Telerehabilitation services for stroke

Kate E Laver; Zoe Adey‐Wakeling; Maria Crotty; Natasha A Lannin; Stacey George; Catherine Sherrington

doi:10.1002/14651858.CD010255.pub3

. 2020 Jan 31;2020(1):CD010255. doi: 10.1002/14651858.CD010255.pub3

Telerehabilitation services for stroke

Kate E Laver ^1,^✉, Zoe Adey‐Wakeling ², Maria Crotty ¹, Natasha A Lannin ³, Stacey George ¹, Catherine Sherrington ⁴

Editor: Cochrane Stroke Group

PMCID: PMC6992923 PMID: 32002991

Abstract

Background

Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face‐to‐face or when added to usual care.

Objectives

To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in‐person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face‐to‐face); or (2) no rehabilitation or usual care.

Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self‐care and domestic life and improved mobility, balance, health‐related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in‐person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost‐effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions.

Search methods

We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists.

Selection criteria

Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in‐person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in‐person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation.

Data collection and analysis

Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings.

Main results

We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies. Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post‐hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post‐stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke.

Primary outcome: we found moderate‐quality evidence that there was no difference in activities of daily living between people who received a post‐hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) ‐0.00, 95% confidence interval (CI) ‐0.15 to 0.15)). We found low‐quality evidence of no difference in effects on activities of daily living between telerehabilitation and in‐person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI ‐0.43 to 0.48). Secondary outcomes: we found a low quality of evidence that there was no difference between telerehabilitation and in‐person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI ‐0.30 to 0.46). Pooling of three studies with 569 participants showed moderate‐quality evidence that there was no difference between those who received post‐discharge support interventions and those who received usual care on health‐related quality of life (SMD 0.03, 95% CI ‐0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate‐quality evidence that there was no difference in depressive symptoms when comparing post‐discharge tele‐support programs with usual care (SMD ‐0.04, 95% CI ‐0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI ‐2.17 to 4.64, low‐quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in‐person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost‐effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial‐related adverse events were reported.

Authors' conclusions

While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate‐level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short‐term post‐hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in‐person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost‐effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.

Plain language summary

Telerehabilitation services for stroke

Review question  This review aimed to gather evidence for the use of telerehabilitation after stroke. We aimed to compare telerehabilitation with therapy delivered face‐to‐face and with no therapy (usual care).

Background  Stroke is a common cause of disability in adults. After a stroke, it is common for the individual to have difficulty managing everyday activities such as walking, showering, dressing, and participating in community activities. Many people need rehabilitation after stroke; this is usually provided by healthcare professionals in a hospital or clinic setting. Recent studies have investigated whether it is possible to use technologies such as the telephone or the Internet to help people communicate with healthcare professionals without having to leave their home. This approach, which is called telerehabilitation, may be a more convenient and less expensive way of providing rehabilitation. Telerehabilitation may be used to improve a range of outcomes including physical functioning and mood.

Study characteristics  We searched for studies in June 2019 and identified 22 studies involving 1937 people after stroke. The studies used a wide range of treatments, including therapy programmes designed to improve arm function and ability to walk and programmes designed to provide counselling and support for people upon leaving hospital after stroke.

Key results  As the studies were very different, it was rarely appropriate to combine results to determine overall effect. We found that people who received telerehabilitation had similar outcomes for activities of daily living function to those that received face‐to‐face therapy and those that received no therapy (usual care). At this point, not enough research has been done to show whether telerehabilitation is a more effective way to provide rehabilitation. Some studies report that telerehabilitation is less expensive to provide but information is lacking about cost‐effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. Further trials are required.

Quality of the evidence  The quality of the evidence was generally of low or moderate quality. The quality of the evidence for each outcome was limited due to small numbers of study participants and poor reporting of study details.

Summary of findings

Background

Description of the condition

Stroke is one of the most common causes of death and acquired disability worldwide (Thrift 2017). Survivors of stroke commonly experience a range of symptoms affecting motor function, speech, swallowing, vision, sensation and cognition, and recovery can be slow and incomplete (Crichton 2016; Langhorne 2011). These symptoms often lead to difficulty managing activities and limited participation in home and community activities. Approximately half of stroke survivors access some form of rehabilitation on discharge from acute services (National Institutes of Health 2014; Stroke Foundation 2017). Rehabilitation programmes are often lengthy and resource intensive. Therefore, determining the most effective and efficient ways to deliver stroke rehabilitation services is a matter of priority.

Description of the intervention

Telerehabilitation is the provision of rehabilitation services to patients at a remote location using information and communication technologies (Brennan 2009). Communication between the patient and the rehabilitation professional may occur through a variety of technologies such as the telephone, Internet‐based videoconferencing and sensors (such as pedometers). Virtual reality programmes may also be used as a medium for therapy; the patient completes therapy tasks within a computer‐generated virtual environment, and data are transmitted to the therapist (Rogante 2010). Telerehabilitation consultations may include assessment, diagnosis, goal‐setting, therapy, education, and monitoring (Russell 2009).

Stemming from the broader approach of telehealth, telerehabilitation has been described as an alternative method of delivering conventional rehabilitation services rather than a subspecialty (Winters 2002). There has been increasing interest in the use of telerehabilitation over time as technologies have become increasingly prevalent and more sophisticated (Brochard 2010; Galea 2019); however, translation into clinical practice has been slow and barriers experienced early in the development of the field persist (Standing 2018).

Many examples in the current literature demonstrate the scope of telerehabilitation. For example, home assessments to determine the need for modifications have been completed remotely by occupational therapists using a combination of still photography, telephone calls, and videoconferencing technology (Ninnis 2019). Physiotherapists have used telerehabilitation for treatment of musculoskeletal conditions and post‐surgical care (Richardson 2017; Van Egmond 2018), and speech pathologists have demonstrated the feasibility of providing aphasia rehabilitation using asynchronous telerehabilitation (Hill 2018).

How the intervention might work

Telerehabilitaton has been described simply as an alternative method of providing rehabilitation. Therefore, in theory, the mechanisms leading to recovery should mirror those associated with conventional rehabilitation programmes. It is now well established that organised, interdisciplinary stroke care reduces the likelihood of institutional care and long‐term disability and increases independence in activities of daily living (Kalra 2007; Pollock 2014). Improvements in function after completion of rehabilitation programmes have been attributed to a combination of physiological recovery, reorganisation within the brain (known as neuroplasticity), and compensation (Kwakkel 2004).

One of the key advantages of telerehabilitation is that it provides the opportunity for people who are isolated to access rehabilitation services. This feature is particularly beneficial in vast countries such as Canada and Australia, where many people live long distances away from specialised rehabilitation centres. People in rural and remote areas are unlikely to have access to rehabilitation teams with expertise in stroke, and they may not have access to rehabilitation clinicians at all. Eliminating the need for travel to rehabilitation centres may also benefit people with severely restricted mobility who have difficulty travelling or are unable to travel. Telerehabilitation is also likely to be beneficial in low‐resource settings where access to health professionals is poor but access to devices such as mobile phones is present.

Telerehabilitation services may also be used to complement and enhance the quality of current rehabilitation services. Stroke survivors have expressed concern regarding the lack of available long‐term support and ongoing unmet rehabilitation needs (Ullberg 2016). It is possible that the use of telerehabilitation may help to address these gaps by supporting patients as they resume life roles on discharge from inpatient facilities.

Furthermore, the use of telerehabilitation may result in cost savings in various ways. Reduced travel time (for clinicians who visit patients in their own home) may mean that clinicians are able to fit more consultations into a single day. In addition, it may be possible to discharge patients from inpatient rehabilitation facilities earlier and offer telerehabilitation as a way of continuing the rehabilitation programme. Furthermore, telerehabilitation may provide a mechanism for increasing the dose of therapy without an increase in face‐to‐face supervision.

Despite its apparent advantages, the challenges associated with telerehabilitation are well documented (Standing 2018; Theodoros 2008). One of the key issues facing clinicians is how to conduct assessments or provide interventions that are typically 'hands on', for example, assessment of muscle strength. The inability to conduct hands‐on assessment or treatment means that therapists need to modify current techniques, for example, by utilising family members or teaching the patient ways to perform the intervention independently (Russell 2009).

Furthermore, clinicians and patients may not possess the technical expertise to establish systems and to troubleshoot information and communication technologies. It has been recommended that service providers ensure that technical requirements are met (such as having adequate bandwidth), provide access to technical support and provide training to all users (clinicians and patients). Concerns have also been raised about the security of data transfer and how patient confidentiality can be maintained (American Telemedicine Association 2010).

Why it is important to do this review

Changes in the demographics of the population mean that the burden of stroke is projected to increase (Feigin 2017). New approaches that are demonstrated to be clinically sound and cost‐effective will be required. Increasing interest in telerehabilitation suggests that this area will continue to grow (Brochard 2010; Galea 2019), and there is great potential to implement effective telehealth interventions in low and middle‐income countries. Furthermore, clinical guidelines for stroke recommend telerehabilitation for people without access to centre‐based rehabilitation services (Blacquiere 2017). However, establishment of telerehabilitation services may be expensive because of the costs of equipment, training, and ongoing technical support. Therefore, it is important to determine whether telerehabilitation services once established may result in the desired outcomes.

Our first version of this review, published in 2013, included 10 RCTs which were heterogeneous in terms of the aims of their intervention (Laver 2013). Based on the lack of information available at that time, we were unable to reach conclusions about the effectiveness of telerehabilitation after stroke. Another recently published systematic review examined the effectiveness of telerehabilitation after stroke and, using different inclusion criteria, identified 11 RCTs (Chen 2015). The authors concluded that despite the relatively small field of evidence from which to draw information, telerehabilitation was non‐inferior to conventional rehabilitation approaches in improving activities of daily living and motor function (Chen 2015).

