Review
Effectiveness of telerehabilitation interventions in persons with multiple sclerosis: A systematic review

https://doi.org/10.1016/j.msard.2015.06.011Get rights and content

Highlights

  • A wide range of telerehabilitation interventions is used in multiple sclerosis.

  • Telerehabilitation can be beneficial in improving function and symptoms.

  • There is some benefit of telerehabilitation in improving psychological outcomes.

  • Telerehabilitation can improve quality of life of persons with multiple sclerosis.

  • There is limited data on safety and costs of telerehabilitation programmes.

Abstract

Background

Telerehabilitation, a service delivery model using telecommunications technology to provide therapy at a distance, is used in persons with multiple sclerosis (pwMS), but evidence for their effectiveness is yet to be determined.

Objective

To investigate the effectiveness and safety of telerehabilitation intervention pwMS.

Method

A comprehensive literature search was conducted using medical and health science electronic databases. Three reviewers selected potential studies and independently assessed the methodological quality. A meta-analysis was not possible due to heterogeneity amongst included trials, and a qualitative analysis was performed for best evidence synthesis.

Results

Ten RCTs and 2 observational studies (n=564 participants) investigated a wide variety of telerehabilitation intervention in pwMS, which included: physical activity; educational, behavioural and symptom management programmes. All studies scored “low to moderate” on the methodological quality assessment implying high risk of bias. Overall, the review found low level evidence for the effectiveness of telerehabilitation on reducing short-term disability and reducing and/or improving symptoms, such as fatigue. There was low level evidence suggesting some benefit of telerehabilitation in improving functional activities; improving symptoms in the longer-term; and psychological outcomes and quality of life. There is limited data on safety, process evaluation and no data on cost-effectiveness of telerehabilitation.

Conclusions

A wide range of telerehabilitation is used in pwMS, however, the quality of evidence on these interventions was low. More robust trials are needed to build evidence about these interventions.

Introduction

Multiple sclerosis (MS) is the most common cause of neurological disability in young adults aged 18–50 years (Dombovy, 2011). The care needs in this population are complex, requiring longer-term multidisciplinary management (Khan and Gray, 2010; Khan et al., 2011; World Health Organisation (WHO), 2008). Despite recent advances in MS management, many persons with MS (pwMS) are unable to access these developments due to limited mobility, fatigue and related issues, costs associated with travel and limited access to services (Khan et al., 2009). With increasing financial constraints on healthcare systems, alternative methods of service delivery in the community and over a longer-term are regarded as a priority (Huijgen et al., 2008). The emerging advances in information and communication technology (ICT), telerehabilitation represent an alternative method to deliver therapy in a setting convenient to the patient, such as their home, by minimising the barriers of distance, time, cost and healthcare system load (Hailey et al., 2011; Khan et al., 2013).

Telerehabilitation can facilitate multifaceted, multidisciplinary management of person with MS (pwMS) beyond the clinical settings (Huijgen et al., 2008) and provide equal access to individuals who are geographically remote and are physically and economically disadvantaged (Hailey et al., 2011, Rogante et al., 2010). It can improve the quality of rehabilitation delivered (Hailey et al., 2011, Kairy et al., 2009, McCue et al., 2010, Rogante et al., 2010) by providing an opportunity to the therapists to evaluate the intervention previously prescribed, monitor adverse events, and patients' progress (Hailey et al., 2011, Steel et al., 2011). Moreover, through these programmes an intervention can be delivered to the number of the participants at any single time, which may not always be possible within the constraints of face-to-face treatment protocols (Hailey et al., 2011, Steel et al., 2011).

Telerehabilitation has been evaluated widely in literature and was found to be feasible and effective in various neurological conditions including stroke (Chumbler et al., 2012, Johansson and Wild, 2011, Legg and Langhorne, 2004, Perry et al., 2011), Parkinson's disease (Giansanti et al., 2008) and other non-neurological conditions such as musculoskeletal conditions (Russell et al., 2011, Tousignant et al., 2011), injuries (Bendixen et al., 2008, Forducey et al., 2003, Houlihan et al., 2011) and chronic diseases (Steel et al., 2011). A systematic review analysing telerehabilitation therapies in stroke survivors showed positive outcomes, with a reduction in the risk of deterioration, improved ability to perform activities of daily living, reduced costs and duration of rehabilitation (Legg and Langhorne, 2004). A wide range of telerehabilitation interventions have been trailed in pwMS (Hailey et al., 2011, Kairy et al., 2009, McCue et al., 2010, Rogante et al., 2010). However, there is as yet no systematic review of studies using telerehabilitation in pwMS to guide treating clinicians with evidence regarding its feasibility, reliability, effectiveness and efficiency in this population. Therefore, the aim of this systematic review was to assess the effectiveness, safety and cost-efficiency of telerehabilitation interventions currently used for pwMS. This review included both qualitative (observational studies) and quantitative studies (experimental studies), to provide the broader picture of currently available evidence.

Section snippets

Methods

An integrated approach was employed, which included a comprehensive review of literature (peer review and grey literature), using medical and health science electronic databases: Medline, PubMed, EMBASE, AMED, CINHAL, PsycINFO, Cochrane Library databases up to August 2014. Bibliographies of identified articles and manual search of relevant journals for additional references was conducted. Authors and known experts in the field were contacted. Further, a grey literature search was conducted

Results

The searches retrieved 40,790 published titles and abstracts. Forty-four articles met the abstract inclusion criteria and were selected for closer scrutiny. Full texts of these articles were retrieved and both reviewers performed final selection. Two articles that met the inclusion criteria were identified from the bibliographies of relevant articles. Of these 12 studies (10 RCTs, and 2 cohort studies) examining different telerehabilitation interventions fulfilled the inclusion criteria for

Discussion

This systematic review applied a multipronged and broad approach to assimilate published literature to provide the wider picture of currently available evidence, by including both qualitative and quantitative studies. It highlights the lack of robust, methodologically strong studies. The telerehabilitation interventions evaluated in the included studies showed marked heterogeneity in terms of characteristics, type and mode of delivery of the interventions, measurement tools used (even for

Conclusions

In conclusion, there is increasing awareness of telerehabilitation for effective management of pwMS. Although this review highlights the lack of high quality studies evaluating showing the effectiveness of telerehabilitation (types, components, modalities and duration of therapy, and the long-term functional outcomes), it summarises the existing evidence to support telerehabilitation in this population. Telerehabilitation programmes have been shown to be beneficial in improving different

Conflict of interest

The authors declared that they have no competing interests and no conflicts of interest.

Acknowledgements

This review did not receive any external funding and was supported from internal resources of the Rehabilitation Department, Royal Melbourne Hospital, Royal Park Campus, Melbourne, Australia.

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