Quality of methodology
There was substantial interrater agreement concerning the methodological quality criteria (κ = 0.84, P < .001), with disagreement resolved through discussion to yield final ratings. As shown in Table 2, the majority of studies (≥80%) described eligibility criteria, employed relevant outcome measures, described the sample size, and conducted a statistical comparison of treatment effects. Conversely, less than 30% of studies ensured that cointerventions were avoided or equivalent, had blinded outcome measures, and assessed long-term outcomes (see the Appendix). Overall, the number of criteria met ranged from 634 to 1535 out of 16.
A total of 1838 participants with TBI (14-433 per study) were involved in telerehabilitation across 13 independent studies. Twelve studies were conducted in the United States and 1 in Canada.36 Samples included mild TBI,37 active-duty service members with mild TBI,32 , 33 mild-to-moderate TBI,36 moderate-to-severe TBI,30 , 38 and severe TBI.34 Other studies recruited mixed mild-to-severe TBI samples.35 , 39 – 41 Severity of TBI was not specified in 2 studies.42 , 43 Recruitment sources included emergency departments,37 army medical or veteran services,32 , 33 , 40 inpatient rehabilitation,30 , 39 outpatient rehabilitation,36 substance abuse services,42 community organizations,34 , 41 , 43 or a combination of hospital and community services.35
Program-level data such as commencement (percentages starting treatment), attendance, completion, satisfaction, and early termination represented main outcomes of 3 studies.36 , 42 , 44 Other participation indices included return to work and fitness for military duty,38 exercise maintenance,43 and signing a service plan.42 Researcher-rated outcomes were blinded in 3 studies30 , 35 , 39 and included functional status and depressive symptoms. Bell et al30 , 39 used a global composite of functioning. Self-report measures assessed mood, behavior,30 posttraumatic or post-concussion symptoms,32 , 37 sleep quality,33 and quality of life.39 Family caregivers reported everyday memory problems, goals, and strategy use.34 , 41
Ten interventions were conducted over the telephone and 3 were Internet based. Session numbers ranged from 142 to 30,34 (mean = 10.5).
Comparison of telephone interventions relative to usual care/education only
The efficacy of a scheduled telephone intervention (STI) relative to usual care or education only was evaluated by Bell et al30 , 32 , 37 , 39 In their initial RCT30 involving people with moderate-to-severe TBI (n = 157), 7 STI sessions (30-45 minutes) were delivered at set intervals over 9 months postdischarge. Sessions focused on managing self-identified concerns through tailored interventions. Participants receiving STI (n = 79) demonstrated significantly better overall functioning at 1-year postinjury relative to usual care (n = 78). Bombardier et al31 reanalyzed data for depression (available for 126/157) and found that those receiving STI reported significantly lower depression at 1-year postinjury relative to usual care.
In a subsequent multicenter study (n = 433) involving people with mild-to-severe TBI (32% mild), Bell et al39 sought to replicate their previous findings.30 Eleven sessions of STI were conducted over 21 months with outcomes assessed at 1- and 2-year follow-up. In contrast to their earlier study, there were no significant benefits of STI over usual care at follow-up. The variation in TBI severity between the studies is noteworthy, and may have influenced how STI was adapted to participants' functional level.
Bell et al37 evaluated the efficacy of STI for managing posttraumatic symptoms after mild TBI (n = 313). Five brief STI sessions (mean duration = 8 minutes) were delivered at set intervals over 12 weeks postinjury. STI participants also received a concussion booklet and wallet card with a toll-free number along with standard emergency department care. At 6 months postinjury, STI participants reported significantly fewer posttraumatic symptoms compared with those receiving usual care.
Reported in 2 articles,32 , 33 the efficacy of a 12-session telephone-based problem-solving treatment (PST; n = 178) was evaluated relative to education only (n = 178) for active-duty service members with mild TBI. The PST group received biweekly therapy focusing on identified problem areas, whereas the education-only group received biweekly mail outs of educational brochures. The PST group reported significantly better sleep quality at 6 months compared with controls; however, there were no differences at 12-month follow-up.33 Bell et al32 further reported that psychological distress levels were significantly lower for the PST group at 6 months, but not at 12-month follow-up. Overall, benefits of telephone-based PST were found for sleep and psychological well-being at 6 months, but were not maintained at longer follow-up.