Given the growth of research in this area and the potential for telerehabilitation to improve access to, and quality of, rehabilitation services while reducing costs, an update of our previous review was warranted. Furthermore, health services are increasingly offering telerehabilitation services for their clients so evaluation of this approach is important.

Objectives

Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self‐care and domestic life and improved mobility, balance, health‐related quality of life, depression, upper limb function, cognitive function, or functional communication when compared with in‐person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost‐effectiveness, feasibility, and levels of user satisfaction associated with telerehabilitation interventions.

Methods

Criteria for considering studies for this review

Types of studies

We included only RCTs. We considered cross‐over trials as RCTs in accordance with the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We included studies if they compared telerehabilitation with in‐person rehabilitation or no rehabilitation, two different methods of delivering telerehabilitation services, different doses of telerehabilitation or telerehabilitation plus usual care compared with usual care alone.

Types of participants

All study participants had received a clinical diagnosis of stroke as defined by the World Health Organization ("a syndrome of rapidly developing symptoms and signs of focal, and at times global, loss of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin") (WHO 1989). We included people with all types of stroke, at all levels of severity, and at all stages post‐stroke (acute, subacute, or chronic). We also included participants with subarachnoid haemorrhage. We excluded studies with participants of mixed aetiology (e.g. stroke and traumatic brain injury) unless data were available for stroke survivors only. We set no age limits; however, we planned to acknowledge the inclusion of any participants who were younger than 18 years of age.

Types of interventions

We included Interventions if they matched the following definition of telerehabilitation: "the delivery of rehabilitation services via information and communication technologies" (Brennan 2009). Clinically, this term encompasses a range of rehabilitation services that include assessment, prevention, intervention, supervision, education, consultation, and counselling. Interventions must have lasted longer than one session. Interactive and communication technologies included the telephone, the Internet, virtual reality, and monitoring via sensors or wearable devices. We included rehabilitation programmes that used "store and forward" methods of communication, or real‐time interaction. Interventions were provided by one or more health disciplines (e.g. we planned to include studies involving only one health profession and studies which involved a multidisciplinary intervention). We included rehabilitation programmes that used a combination of telerehabilitation and in‐person rehabilitation to conduct assessment or intervention, provided that the greater proportion of intervention was provided via telerehabilitation. We did not include the use of telerehabilitation when the purpose was to provide education or support for healthcare professionals rather than patient care.

Types of outcome measures

Primary outcomes

The primary outcome of interest was independence in activities of daily living assessed post‐intervention. In the review, this encompassed the self‐care, mobility and domestic life activity and participation domains derived from the International Classification of Functioning, Disability and Health (WHO 2010). Included assessment tools were those such as the Functional Independence Measure, the Barthel Index, Lawton Instrumental Activities of Daily Living, Frenchay Activities Index, and the Nottingham Extended Activities of Daily Living Index.

Secondary outcomes

Self‐care and domestic life.
Mobility (e.g. Timed Up and Go test, walking speed, functional ambulation category).
Balance.
Participant satisfaction with the intervention.
Self‐reported health‐related quality of life.
Depression.
Upper limb function (e.g. Action Research Arm Test, Wolf Motor Function Test, Fugl‐Meyer Upper Extremity measure).
Cognitive function (global measures such as the Mini Mental State Examination, or specific measures such as tests of attention or executive functioning).
Functional communication.
Cost‐effectiveness (as measured by comparing the costs and outcomes of each intervention approach).
Adverse events.

We also aimed to provide information on the feasibility of telerehabilitation for use with people after stroke by reporting on participant eligibility criteria and recruitment methods used in the individual studies identified.

Search methods for identification of studies

See the 'Specialized register' information at the Cochrane Stroke Group's website. We searched for relevant trials in all languages and arranged translation of trial reports where necessary.

Electronic searches

The searches for studies in our previous reviews were conducted in November 2012. The searches for this update were completed in July 2017 and then updated in June 2018, and again in June 2019.

We searched the Cochrane Stroke Group Trials Register, which was searched by the Managing Editor in November 2012, and by the Information Specialist in July 2017, June 2018, and June 2019 using the intervention code, telemedicine. In addition, we searched the following electronic bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 6) in the Cochrane Library (searched 4 June 2019) (Appendix 1), MEDLINE (Ovid, 1946 to 3 June 2019) (Appendix 2), Embase Ovid (1974 to Week 22, 2019) (Appendix 3), AMED Ovid (Allied and Complementary Medicine; 1985 to May 2019) (Appendix 4), CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1982 to 4 June 2019) (Appendix 5), PsycINFO Ovid (from 1806 to 4 June 2019) (Appendix 6), PsycBITE (Psychological Database for Brain Impairment Treatment Efficacy, www.psycbite.com/ to 20 September 2018) (Appendix 7), OTseeker (www.otseeker.com to 20 September 2018) (Appendix 8), Physiotherapy Evidence Database (www.pedro.org.au to 20 September 2018) (Appendix 9), REHABDATA (www.naric.com/research/rehab/ to 20 September 2018) (Appendix 10), and the Health Technology Assessment Database (HTA) (www.crd.york.ac.uk/crdweb/ to 20 September 2018) (Appendix 11). We developed the MEDLINE search strategy with the help of the Cochrane Information Specialist and used a combination of controlled vocabulary and text‐word terms. We adapted this strategy for use with the other databases. Search words for trial registers and for other Web‐based databases included telerehabilitation, telemedicine, telehealth, videoconferencing, and stroke.

We also:

searched the following ongoing trials registers: US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) and World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch) to 4 June 2019 (Appendix 12);
used the Cited Reference Search within Science Citation Index (SCI) and Social Science Citation Index (SSCI) to track relevant references;
searched ProQuest Dissertations and Theses (to 4 June 2019) (Appendix 13);
searched the UK Telemedicine and E‐health Information Service (www.teis.port.ac.uk/) for the first version of this review. The website was discontinued and was not searched for this version of the review; and
searched the grey literature using Open Grey (www.opengrey.eu) and Google Scholar (www.scholar.google.com) on 4 June 2019.

Searching other resources

To identify further published, unpublished and ongoing trials, we:

scanned the reference lists of all identified studies and reviews; and
scanned the abstracts of non–English language studies if they were available in English.

Data collection and analysis

Selection of studies

Two review authors (KEL and ZA) independently reviewed titles and abstracts of the records identified through searches and excluded obviously irrelevant studies. We obtained the full text of the remaining studies, and two review authors (KEL and ZA) selected studies for inclusion based on the inclusion criteria of the review. When unsure regarding inclusion of a particular study, a third review author (MC, SG or CS) made the final decision. We contacted trial authors for further details when required and documented the reasons for exclusion.

Data extraction and management

Two review authors (KEL and ZA) independently extracted study data and recorded information on a predesigned data extraction form. We extracted the following study details.

Citation details: title, authors, source and year of publication.
Participant inclusion and exclusion criteria.
Participant details: age, gender, location of stroke, time since onset of stroke and level of disability.
Recruitment details: numbers of people screened, eligible, recruited and randomly assigned; withdrawals.
Methodological quality: the Cochrane Collaboration's tool for assessing risk of bias.
Intervention details: descriptions of procedures, personnel involved, duration, dose and comparison interventions.
Outcome measures: measures used, by whom, when they were administered and how they were administered (in‐person or via information and communication technologies).

We contacted trial authors to ask for missing information when required. We resolved differences by discussion or by consultation with a third review author when necessary.

Assessment of risk of bias in included studies

Two review authors (KEL and ZA) independently assessed the risk of bias of included studies using Cochrane's 'Risk of bias' tool (Higgins 2011). This tool allows assessment of the following possible sources of bias: random sequence generation; allocation concealment; blinding of outcome assessors; incomplete outcome data; selective reporting; and any other potential sources of bias. We did not report on whether studies were able to blind participants or personnel because of the difficulties involved in achieving this in rehabilitation trials. We compared each study against the tool and assessed it as 'low risk', 'high risk', or 'unclear risk' of bias, depending on whether it met the criteria for each aspect of the tool. A third review author resolved any disagreements.

Measures of treatment effect

Two review authors (KEL and ZA) independently assigned outcome measures to the domain assessed (activities of daily living, participant satisfaction, health‐related quality of life, depression, mobility, upper limb function, cognitive function, functional communication). If more than one outcome measure was used in the same domain from the same study, we included the measure most frequently used across included studies.

We intended to conduct separate analyses between short‐term (less than three months after intervention) and long‐term (three months or longer) outcomes.

We planned to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for dichotomous outcomes and mean differences (MDs), or standardised mean differences (SMDs) and 95% CIs for continuous outcomes, as appropriate.

Unit of analysis issues

The unit of randomisation in these trials was the individual participant. For three‐armed trials in which telerehabilitation was compared with in‐person or no rehabilitation, we intended to enter half the sample size for the telerehabilitation group. Thus, each alternative intervention would be included in a separate comparison, and the number of participants in the telerehabilitation group would be divided equally between comparisons; the telerehabilitation group mean and standard deviation would remain unchanged.

Dealing with missing data

We contacted trial authors to request missing data. We converted available data, when possible, using the procedures detailed in section 16.1.2 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We intended to deal with missing data as recommended by the Cochrane Handbook for Systematic Reviews of Interventions. When dropouts were clearly identified, we used the denominator of participants contributing data at the relevant outcome assessment.

