
Dallolio etal.reported significant improvement in the FIM scores mainly in the domains of dressing (upper & lower body) and bed/chair/wheelchair transfers [4].The mean Continued.

Table 2 .
Characteristics of study participants.
Figure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.