Fann et al35 compared the efficacy of cognitive-behavioral therapy (CBT) over the telephone (CBT-T; n = 40) or in-person (CBT-IP; n = 18) with usual care (UC; n = 42) for people with major depression following mild-to-severe TBI. A choice-stratified approach to randomization enabled participants to choose between randomization options. Most opted for the 3-arm or CBT-T versus usual care option, thus resulting in the smaller CBT-IP sample. There were no significant differences between the combined CBT group and the UC group on clinician-rated depression at 8-, 16-, or 24-week follow-up. However, of specific relevance to this review, the CBT-T group self-reported significantly less severe depressive symptoms compared with the UC group at 16-week follow-up. Conversely, there were no significant differences between the CBT-IP and UC groups, which may be related to the smaller sample for CBT-IP. Ratings of therapeutic alliance on the Working Alliance Inventory-Short Form did not differ between the CBT-T and CBT-IP groups.
Comparison of telephone and in-person rehabilitation
Salazar and colleagues38 employed telephone counseling as a control condition in an RCT of an intensive, standardized 8-week inhospital cognitive rehabilitation program for active-duty service members with moderate-to-severe TBI. Delivered by a psychiatric nurse, the 8 × 30-minute telephone counseling sessions focused on education and strategies for enhancing cognitive and physical functioning. There were no significant group differences in return-to-work (90%-94%), fitness for military duty (66%-73%), cognitive or psychological function at 1-year follow-up. The high overall reemployment rates may reflect structured processes for supporting members to resume military duties. Limitations included lack of details on the total amount of therapy received during the 8-week inhospital program, which appeared much greater than for telephone counseling.
Comparison of different telephone-based approaches
Corrigan et al42 compared the efficacy of telephone-based methods for increasing participation in substance abuse treatment (n = 195). The single-session interventions included barrier reduction, motivational interviewing, financial incentive, and attention control. Participants receiving the barrier reduction (ie, identifying and addressing possible barriers to attendance) and financial incentive methods were significantly more likely to sign an individualized service plan within 30 days than those in the motivational interviewing or attention control conditions. Participants in the former 2 groups also had significantly fewer premature treatment terminations (16%-21%) relative to the attention control group (47%). However, groups did not differ on attendance or treatment status at 3- to 6-month follow-up. Limitations included lack of information on TBI severity and the sample size for each group and duration of calls for each condition.
Using a quasirandomized design, Bourgeois et al41 compared the efficacy of spaced retrieval (SR; n = 22) and didactic strategy instruction (DSI: n = 16). Both interventions were delivered via 30-minute telephone calls, 4 to 5 days per week. The SR program identified prompt questions and responses for 3 memory goals, with intervals increased following correct responses. The program ended when memory goals were mastered (mean = 11.8 sessions). The DSI group received a similar amount of therapy (mean = 10.2 sessions) focusing on internal and external memory strategies. The SR group had significantly greater goal mastery at 1-week and 1-month posttraining than the DSI group (inferred from reported strategy use). However, the varied approach to measuring goal mastery complicates interpretation of these findings.
Pre-/poststudies of telephone-based support
Henry and Greenfield40 piloted the efficacy of telephone-based management of tinnitus in a pre-/poststudy. Thirty-six participants with tinnitus (15 mild TBI, 9 moderate-to-severe TBI, and 12 with no TBI) completed 6 × 90-minute sessions. Delivered by a psychologist and an audiologist, CBT and tinnitus management techniques were used in combination. The mild TBI subgroup reported a significant reduction in functional limitations due to tinnitus at the 12-week but not 24-week follow-up. Overall, the findings supported feasibility of the intervention, although the efficacy could not be determined because of the lack of a nontreatment control group and small sample.
The utility of telephone-based support for maintaining exercise gains was examined in a pre-/poststudy by Wise et al.43 It involved 40 participants from an earlier RCT45 who received the structured aerobic exercise program. They subsequently received 12 telephone calls over 6 months, which focused on maintenance of exercise and positive lifestyle changes. At postintervention, 48% of participants maintained their increase in physical activity relative to their baseline. There was a significant reduction in depressive symptoms and improvement in mental health between the baseline and 10-week and 6-month follow-up. Those who exercised more than 90 minutes per week reported better mental health and quality of life. These findings support the feasibility of telephone-based support for maintaining exercise gains; however, the efficacy of this approach cannot be determined because of the lack of a control group.
Using a crossover RCT design, Bergquist et al34 compared the efficacy of 2 Internet-based interventions involving IM (30 sessions, 2-3 weekly) after moderate-to-severe TBI. The main intervention (n = 6) taught participants to use a calendar to cope with daily memory problems. The diary control condition (n = 8) involved recording daily activities and reviewing these in therapy. All participants received initial training in-person to use the IM system. Two people from each condition did not complete the intervention and there were no significant effects of intervention type. Strategy use, mood, and memory improved relative to baseline for both conditions combined.