Assessment of heterogeneity

When appropriate, we pooled results to present an estimate of treatment effect using a random‐effects model. We assessed heterogeneity by performing visual inspection of the forest plot along with the I² statistic (Higgins 2011) where we considered that up to 40% heterogeneity might not be important, but higher levels indicated moderate or substantial heterogeneity.

Assessment of reporting biases

We sought to assess the impact of publication bias by searching clinical trials registers for studies. In addition, we investigated whether selective reporting occurred by comparing study protocols and the methods sections of papers with the results sections. We intended to assess small sample bias by preparing a funnel plot if we had 10 or more studies included in any meta‐analysis.

Data synthesis

We conducted a meta‐analysis based on a random‐effects model with 95% CIs using RevMan 5.3 (RevMan 2014). We explored heterogeneity as detailed below.

Subgroup analysis and investigation of heterogeneity

If we identified a sufficient number of comparable studies (eight or more), we planned to perform subgroup analyses to determine whether the effect on the primary outcome varied according to time since onset of stroke, severity of stroke, frequency of the intervention (occasions of service per week), intensity of the intervention (total hours of intervention), intervention approach selected (e.g. speech therapy, upper limb retraining), mode of delivery (e.g. telephone versus videoconferencing, real‐time communication versus 'store and forward'), and whether the intervention was provided by a multidisciplinary team or by members of a single discipline.

Sensitivity analysis

We intended to perform sensitivity analyses for all outcomes based on the methodological quality of studies (allocation concealment, blinding of outcome assessor, intention‐to‐treat analysis) to assess the impact of risk of bias in the included studies. We planned to conduct sensitivity analysis regardless of the level of heterogeneity detected. We also planned to conduct a sensitivity analysis to identify differences noted when a fixed‐effect versus a random‐effects model was used.

GRADE and Summary of findings

We used GRADE to interpret findings (Guyatt 2008), and presented 'Summary of findings' tables. The tables provide outcome‐specific information concerning the overall quality of evidence, magnitude of effect, and the sum of available data. When using GRADE, we downgraded the evidence from 'high quality' by one level for serious (or by two levels for very serious) study limitations (risk of bias), indirectness of evidence, serious inconsistency, imprecision of effect estimates, or potential publication bias. We presented the following outcomes in our 'Summary of findings' tables: activities of daily living, self‐care and domestic life, mobility, balance, self‐reported health‐related quality of life, depression, and upper limb function.

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies; Characteristics of studies awaiting classification.

Results of the search

We identified 189 studies by searching the Cochrane Stroke Group trials register and clinical trial registries, and 25,234 references by searching electronic databases, totaling 25,423 references. We reviewed 416 articles in full text and contacted study authors to request more information when required, excluding articles that clearly did not meet the inclusion criteria. Details of 29 excluded studies are provided in the 'Characteristics of excluded studies' table. We listed studies in the excluded studies section of the review if they prompted conversations between the review authors regarding their eligibility. We identified 22 ongoing studies (Characteristics of ongoing studies), and six studies which are awaiting classification (Characteristics of studies awaiting classification). Search details are presented in the flow diagram (Figure 1).

Included studies

We included 22 RCTs, with a total of 1937 participants, in the review.

Sample characteristics

Included studies were conducted in the USA (n = 8), Canada (n = 3), the Netherlands (n = 2), Italy (n = 2), Germany (n = 2), China (n = 2), Taiwan (n = 1), Spain (n = 1), and Slovenia (n = 1). All studies were published within the previous 15 years (between 2004 and 2019). Sample sizes ranged from 10 to 536; most studies (71%, n = 16) included fewer than 100 participants (Table 3; Table 4).

1. Numbers of participants screened, recruited and followed up.

Study	Screened	Randomised	Allocated to intervention group	Allocated to control group	Assessed at follow‐up
Bishop 2014	Not reported	49	23	26	41
Bizovičar 2017	Not reported	10	5	5	Unclear
Boter 2004	691	536	263	273	486
Carey 2007	167	25	13	12	20
Chen 2017	97	54	27	27	50
Chumbler 2012	52	52	27	25	44
Cramer 2019	232	124	62	62	124 analysed
Deng 2012	62	19	9	10	16
Forducey 2012	Not reported	11	Not reported	Not reported	9
Huijgen 2008	Not reported	16	Not reported	Not reported	Not reported
Kirkness 2017	416	100	37	35 (in‐person), 28 (usual care)	91
Lin 2014	94	24	12	12	23
Llorens 2015	115	31	15	16	30
Mayo 2008	294	190	96	94	157
Meltzer 2018	Not reported	53	20	22	Unclear
Piron 2008	Not reported	10	5	5	10
Piron 2009	Not reported	36	18	18	36
Rochette 2013	286	186	92	94	139
Saal 2015	1045	265	130	135	230
Smith 2012	161	38	19	19	32
Vauth 2016	Unclear	17	Unclear	Unclear	Unclear
Wan 2016	186	91	46	45	80

Study	Intervention	Comparison	Time after stroke	Country of study
Bishop 2014	Family therapy phone calls to assist with transition home (up to 26 phone calls over 6 months)	Usual care	Not reported however occurred on discharge from hospital to home	USA
Bizovičar 2017	Web‐based exercises (posture and upper limb) and therapist weekly consultations	Provision of written exercises without additional therapist contact	Subacute	Slovenia
Boter 2004	Case management via 3 telephone calls and a home visit up to 24 weeks after discharge from an acute hospital following stroke	Usual care	Not reported; however, intervention was provided on discharge from acute facility	Netherlands
Carey 2007	Upper limb therapy targeting finger and wrist movements provided via a computerised programme in which explicit feedback on performance was provided. Regular teleconferencing occurred between participant and therapist.	Upper limb therapy targeting finger and wrist movements provided via a computerised programme whereby explicit feedback on performance was not provided. Regular teleconferencing occurred between participant and therapist.	Chronic phase	USA
Chen 2017	Exercise programme and electrical stimulation which was supervised and monitored remotely via a telerehabilitation system	Same programme of exercises but provided face to face in an outpatient therapy service	Subacute phase	China
Chumbler 2012	A programme designed to improve the person's functional mobility administered via televisits, use of an in‐home messaging device, and 5 telephone calls over a 3‐month period	Usual care	Subacute phase	USA
Cramer 2019	Telehrehabilitaiton program designed to improve upper limb function and involving on‐screen games	Similar therapy content and same dose of therapy but provided in the clinic	Subacute	USA
Deng 2012	Lower limb therapy targeting ankle movements provided via a computerised programme in which explicit feedback on performance was provided. Teleconferencing was used regularly, and performance data were emailed to the therapist.	Lower limb therapy targeting ankle movements provided via a computerised programme whereby explicit feedback on performance was not provided. Teleconferencing was used regularly, and performance data were emailed to the therapist.	Chronic phase	USA
Forducey 2012	A total of 12 therapy sessions (occupational therapy and physiotherapy) were conducted via a desktop videophone. Interventions included education, retraining of self‐care, functional mobility and posture, home modifications and therapy to improve function in impaired limbs.	The same intervention programme was delivered face‐to‐face.	Not reported	USA
Huijgen 2008	Upper limb therapy using the Home Care Activity Device (computer‐based programme) for 1 month	Usual care and generic exercises were provided by a physician	Chronic phase	Netherlands
Kirkness 2017	Living Well with Stroke intervention designed to reduce depressive symptoms in people with stroke and depression delivered via telephone	Living Well with Stroke (in‐person) Usual care	Subacute	USA
Lin 2014	Physical exercises especially balance and lower limbs provided remotely via telerehabilitation system	Similar exercises provided face‐to‐face	Chronic	Taiwan
Llorens 2015	Virtual reality system used in the home with the aim of improving balance. Remote monitoring and phone call checks	Virtual reality system used in the clinic with the aim of improving balance	Chronic	Spain
Mayo 2008	Case management intervention provided via home visits and telephone calls for 6 weeks following discharge from acute care	Participants were instructed to make an appointment with their general practitioner.	Acute phase	Canada
Meltzer 2018	Aphasia rehabilitation provided remotely via telerehabilitation	Aphasia rehabilitation provided in‐person	Chronic phase	Canada
Piron 2008	Upper limb therapy that was delivered using a virtual reality programme at home and supplemented by videoconferencing	Upper limb therapy that was delivered using a virtual reality programme and conducted in the clinic setting	Chronic phase	Italy
Piron 2009	Upper limb therapy that was delivered using a virtual reality telerehabilitation programme and that took place in the home	A programme of conventional upper limb exercises	Chronic phase	Italy
Rochette 2013	Regular phone calls to discuss family functioning and risk factors after discharge from hospital	Phone number to call health professional if queries	Acute phase	Canada
Saal 2015	Stroke support service upon discharge from acute hospital	Usual care	Post‐acute phase	Germany
Smith 2012	An intervention to support the caregivers of stroke survivors by enhancing knowledge, skills, and coping. Delivered via email, online chat sessions, and online resources	Participants had access to some of the online resources.	Not reported	USA
Vauth 2016	Rehabilitation for people with aphasia after discharge from hospital	Conventional therapy	Chronic phase	Germany
Wan 2016	Goal‐setting telephone follow‐up relating to health behaviours	Usual stroke education	Subacute phase	China

