Clinical Efficacy and Cost-effectiveness of Telerehabilitation for Post-stroke Patients

In the last few years, due to limited resources, stroke patients hospitalization has been progressively shortened with the increasing shift of some rehabilitation procedures towards outpatient settings. This led to a high percentage of discharged patients who doesn't receive an adequate amount of rehabilitation. This was because of some non-clinical factors, such as resources availability, geographical location, age and personal wealth. Unfortunately, the benefits gained during inpatient rehabilitation are often not sustained in the long term. Thus stroke patients progressively decrease their activity level leading to functional deterioration. To face these difficulties, telerehabilitation may be useful to deliver rehabilitative treatments to homebound subjects with no moving of therapists or patients. To date some studies highlighted that rehabilitation delivered from-distance has similar results of face-to-face one, confirming that telerehabilitation may be effectively used to address the growing call for improving home care. Despite these observations, telerehabilitation is still few integrated into outpatients territorial rehabilitative practice. Furthermore, the current literature about telerehabilitation is mainly focused on a single domain of intervention (i.e. motor, cognitive, speech), with scant data about the impact of telerehabilitation on global disability. Finally, the cost-benefit ratio of telerehabilitation, compared to usual territorial rehabilitation or prolonged hospitalization, still objects of debate.

Preliminary Data:

Previous literature about telerehabilitation evidenced an improved upper limb motor function with positive interaction stroke patient-therapist. A previous RCT evidenced similar recovery of motor performances in stroke patients who received telerehabilitation compared to "face to face" treatment. Moreover, was highlighted that patients treated with telerehabilitation were able to have good management of the system and a good relationship with therapists. Recently was showed feasibility and effectiveness of speech telerehabilitation, applied to lexical deficits in chronic stroke patients as well as of cognitive telerehabilitation in people with mild cognitive impairment, with results similar to "face-to-face" treatment.

In a systematic review on motor telerehabilitation, was supported the equivalence of "face to face" and "from a distance" delivery of neuromotor rehabilitation, showing no difference as to the effect of telerehabilitation compared to other rehabilitative interventions in neurological diseases. Furthermore, within the framework of an EU FP7 project focused on Integrated Home Care, was performed a review on home care in stroke patients, evidencing relevant suggestions to plan telerehabilitation trials, in order to observe the expected effectiveness from a multi-domains point of view in clinical, financial and social perspectives.

A multi-domain Health Technology Assessment approach was set up by the Istituto Superiore di Sanità (ISS), validated and implemented within the EU Project CLEAR. The model, a specialization of EUnet Health Technology Assessment model to telerehabilitation services, was applied to a 960-patients Pilot study in 4 EU Countries to address remote rehabilitation and management of several chronic neurological and motor diseases and was found appropriate for the purpose. The above ISS Health Technology Assessment model proved to have the potential to investigate telerehabilitation services in agreement with the Italian Guidelines on Telemedicine. Highly relevant, it allows exceeding the boundaries and limitations of a specific Hospital-based Health Technology Assessment, thus reaching the more general level of a national-based Health Technology Assessment.