Telerehabilitation compared with in‐person rehabilitation for stroke
Patient or population: people with stroke Settings: living in the community Intervention: telerehabilitation Comparison: in‐person rehabilitation
Outcomes	*Illustrative comparative risks (95% CI)**	Number of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
Independence in ADL post‐intervention	No significant difference found on total ADL function score: MD 0.59 (‐5.50 to 6.68) (Analysis 1.1)	75 (2 studies)	⊕⊕⊝⊝  low^a,b
Self‐care and domestic life Post‐intervention	Outcome not assessed in included studies
Mobility post‐intervention	Outcome not assessed in included studies
Balance post‐intervention	No significant difference found on balance outcomes: MD 0.48 (‐1.36 to 2.32) (Analysis 1.2)	106 participants (3 studies)	⊕⊕⊝⊝  low^a,b
Self‐reported health‐related quality of life post‐intervention	Outcome not assessed in included studies (where the comparison was telerehabilitation versus in‐person rehabilitation)
Depression post‐intervention	Outcome not assessed in included studies (where the comparison was telerehabilitation versus in‐person rehabilitation)
Upper limb function post‐intervention	No significant difference found on total UL function score: MD 1.23 (‐2.17 to 4.64) (Analysis 1.3)	170  (3 studies)	⊕⊕⊝⊝  low^a,b
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  ADL: activities of daily living; CI: confidence interval; MD: mean difference
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Telerehabilitation (post hospital discharge support) compared with usual care for stroke
Patient or population: people with stroke Settings: living in the community Intervention: telerehabilitation Comparison: usual care
Outcomes	*Illustrative comparative risks (95% CI)**	Number of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
Independence in ADL post‐intervention	No significant difference found on total ADL function score: SMD ‐0.00 (‐0.15 to 0.15) (Analysis 2.1)	661  (2 studies)	⊕⊕⊕⊝  moderate^a
Self‐care and domestic life post‐intervention	Outcome not assessed in included studies
Mobility post‐intervention	No significant difference found in gait speed: MD 0.01 (‐0.12 to 0.14) (Analysis 2.2)	144 (1 study)	⊕⊕⊝⊝  low^a,b
Balance post‐intervention	Outcome not assessed in included studies
Self‐reported health‐related quality of life post‐intervention	No significant difference found in self‐reported quality of life: SMD 0.03 (‐0.14 to 0.20) (Analysis 2.3)	569  (3 studies)	⊕⊕⊕⊝  moderate^a
Depression post‐intervention	No significant difference found in depressive symptoms SMD ‐0.04 (‐0.19 to 0.11) (Analysis 2.4)	1145  (6 studies)	⊕⊕⊕⊝  moderate^a
Upper limb function post‐intervention	No significant difference found in upper limb function: SMD 0.33 (‐0.21 to 0.87) (Analysis 2.5)	54 (2 studies)	⊕⊕⊝⊝  low^a,b
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  ADL: activities of daily living; CI: confidence interval; SMD: standard mean difference; MD: mean difference
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Date	Event	Description
4 July 2019	New citation required but conclusions have not changed	The conclusions of the review have not changed.
4 July 2019	New search has been performed	We updated the searches to June 2019. We have added 12 new studies bringing the total number of included studies to 22 (involving a total of 1937 participants). We have revised the review throughout. We have added new studies to the 'studies awaiting classification' list.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activities of daily living	2	75	Mean Difference (IV, Random, 95% CI)	0.59 [‐5.50, 6.68]
2 Balance	3	106	Mean Difference (IV, Random, 95% CI)	0.48 [‐1.36, 2.32]
3 Upper limb function	3	170	Mean Difference (IV, Random, 95% CI)	1.23 [‐2.17, 4.64]
4 Functional communication	1	30	Mean Difference (IV, Random, 95% CI)	1.10 [‐2.52, 4.72]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Activities of daily living	2	661	Std. Mean Difference (IV, Random, 95% CI)	‐0.00 [‐0.15, 0.15]
2 Mobility	1	190	Mean Difference (IV, Random, 95% CI)	0.01 [‐0.12, 0.14]
3 Health‐related quality of life	3	569	Std. Mean Difference (IV, Random, 95% CI)	0.03 [‐0.14, 0.20]
4 Depression	6	1145	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.19, 0.11]
5 Upper limb function	2	54	Std. Mean Difference (IV, Random, 95% CI)	0.33 [‐0.21, 0.87]

Methods	RCT
Participants	Recruited from University Medical Centre in the USA Inclusion criteria: fully oriented; able to follow a 3‐step command; evidence of stroke on neuroimaging or hemiparetic. Caregivers were defined as family or friends living with survivors or within a 30‐minute driving distance and acting as the primary source of assistance for survivors. Exclusion criteria: < 35 years old; subarachnoid haemorrhage; psychosis; lack of a caregiver; admission from a nursing home; non‐English speaking Age, years: mean (SD) 70.1 (11.6) Gender: 35% men Time post‐stroke: not reported but conducted on discharge home from hospital
Interventions	Telerehabilitation intervention: Family Intervention Telephone Tracking (FITT) which focuses on 5 key areas: (1) family functioning, (2) mood, (3) neurocognitive functioning, (4) functional independence, and (5) physical health. Telephone contacts took place during the 6‐month transition period after discharge from an acute care setting, with the FITT intervention formally beginning when stroke survivors arrived home. FITT contacts occurred weekly for 6 weeks, biweekly for the next 2 months, and then monthly for 2 months, for a total of 13 calls to each individual (26 calls per dyad). Calls were made by clinicians who came from different professional backgrounds (medical practitioner, nurse, and family therapist) Control intervention: usual care
Outcomes	Timing of outcome assessment: baseline, 3 months, 6 months Measures: healthcare utilisation (direct report), Frenchay Activities Index; Geriatric Depression Scale; Family Assessment Device; Perceived Criticism Scale
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Used urn randomisation
Allocation concealment (selection bias)	Unclear risk	Detail not reported
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Assessors were blinded to group allocation
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Details of dropouts not clearly reported
Selective reporting (reporting bias)	Unclear risk	No mention of protocol or trial registration
Other bias	Low risk	No other bias noted

Methods	RCT
Participants	Recruited from patients discharged from inpatient stroke rehabilitation in Slovenia Inclusion criteria: stroke, requiring help with ADLs (FIM score 40 to 80) Exclusion criteria: orthopaedic problems, other neurological diseases and severe health complications that would prevent participation Age: intervention group mean 70, control group mean 63 Gender: intervention group 60% men, control group 40% men Time post‐stroke: intervention group mean 8.2 months, control group mean 5.1 months
Interventions	Telerehabilitation: participants were taught how to use a computer tablet and access selected videos on a web portal. Training focused on posture and exercises for the neck, shoulders, torso, and upper limbs. The participant was asked to do exercises daily 3 months after discharge from the rehabilitation setting. Therapists interviewed the participant and relatives once a week during which they checked adherence to exercises, answered questions, monitored progress, and adjusted the content of the exercise programme, as required. Control intervention: classified as usual care. Were provided with oral and written instructions for similar exercises. The person was instructed to do the exercises of their choice and abilities 1 to 2 times per day.
Outcomes	Timing of outcome assessment: baseline and 3 months after randomisation Measures: joint flexibility, Modified Ashworth Scale, Visual Analogue Scale for Pain Assessment, Motor Assessment Scale, Wolf Motor Function Test, Fugl Meyer Assessment
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Method not reported
Allocation concealment (selection bias)	Unclear risk	Method not reported
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Unable to determine
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	No information provided about whether or not there were withdrawals
Selective reporting (reporting bias)	Unclear risk	No protocol or trial registration available
Other bias	Low risk	None noted

Methods	RCT
Participants	Recruited from 12 hospitals in the Netherlands Inclusion criteria: Dutch speaking, ≥ 18 years of age, first admission for a stroke, hospitalisation within 72 hours after onset of symptoms, life expectancy > 1 year, independent from or partially dependent on discharge (Rankin grade 0 to 3), discharged home, residence within 40 kilometres of catchment areas served by hospitals Exclusion criteria: failure to meet above criteria Age, years: intervention group median (IQR) = 66 (52 to 76), control group median (IQR) = 63 (51 to 74) Gender: intervention group 49% men, control group 48% men Time post‐stroke: not reported
Interventions	Telerehabilitation intervention: 3 nurses initiated telephone contacts (1 to 4; 4 to 8; and 18 to 24 weeks after discharge) and visits to participants in their homes (10 to 14 weeks after discharge). Stroke nurses used a standardised checklist of risk factors for stroke, consequences of stroke and unmet needs for services. Nurses supported participants and caregivers according to their individual needs (e.g. by providing information or reassurance) or advised participants to contact their GP when further follow‐up was required. Written educational material was provided and discussed. Nurses aimed to support participants and caregivers in solving problems themselves or coping with them rather than solving problems for them. Control intervention: standard care
Outcomes	Timing of outcome assessment: baseline and post‐intervention (6 months after discharge) Measures: Barthel Index, Rankin Grade, Satisfaction with Stroke Care questionnaire, SF‐36, Hospital Anxiety and Depression Scale, health‐service utilisation (GP), readmissions, therapy, activities of daily living care, rehabilitation, aids, secondary prevention drugs, caregiver questionnaires
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computerised programme
Allocation concealment (selection bias)	Low risk	Central telephone service used
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Outcome assessor was blinded to allocation
Incomplete outcome data (attrition bias)   All outcomes	High risk	Additional data collected at 6 months and not reported in the paper
Selective reporting (reporting bias)	Unclear risk	No protocol available
Other bias	Unclear risk	Unable to identify further bias

Methods	RCT
Participants	Recruited from the community via advertising in a local paper and local stroke support group meetings in the USA Inclusion criteria: more than 12 months post‐stroke, between 30 and 80 years old, satisfactory corrected vision to recognise the full tracking target and cursor movement, ≥ 90 degrees of passive extension‐flexion movement at the index finger metacarpophalangeal joint of the paretic hand (no contracture) and at least 10 degrees of active movement at this joint Exclusion criteria: unable to undergo fMRI, pregnancy, or claustrophobia Age, years: intervention group (Track) mean = 65.9 (SD 7.4), intervention group (Move) mean = 67.4 (SD 11.8) Gender: intervention group (Track) 90% men, intervention group (Move) 60% men Time post‐stroke: intervention group (Track) mean 42.5 months (SD 24.3), intervention group (Move) mean 35.6 months (SD 26.1)
Interventions	Both groups received telerehabilitation. The aim of the intervention was to practice finger and wrist movements. Training was completed on a laptop using customised tracking software without direct supervision by the therapist. Both groups performed 180 tracking trials per day for 10 days. Regular teleconferencing (mobile phone and Webcam operating over the Internet) occurred between therapist and participant. Telerehabilitation intervention (Track group): tracking software provided feedback and an accuracy score Telerehabilitation intervention (Move group): tracking software showed a sweeping cursor representing movement, however did not provide the target or response or an accuracy score
Outcomes	Timing of outcome assessment: baseline and post‐intervention Measures: Box and Block test, Jebsen Taylor test, finger ROM, finger movement tracking test, fMRI
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Substantial loss of participants at follow‐up
Selective reporting (reporting bias)	Unclear risk	No protocol available
Other bias	High risk	Small sample size and considerable differences between groups in mean values on some outcome measures at baseline, although these differences were not statistically significant

Trial name or title	Inspiring Virtual Enabled Resources following Vascular Events (iVERVE)
Methods	RCT
Participants	People after stroke recruited from the Australian Stroke Survivor Clinical Registry
Interventions	Structured and comprehensive patient‐centred goal‐setting conducted over the phone in survivors of stroke with SMS support messages
Outcomes	Goal attainment
Starting date	2017
Contact information	Professor Dominic Cadilhac: dominique.cadilhac@monash.edu
Notes

Methods	RCT
Participants	Recruited from a Hospital in Shanghai, China Inclusion criteria: aged 35 to 85 years old; first diagnosis was ischaemic or haemorrhagic stroke or recurrent stroke but without hemiplegia symptoms before; have a symptom of hemiplegia, left or right; 14 to 90 days from stroke onset; National Institute of Health Stroke Scale scores from 2 to 20 and mRS scores from 1 to 5; have not previously received any rehabilitation intervention since this stroke onset Exclusion criteria: Glasgow Coma Scale scores under 15, have been confirmed as having dementia based on Mini Mental State Examination assessment, with mental disorders and unable to cooperate with examination, treatment or follow‐up; disability not induced by stroke or disability induced by historical stroke; associated severe primary disease of heart, liver, kidney, or haematological system; cognitive disorder, history of psychosis, substance abuse, or alcoholism; skin infections in the areas of surface electrodes attached; metal implants in the body, including cardiac pacemaker, metal stent, or steel plate; in the gestation or lactation period or have a fertility plan; associated malignant tumour or severe progressive disease in any other system; have been recruited by any other clinical trial in the preceding 90 days; unable to complete the basic course of treatment, with poor treatment adherence or inability to follow‐up Age, years: intervention group mean 66.5 SD (12.1), control group mean 66.2 SD (12.3) Gender: 67% men Time post‐stroke: intervention group mean (SD) 25.0 (5.6) days, control group 26.9 (4.7) days
Interventions	After discharge, participants in both groups were given physical exercises and electromyography‐triggered neuromuscular stimulation (ETNS). Exercises were conducted for 1 hour, twice in a working day for 12 weeks (total = 60 sessions). ETNS was conducted by using a portable muscle electricity biofeedback instrument for 20 minutes, twice in a working day for 12 weeks, a total of 60 sessions. Telerehabilitation intervention: Individualised telerehabilitation physical exercise plan selected by treating therapists and provided as prescription within the telerehabilitation apparatus. Therapists explained and demonstrated exercises. After discharge, participants received rehabilitation via the telerehabilitation system; therapists supervised via live video and collected data remotely. Therapists were available for advice if needed. Carers kept training logs of training. Control intervention: received rehabilitation in the outpatient therapy department. Exercises and ETNS were the same but the therapy was provided face‐to‐face with therapists.
Outcomes	Timing of outcome assessment: baseline, 12, and 24 weeks after randomisation Measures: Modified Barthel Index; Berg Balance Scale; mRS; Caregiver Strain Index; Root Mean Square
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated sequence
Allocation concealment (selection bias)	Low risk	Held in opaque sealed envelopes
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessors
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Few withdrawals, even across groups, and reasons reported
Selective reporting (reporting bias)	Low risk	Trial registered and all outcomes reported
Other bias	Low risk	No other sources of bias noted

Methods	RCT
Participants	Recruited from 3 Veterans Affairs Medical Centres in the USA Inclusion criteria: ischaemic or haemorrhagic stroke within the previous 24 months; participants aged 45 to 90 years, discharged to the community, not cognitively impaired (no more than 4 errors on the Short Portable Mental Status Questionnaire), able to follow a 3‐step command, discharge motor Functional Independence Measure score of 18 to 88, approval by participants and physician; signed medical media release form Exclusion criteria: failure to meet above criteria Age, years: intervention group: mean = 67.1 (SD 9.5), control group: mean = 67.7 (SD 10) Gender: intervention group: 96% men; control group: 100% men Time post‐stroke: intervention group median 26 days, control group median 74 days
Interventions	Telerehabilitation intervention: the purpose of the intervention was to improve the participant's functional mobility. Intervention included 3 tele‐visits, use of an in‐home messaging device (IHMD) and 5 telephone calls over a 3‐month period. The tele‐visits involved assessment of physical function, goal‐setting and demonstration of exercises; a research assistant used a camcorder to record the home environment and the participant completing tests of physical and functional performance that were later reviewed by the teletherapist. The therapist asked the participant questions via the IHMD and provided positive encouragement to maximise exercise adherence. Telephone calls were used to problem‐solve any barriers to exercise and to review and advance the exercise programmes. Control intervention: usual care
Outcomes	Timing of outcome assessment: baseline, post‐intervention (3 months) and 6 months Measures: motor subscale of the Functional Independence Measure (telephone version), Late Life Function and Disability Instrument, stroke‐specific participant satisfaction with care questionnaire, Falls Self‐Efficacy Scale
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated sequence
Allocation concealment (selection bias)	Low risk	Centralised computer program
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessors
Incomplete outcome data (attrition bias)   All outcomes	Low risk	ITT analyses completed. Small numbers of missing data, which were explained and balanced across groups
Selective reporting (reporting bias)	High risk	The publication does not present the results for all outcome measures listed in the study protocol.
Other bias	Unclear risk	Unable to identify further bias

Methods	RCT
Participants	Recruited from: 11 sites in the USA Inclusion criteria: age ≥ 18 years, stroke onset 4 to 36 weeks prior, arm motor Fugl‐Meyer score 22‐56 (out of 66) Exclusion criteria: major active coexistent neurological or psychiatric disease; severe depression, cognitive impairment (MoCA < 22), communication deficits interfering with participation, life expectancy < 6 months, non‐English speaking, unable to perform the 3 rehabilitation exercise test examples Age, years: intervention group mean age 62 (14), control group 60 (13) Gender: 73% men Time post‐stroke: intervention group mean 132 (65) days, control group 129 (59) days
Interventions	Participants in both groups were offered 36 sessions (18 supervised, 18 unsupervised) lasting for 70 minutes each over 6 to 8 weeks. All participants signed a behavioural contract that included a treatment goal and treatment was based on an upper extremity task‐specific training manual and accelerated skill acquisition programme. Telerehabilitation intervention: rehabilitation treatment sessions via an in‐home internet‐connected computer. The participant performed daily assigned home‐based telerehabilitation exercises and functional training (including use of games and input devices such as PlayStation Move Controller) and 5 minutes of stroke education, all guided by the telerehabilitation system. During half of the sessions, therapists initiated a video conference with the participant's telerehabilitation system to discuss progress, issues, and revise treatment plans as needed. Control intervention: same intensity, duration, and frequency of therapy and stroke education content but provided in clinic with therapist feedback based on observations on supervised days
Outcomes	Timing of outcome assessment: baseline, 30 days after randomisation Measures: Fugl‐Meyer Arm, Box and Block test, Stroke Impact Scale‐Hand Domain
Notes	NCT02360488
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation schedule developed at the StrokeNet National Data Management Centre
Allocation concealment (selection bias)	Low risk	Web‐based central randomisation system
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Low number of withdrawals and balanced across groups
Selective reporting (reporting bias)	Low risk	Trial registered
Other bias	Low risk	None noted

Methods	RCT
Participants	Recruited from the community. Study conducted in the USA Inclusion criteria: post‐stroke duration of at least 5 months, at least 10 degrees of active dorsiflexion/plantar flexion at the paretic ankle, ability to understand the tasks, ability to ambulate 30 metres Exclusion criteria: indwelling devices incompatible with MRI Age, years: telerehabilitation (Track) group mean = 51.4 (SD 11.5), telerehabilitation (Move) group mean = 58 (SD 13.4) Gender: Track group 38% men; Move group 100% men Time post‐stroke: Track group median 66 months; Move group median 16.5 months
Interventions	Both groups received telerehabilitation. The aim of the intervention was to practice ankle movements. Training was completed on a laptop using customised tracking software without direct supervision by the therapist. Both groups performed 180 repetitions for 20 days. Regular teleconferencing using Skype occurred between the therapist and the participant, and the computer automatically emailed daily records to the laboratory computer to allow monitoring of performance. Telerehabilitation intervention (Track group): tracking software provided feedback and an accuracy score. Telerehabilitation intervention (Move group): tracking software showed a sweeping cursor representing the movement; however, did not provide the target or response or an accuracy score.
Outcomes	Timing of outcome assessment: baseline and post‐intervention Measures: gait analysis, 10‐metre walk test, fMRI
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Electronically‐generated randomisation list
Allocation concealment (selection bias)	Unclear risk	Not clearly reported
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessors
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Attrition reported with reasons and similarities between groups
Selective reporting (reporting bias)	Unclear risk	No access to protocol
Other bias	High risk	Small sample size

Methods	RCT
Participants	Recruitment details unclear. Study took place in the USA. Inclusion criteria: first time medical diagnosis of acute stroke, onset of stroke was at 6 or fewer months, Medicare or Blue Cross and Blue Shield insurance coverage, moderate deficits in the areas of self‐care, functional mobility, transfers as documented by the Functional Independence Measure, caregiver present to set up telehealth videophone device Exclusion criteria: aphasia or major depressive disorder, as measured by the Beck Depression Inventory II Age, years: mean age of all participants was 60 Gender: 55% men Time post‐stroke: not reported
Interventions	Telerehabilitation intervention: 12 treatment sessions (6 occupational therapy and 6 physiotherapy) were provided over approximately 6 weeks. Interventions included education, retraining of self‐care, functional mobility and posture, home modifications and therapy to improve function in impaired limbs. Communication between therapist and participant occurred via a desktop videophone using standard telephone lines Control intervention: included the same content; however, was delivered in‐person
Outcomes	Timing of outcome assessment: baseline and post‐intervention Measures: Functional Independence Measure, SF‐12
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not reported
Incomplete outcome data (attrition bias)   All outcomes	High risk	Lack of detail in reporting the results
Selective reporting (reporting bias)	Unclear risk	Not able to access protocol
Other bias	High risk	Small sample size

Methods	RCT
Participants	Recruited from a rehabilitation service in the Netherlands Inclusion criteria: age > 18 years; established diagnosis of multiple sclerosis, stroke or traumatic brain injury; taking more than 25 seconds to perform the Nine‐Hole Peg Test, ability to move at least 1 peg in 180 seconds during the Nine‐Hole Peg Test, sufficient autonomous functioning, Internet connection or telephone line and reachable Internet provider, stable clinical status, living at home Exclusion criteria: disturbed upper limb function not related to multiple sclerosis, traumatic brain injury or stroke; serious cognitive and/or behavioural problems, major visual problems, communication problems, medical complications; other problems, possibly contraindicating autonomous exercise at home Age, years: telerehabilitation group mean = 69 (SD 8), control group mean = 71 (SD 7) Gender: telerehabilitation group 18% men, control group 80% men Time post‐stroke: telerehabilitation group mean 3 (SD 2) years, control group mean 1.8 (SD 0.8) years
Interventions	Telerehabilitation intervention: 1 month of usual care followed by approximately 4 training sessions with the Home Care Activity Device (HCAD) system in the hospital and intervention using the HCAD for 1 month. The system comprised a hospital‐based server and the portable unit installed at the participant's home. The portable unit consisted of 7 sensorised tools; a key, a light bulb, a book, a jar, writing, checkers and keyboard. The unit also had 2 webcams that allowed videoconferencing and recording. It was recommended that participants use the HCAD at least 5 days per week for 30 minutes. Control intervention: usual care and generic exercises prescribed by the physician
Outcomes	Timing of outcome assessment: baseline and post‐intervention Measures: Barthel Index, participant satisfaction assessed using visual analogue scale, SF‐36, Action Research Arm Test, Nine‐Hole Peg Test, Wolf Motor Function Test, grip strength, Abilhand
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Randomisation scheme generated using 2:1 allocation ratio. Participants allocated to the study when the intervention was available
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Not reported
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Dropouts were reported and ITT analyses conducted
Selective reporting (reporting bias)	High risk	Some study data not reported in the published paper
Other bias	High risk	Small sample size Differences between groups at baseline

Methods	RCT
Participants	Recruited from six hospitals in the USA Inclusion criteria: within 4 months of an ischaemic or haemorrhagic stroke (verified by CT or MRI) with clinical depression (≥ 11 on the Geriatric Depression Scale) Age, years: intervention (telephone) group mean 61.7, intervention group (in‐person) 58.5, control group 60.7 Gender: 50% men Time post‐stroke: not reported
Interventions	Telerehabilitation intervention: 'Living Well With Stroke 2 intervention': 1 in‐person orientation session with the psychosocial nurse practitioner therapist, either in their home or at the study offices. They received the participant manuals and discussed goals and expectations. Following the in‐person orientation session, each of the subsequent 6 sessions occurred by telephone. Topics were as follows: (1) introduction to behavioural therapy for depression after stroke, pleasant events; (2) scheduling pleasant events: problems and planning; (3) managing depression behaviours: problem‐solving techniques; (4) changing negative thoughts and behaviours; (5) problem‐solving in depth; (6) review of skills, generalisation and strategies for maintenance of skills. Session length ranged from 10 to 80 minutes, with the telephone sessions somewhat shorter than the in‐person ones (average 26 minutes versus 38 minutes). Participants in the intervention arms saw their primary care or stroke provider for stroke follow‐up care and were provided antidepressants as prescribed by their providers. In‐person intervention: same 'Living Well With Stroke 2' intervention but provided in‐person (usually in the participant's home) Control intervention: usual care
Outcomes	Timing of outcome assessment: baseline, post‐intervention (8 weeks), 21 weeks, and 12 months Measures: Hamilton Rating Scale for Depression, Stroke Impact Scale and perceived recovery
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computerised procedure using modified version of the minimisation method
Allocation concealment (selection bias)	Low risk	Managed online by research nurses and statistician
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Low number of withdrawals; balanced across groups and explained clearly
Selective reporting (reporting bias)	Unclear risk	Trial registered ahead of time on clinical trial register. Published paper did not present results of Stroke Impact Scale or perceived recovery.
Other bias	Low risk	No other sources of bias noted

Methods	RCT
Participants	Recruited from 3 long‐term care facilities (LTCFs) in Taiwan Inclusion criteria: history of cerebral vascular accident (including first and recurrent stroke) for more than 6 months; living in LTCFs for more than 3 months; having active movement of the proximal part of upper extremity in the hemiparetic side (Brunnstrom stage U/E ≥ 3); being able to sit for short periods without hand support for at least 30 seconds; having cognitive status screened using the Mini‐Cog test and being able to follow the instruction; and being able to communicate and follow a 3‐step command Exclusion criteria: having other neuromusculoskeletal condition and systemic diseases such as Parkinson's disease and uncontrolled heart disease; blindness and deafness; and having a psychiatric history Age, years: intervention group mean 74.6 (SE 2.3), control group 75.6 (SE 3.4) Gender: 71% men Time post‐stroke: not reported
Interventions	The treatment programme for both groups included 3 sessions of training per week for 4 weeks, with the duration of approximately 50 minutes for each session. The therapist instructed standing balance training from easy to difficult, depending on the severity and recovery of the participants. Telerehabilitation intervention: the tele‐balance training focused on 10 minutes of standing exercise according to 3D animation exercise videos and about 10 minutes of 3D interactive games with finger touching the touch screen in standing posture. 1 therapist conducted the telerehabilitation balance training at the therapist end to each facility for 1 month, separately. 1 volunteer or non‐medical person was assigned at the patient end for safety and assistance in telerehabilitation and conventional training. Control intervention: 2 post‐stroke participants attended the same session as the small therapy group. The therapist conducted conventional balance training programs following simple to complex principles.
Outcomes	Timing of outcome assessment: baseline, post‐intervention Measures: Berg Balance Scale; Barthel Index
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer number generation
Allocation concealment (selection bias)	Unclear risk	Unclear, details not reported
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Only one dropout and reason explained. Intention‐to‐treat analysis conducted
Selective reporting (reporting bias)	Unclear risk	Outcomes reported for all outcomes assessed in paper; however trial not registered and no protocol available
Other bias	Low risk	No other sources of bias noted

Methods	RCT
Participants	Recruited from outpatients of the neurorehabilitation unit of a large metropolitan hospital in Spain Inclusion criteria: age ≥ 40 and ≤ 75 years; chronicity > 6 months; Brunel Balance Assessment (BBA): section 3, levels 7 to 12; Mini Mental State Examination score > 23; and Internet access in their homes Exclusion criteria: individuals with severe aphasia (Mississippi Aphasia Screening Test cut‐off score < 45); individuals with hemispatial neglect; and individuals with ataxia or any other cerebellar symptom Age, years: intervention group mean 55.47 (SD 9.63), control group man 55.6 (7.29) Gender: intervention group 67% men, control group 47% men Time post‐stroke: intervention group mean 334 (60 days), control group 317 (49 days)
Interventions	All the participants underwent 20 x 45‐minute training sessions with the telerehabilitation system, conducted 3 times a week. The difficulty of the training was initially adjusted by PTA in an exploratory session. During the intervention, the difficulty of the task was adjusted either by the therapist or automatically by the system. The progress of all the participants was checked remotely once a week by PTA to detect possible issues and respond accordingly. In addition, PTB had a brief interview with participants of the experimental group each week to detect possible technical problems and to troubleshoot. On the remaining days (Tuesday and Thursday), both groups received conventional physical therapy in the clinic. The aim of the intervention was to improve balance. Telerehabilitation intervention: participants belonging to the experimental group trained in their homes Control intervention: participants belonging to the control group trained with the system in the clinic
Outcomes	Timing of outcome assessment: baseline, post‐intervention (8 weeks), and follow‐up (12 weeks) Measures: cost, Berg Balance Scale, Performance Oriented Mobility Assessment‐Balance, Performance Oriented Mobility Assessment–Gait, Brunel Balance Assessment, system usability score, Intrinsic Motivation Inventory
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated
Allocation concealment (selection bias)	Low risk	Held by external research in sealed envelopes
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No withdrawals and all participants included in the analysis
Selective reporting (reporting bias)	Unclear risk	No mention of clinical trial registration or protocol
Other bias	Low risk	No other sources of bias noted

Methods	RCT
Participants	Recruited from 5 acute care hospitals in Canada Inclusion criteria: all persons returning home directly from the acute care hospital after a first or recurrent stroke with any of the following criteria indicating a specific need for healthcare supervision postdischarge (lives alone, mobility problem requiring assistive device, physical assistance or supervision, mild cognitive deficit, dysphagia, incontinence, social service consultation during acute hospitalisation, or need for postdischarge medical management for diabetes, congestive heart failure, ischaemic heart disease, arthritis, chronic obstructive pulmonary disease, atrial fibrillation, kidney disease, peripheral vascular disease) Exclusion criteria: people discharged to an inpatient rehabilitation facility or to long‐term care Age, years: telerehabilitation group = 70 (SD 14.5), control group = 72 (SD 12.95) Gender: telerehabilitation group 67% men, control group 55% men Time post‐stroke: telerehabilitation group 12 (SD 11.7 days), control group 13 (SD 15.7 days)
Interventions	Telerehabilitation intervention: received case management (defined as a 'collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost‐effective outcomes'). Managed through home visits and telephone contacts for a period of 6 weeks. The nurse established contact with the GP and provided 24‐hour contact. Interventions included surveillance, information exchange, medication management, health system guidance, active listening, family support, teaching and risk identification. Control intervention: participant and family were instructed to make an appointment with their local GP.
Outcomes	Timing of outcome assessment: baseline, post‐intervention, and 6‐month follow‐up Measures: reintegration to normal living index, Barthel Index, gait speed, Timed Up and Go test, SF‐36, EQ5D, Geriatric Depression Scale, health service utilisation
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Reported that 'sealed envelopes' were used
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessor
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Few instances of missing data. Balanced attrition across groups. ITT analyses conducted. Multiple imputation used for missing data
Selective reporting (reporting bias)	Unclear risk	Not able to access protocol
Other bias	Low risk	None apparent

PERMALINK

Telerehabilitation services for stroke

Kate E Laver

Zoe Adey‐Wakeling

Maria Crotty

Natasha A Lannin

Stacey George

Catherine Sherrington

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

GRADE and Summary of findings

Results

Description of studies

Results of the search

1.

Included studies

Sample characteristics

1. Numbers of participants screened, recruited and followed up.

2. Comparison of characteristics of studies included within the review.

Interventions

Comparisons

Studies included in the meta‐analysis

Excluded studies

Risk of bias in included studies

2.

3.

Allocation

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Effects of interventions

for the main comparison.

2.

Telerehabilitation versus in‐person rehabilitation

Comparison 1.1: Telerehabilitation vs in‐person rehabilitation: activities of daily living

1.1. Analysis.

Comparison 1.2: Telerehabilitation vs in‐person rehabilitation: balance

1.2. Analysis.

Telerehabilitation vs in‐person rehabilitation: participant satisfaction with the intervention

Telerehabilitation vs in‐person rehabilitation: health‐related quality of life

Comparison 1.3: Telerehabilitation vs in‐person rehabilitation: upper limb function

1.3. Analysis.

Methods	RCT
Participants	Recruited from the community in Canada Inclusion criteria: a history of unilateral stroke resulting in a communication disorder, occurring at least 6 months in the past; availability of a communication partner to participate in the treatment programme; ability to travel to the treatment site if not at home, and ability to hear instructions and operate an iPad tablet to perform homework exercises Exclusion criteria: dementia or other neurological disorder Age, years: intervention group 66.8 (11.2), control group 62.9 (11.6) Gender: 59% men intervention group, 69% men control group Time post‐stroke: not reported (at least 6 months post‐stroke)
Interventions	The study took place over 12 weeks for each participant, with an assessment in the first and last weeks and therapy during the intervening 10 weeks. Telerehabilitation intervention (Aphasia telerehab): remote therapy sessions were conducted via teleconferencing equipment and software. Participants possessing adequate equipment at home consulted the therapist using WebEx, a commercial teleconferencing program. Some clients visited the clinic to receive the telerehabilitation (provided in a separate room and contact with the therapist prohibited). During weeks 2‐11, the therapist conducted a 1‐hour weekly treatment session and TalkPath software was used for homework exercises. Control intervention (Aphasia in‐person): same therapy provided in‐person
Outcomes	Timing of outcome assessment: baseline and post‐intervention (12 weeks) Measures: Western Aphasia Battery Revised Part 1, Cognitive Linguistic Quick Test, Communication Confidence Rating Scale for Aphasia, Communication Effectiveness Index
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Assessments were conducted by a therapist not involved in the study but not clear if they were blind to allocation.
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Reporting of recruitment and withdrawals had limited detail including balance between groups.
Selective reporting (reporting bias)	Unclear risk	Could not identify study protocol or trial registration
Other bias	Unclear risk	Groups were separated by diagnosis; however it was not clear whether this was factored into the randomisation process.

Methods	RCT
Participants	Study took place in Italy Inclusion criteria: mild to intermediate arm motor impairment due to ischaemic stroke in the area of the middle cerebral artery; without cognitive problems that could interfere with comprehension Exclusion criteria: failure to meet above criteria Age, years: telerehabilitation group = 53 (SD 15) years, control group = 65 (SD 11) years Gender: telerehabilitation group 40% men, control group 60% men Time post‐stroke: telerehabilitation group 10 months (SD 3), control group 13 months (SD 2)
Interventions	Telerehabilitation intervention: the purpose of the intervention was to improve upper limb function using a virtual reality programme. Patient‐therapist interaction facilitated by a videoconferencing unit beside the telerehabilitation equipment. 1 computer was at the hospital and 1 at the participant's home Control intervention: virtual reality workstation with a 3D motion tracking system that recorded the participant's arm movements. The participant's movement was represented in the virtual environment. The therapist created a sequence of virtual tasks for the participant to complete with the affected arm. Participants could see their own trajectory and the ideal/desired trajectory.
Outcomes	Timing of outcome assessment: baseline and post‐intervention Measures: participant satisfaction questionnaire, Fugl‐Meyer Upper Extremity Scale
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Described as 'simple randomisation'
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessor
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No missing outcome data
Selective reporting (reporting bias)	Unclear risk	Not able to access protocol
Other bias	High risk	Small sample size

Methods	RCT
Participants	Recruited from 11 acute care hospitals located in urban and rural areas across 4 Canadian provinces Inclusion criteria: all adults who sustained a first mild stroke defined as a score > 8.5/11.5 on the Canadian Neurological Scale or a mRS between 0 and 2 on admission and who were discharged home within 3 weeks of the index event were invited. They needed to have telephone access, ability to understand basic instructions and express basic needs, and ability to communicate in English or French. Exclusion criteria: individuals with moderate or severe cognitive deficits (based on clinical judgement) and those who experienced another stroke before baseline measures were completed Age, years: intervention group mean 61.7 (SD 12.7), control group mean 63.2 (12.4) Gender: intervention group 65% men, control group 56% men Time post‐stroke: intervention group mean 6.5 days, control group 5.2 days
Interventions	Telerehabilitation intervention: WE CALL participants received a multimodal (telephone, Internet, and paper) support intervention. Telephone interactions focused on any new or ongoing issues, as well as 6 key areas, including family functioning and individualised risk factors. Call frequency was weekly for the first 2 months, biweekly during the third month, and monthly for the past 3 months. Additional written information on stroke management was provided as needed (by regular mail, email, or Internet). Control intervention: YOU CALL participants were provided with the name and phone number of a trained healthcare professional who was not involved in providing the WE CALL intervention, whom they were free to contact should they feel the need. The health professional was instructed to answer the participant's queries on those topics initiated by the participant but not to probe further on other potential issues.
Outcomes	Timing of outcome assessment: baseline, post‐intervention (6 months), 12 months Measures: unplanned use of health services (calendar), Quality of Life Index, EQ5D, Beck Depression Inventory, Assessment of Life Habits
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐managed stratified block randomisation
Allocation concealment (selection bias)	Low risk	Sealed envelopes with external research managing randomisation
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	High risk	Large number of people were not able to be reached.
Selective reporting (reporting bias)	Low risk	Protocol published and all outcomes reported
Other bias	Low risk	No other sources of bias noted

Methods	RCT
Participants	Recruited from 2 acute hospitals in Germany Inclusion criteria: age ≥ 18 years, ischaemic or haemorrhagic stroke for the first time (confirmed by imaging), main residency in the Federal States of Saxony‐Anhalt, Saxony, or Thuringia, and able to speak German Exclusion criteria: previous ischaemic or haemorrhagic stroke, alcoholism, National Institute of Health Stroke Scale (NIHSS) score > 25, and homelessness Age, years: intervention group mean 68.1 (SD 12.6), control group 68.4 (12.7) Gender: intervention group 34% men, control group 38% men Time post‐stroke: not reported but participants recruited from an acute hospital
Interventions	Telerehabilitation intervention: in‐depth assessment and stroke support service provided by a nurse and physiotherapist. The stroke support service comprised stroke outreach support, educational sessions, and written patient information and was directed to both the patient and the next of kin. The stroke outreach support included home visits and telephone contacts and was individually tailored based on an agreement between the stroke support organiser and the patient and carer. The number of contacts between stroke support organiser and patient/carer was: 12.31% of contacts face‐to‐face and 61% via telephone; the remaining were written communications per email and normal post, or patient educational sessions. Control intervention: usual care
Outcomes	Timing of outcome assessment: pre (prior to discharge from acute care), baseline (4 weeks after discharge prior to randomisation), and post (12 months after randomisation) Measures: Stroke Impact Scale (physical function domain), WHOQOL‐BREF, Geriatric Depression Scale, Symptom Checklist 90 Revised, health service use
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated
Allocation concealment (selection bias)	Low risk	Sequentially numbered, opaque, sealed and stapled envelopes
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	High risk	Withdrawals across both groups but more in the usual care group
Selective reporting (reporting bias)	Low risk	Registration as clinical trial performed in advance. All outcomes reported
Other bias	Low risk	No other sources of bias noted

Methods	RCT
Participants	Study took place in the USA Inclusion criteria: female caregiver providing care at home to husband after a stroke; either stroke survivor or caregiver scored 5 or greater on the PHQ‐9 (at least mild depression), neither stroke survivor nor caregiver were medically unstable or terminally ill and both were cognitively able to participate Exclusion criteria: failure to meet above criteria Age, years: telerehabilitation group mean = 59.9 (SD 8.2), control group mean = 59.1 (SD 13.6) Gender: 100% men Time since onset of stroke: details not reported
Interventions	Telerehabilitation intervention: consisted of 5 components designed to support the caregiver and provide caregiver with knowledge, resources and skills to assist him or her in reducing 'personal distress' and providing optimal emotional care to the stroke survivor. The 5 components included: a professional guide to facilitate the intervention and provide email support; educational videos; online chat sessions; email and message board; and Resource Room (a virtual online library). Intervention took place over 11 weeks. Control group: had access to the Resource Room only
Outcomes	Timing of outcome assessment: baseline, post‐intervention and at 1 month Measures: CES‐D, PHQ‐9, parts of the Mastery Scale, 10‐item self‐esteem scale, parts of the MOS Social Support Survey, ratings of treatment credibility, reported effort and perceived benefit
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated design
Allocation concealment (selection bias)	Low risk	Sealed opaque envelopes
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessor
Incomplete outcome data (attrition bias)   All outcomes	Low risk	ITT analyses conducted. Few dropouts, all accounted for and balanced across groups
Selective reporting (reporting bias)	High risk	Additional outcomes assessed that were not reported in the paper
Other bias	Unclear risk	No other sources of bias identified

Methods	RCT
Participants	Recruited from Bayreuth, Germany Inclusion criteria: > 12 months post‐stroke, aphasia, lesion on language dominant hemisphere Exclusion criteria: cognitive deficit, perceptual disorders, other motor deficits Age: mean 56 years, range 18 to 76 Gender: not reported Time post‐stroke: more than 12 months as per inclusion criteria but detail not reported
Interventions	Telerehabilitation: therapy was delivered via a screen and the person and therapist were in separate rooms. 1 screen displayed the therapy material and the other displayed the people communicating. Control group: same form of therapy but delivered in‐person Dose: 3 times per week (60 minutes each) for 8 weeks. Assessment pre and post‐intervention lasting 5 to 8 hours
Outcomes	Timing of outcome assessment: baseline, 8 weeks Measures: series of aphasia‐related measures and conversation analysis
Notes	Article published in German and translated. Contacted the study author for more details but they did not respond
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Details not reported
Allocation concealment (selection bias)	Unclear risk	Details not reported
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	Details not reported
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Details not reported
Selective reporting (reporting bias)	Unclear risk	Details not reported
Other bias	Unclear risk	Unclear

Methods	RCT
Participants	Recruited from neurology departments of 2 major general hospitals in Guangzhou, China Inclusion criteria: age above 35 years, hospitalisation within 1 month from the onset of ischaemic stroke as diagnosed by neuroimaging (CT or MRI) based on Chinese Neuroscience Society criteria, previous independence in daily activities, score of 0 to 3 on the mRS at discharge and upon returning home following discharge, and ability to communicate and provide informed consent Exclusion criteria: a history of cardio‐embolic infarction, Wernicke's aphasia, cognitive impairment, a history of severe liver or kidney disease, and any known malignancy or other neurological diseases Age, years: intervention group mean (SD) 59.07 (12.36), control group 60.24 (12.57) Gender: intervention group 75% men, control group 68% men Time post‐stroke: not reported
Interventions	Telerehabilitation intervention: structured guideline‐based, goal‐setting programme for secondary prevention of ischaemic stroke. The telephone follow‐up sessions were conducted by stroke nurses and consisted of goal‐setting advice focused on selected areas. Participants set measurable behavioural goals and developed action plans. Participants received the same stroke education as the control group with an additional 3 telephone follow‐up calls at 1 week, and at 1 and 3 months after discharge, each lasting 15 to 20 minutes, to promote self‐management techniques and maintenance of behavioural improvements. Control intervention: usual care and education
Outcomes	Timing of outcome assessment: baseline, 3 months, 6 months Measures: Chinese version of the Health Promoting Lifestyle Profile II; mRS score
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated sequence
Allocation concealment (selection bias)	Low risk	Sealed opaque envelope
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	Blinded outcome assessment
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Withdrawal in both groups and reporting of details unclear
Selective reporting (reporting bias)	Low risk	Registered with clinical trial registry and outcomes reported
Other bias	Low risk	No other sources of bias noted

Study	Reason for exclusion
Adie 2010	Included participants with TIA
Bergquist 2012	Included participants with diagnoses other than stroke
Burton 2005	Intervention did not match our definition of telerehabilitation
Eames 2013	Intervention did not match definition of telerehabilitation ‐ little remote contact once discharged home
Eide 2012	Included participants with diagnoses other than stroke and intervention did not meet our criteria
Emmerson 2017	Intervention did not involve telerehabilitation
Gillham 2010	Included participants with TIA
Graven 2016	Did not meet definition of telerehabilitation
Held 2018	Did not meet definition of telerehabilitation
Hodson 2018	Mixed methods study underway in order to test feasibility of intervention and inform future RCT
Hoffman 2010	Intervention did not match our definition of telerehabilitation
Huijbregts 2010	Not an RCT
Jackson 2010	Intervention did not match our definition of telerehabilitation
Joubert 2006	Intervention did not match our definition of telerehabilitation
Joubert 2009	Intervention did not match our definition of telerehabilitation
Kamwesiga 2018	Not randomised ‐ pre/post design
Kerry 2010	Intervention did not match our definition of telerehabilitation
Kim 2013	Included population with TIA or stroke
Krpic 2013	Intervention did not meet our definition of telerehabilitation
Linder 2015	Both groups received tele‐consultations; the difference between groups was the use of a robotic vs conventional home exercises
Mclaughlin 2010	Not an RCT
Nijenhuis 2017	Intervention did not meet our definition of telerehabilitation
Palmer 2011	Intervention did not match our definition of telerehabilitation
Palmer 2014	Intervention did not match definition of telerehabilitation
Redzuan 2012	Intervention did not match our definition of telerehabilitation
Reeves 2017	Intervention did not meet our definition of telerehabilitation
Song 2010	Intervention did not match our definition of telerehabilitation
Van den Berg 2016	Intervention group received more home visits than telerehabilitation consultations
Zucconi 2012	Intervention did not match our definition of telerehabilitation

Methods	RCT
Participants	Adults with stroke (n = 15)
Interventions	Telerehabilitation intervention: delivery of Cognitive Orientation to Occupational Performance approach (CO‐OP) via telerehabilitation. Dose of 16 hours over 10 weeks. CO‐OP involves having clients set meaningful everyday‐life goals and guiding them to discover contextually and personally relevant ways to improve performance on those goals. Control intervention: waiting‐list control group
Outcomes	Measures: Canadian Occupational Performance Measure
Notes	Abstract published in International Journal of Stroke (2017) detailing progress to date

Methods	RCT
Participants	Adults with stroke, aged between 18 and 80 years, and living at home eligible to participate. Participants needed to be 2 to 72 months post‐stroke, and no longer receiving rehabilitation as in or outpatient. They should have moderate impairment of the affected upper extremity determined by range of motion.
Interventions	Each participant receives 12 x 45‐60‐minute sessions over 4 weeks while seated. Telerehabilitation intervention: Gertner Tele‐Motion‐Rehabilitation System treatment of comparable duration and intensity to those in the conventional treatment group with remote online monitoring by the therapist. Treatment feedback given in the form of knowledge of results (game scores) and knowledge of performance (feedback of compensatory movements made while using the upper extremity) to enhance motor learning. The software generates a report which will include the duration and type of exercises performed by the participant. The Gertner TMR system is implemented via Microsoft's Kinect 3‐D camera‐based gesture recognition technology. Using the patient's natural hand and body movements to control all activity within customised computer games. The system runs off a standard desktop computer and is displayed on a large television screen. Control intervention: the control group receives self‐training exercises that are based on conventional therapy using principles of motor control and includes training of upper extremity movements in order to achieve better use of the affected arm in ADL.
Outcomes	Shoulder and elbow range of motion (measured with goniometer), Chedoke Arm and Hand Activity Inventory, Motor Activity Log, Functional Reach Test, Lawton's IADL, Fugl‐Meyer Motor Assessment, Visual Analogue Scale, Functional Independence Measure, Stroke Impact Scale
Notes