An RCT by Raina et al44 examined the feasibility and efficacy of an Internet-based intervention for managing fatigue in individuals with mild-to-severe TBI (n = 41). The intervention and control (health education) entailed 16 × 30-minute sessions delivered by occupational therapists using web camera technology. The maximizing energy (MAX) intervention (n = 20) involved fatigue education and problem-solving therapy to manage fatigue-related problems, whereas the control group (n = 21) received health-related education relevant to TBI, including fatigue and energy conservation. The MAX intervention was found to be feasible, although 3 participants did not complete the program. There were no significant group differences in participant satisfaction or fatigue at postintervention. Hence, the problem-solving component of the MAX intervention did not show benefits beyond the education component, which was common to both interventions.
A pre-/poststudy by Topolovec-Vranic et al36 examined feasibility of a 6-week Internet-delivered CBT program (MoodGym developed for the general community) for people with mild-to-moderate TBI with depression (n = 21). Participants received weekly telephone calls to monitor their depression and progress with the Internet-based modules. Thirteen participants (62%) completed all 6 sessions and 9 completed the 12-month follow-up. Participants reported that technological difficulties and concentration, memory, and comprehension problems affected their participation. Those retained in the study reported a significant reduction in depressive symptoms at postintervention, which was maintained at 12-month follow-up.
This systematic review aimed to identify the different forms of telerehabilitation used remotely with adults with TBI, appraise the methodological quality of studies, and determine the efficacy of telerehabilitation interventions. We identified 13 studies (10 RCTs and 3 pre-/poststudies) evaluating the feasibility and/or efficacy of telephone-based (10 studies) and Internet-based (3 studies) interventions. Five different study types were identified, including comparison of telephone-based interventions relative to usual care or education only (5 RCTs30 , 33 , 35 , 37 , 39), comparison of telephone-based and in-person rehabilitation (1 RCT38), comparison of telephone-based interventions (2 RCTs41 , 42), comparison of Internet-based interventions (2 RCTs34 , 44), and pre-/poststudies on telephone and Internet-based approaches.36 , 40 , 43 The number of methodological quality criteria met for the 10 RCTs ranged from 6 to 15 out of 16, with the study by Fann et al35 meeting the highest number of criteria.
For the studies evaluating the efficacy of telephone-based interventions relative to usual care (5 RCTs), telephone-based therapy (5–12 sessions) was found to improve particular outcomes at postintervention relative to usual care in 4 RCTs (n = 100-356).30 , 33 , 35 , 37 Effect sizes for between-group pre-/postmean differences46 ranged from small to medium (d = 0.28-0.51) for significant outcomes. Improvements in global functioning after moderate-severe TBI,30 posttraumatic symptoms and sleep quality after mild TBI,33 , 37 and depressive symptoms after mild-to-severe TBI35 were reported at postintervention. Notably, however, a large RCT (n = 433) by Bell et al39 reported no significant benefits of telephone-based therapy over usual care. Furthermore, in 2 RCTs33 , 35 the positive outcomes of telephone-based therapy for improving sleep quality33 and reducing depressive symptoms35 at postintervention were not maintained at the later follow-up assessment.
In relation to the other study types, the evidence of efficacy was somewhat mixed. Only one RCT38 compared the efficacy of telephone-based and in-person rehabilitation and found no significant difference in outcomes. However, the content and intensity of these interventions differed along with the mode of delivery; hence, this study does not provide specific evidence of the efficacy of telerehabilitation. Two RCTs41 , 42 comparing telephone-based interventions indicated that a particular telephone-based intervention was more effective than a control intervention that was also delivered via telephone. Two other RCTs34 , 44 found no significant difference in the outcomes of interventions (experimental vs active control) that were delivered via the Internet. Finally, 3 studies with a pre-/postdesign36 , 40 , 43 generally supported the feasibility of delivering interventions by telephone40 , 43 or the Internet36; however, the efficacy of these interventions could not be determined because of the lack of a control group.
The telephone is currently the most common means of delivering rehabilitation remotely to adults with TBI. Interventions targeted diverse aspects of functioning including posttraumatic symptoms,32 , 39 tinnitus,40 sleep,33 depression,35 memory problems,41 treatment participation,42 and exercise maintenance,43 thus highlighting the versatility of telephone-based delivery. Interestingly, a large RCT39 (n = 433) found no significant benefits of STI (11 sessions over 2 years), which conflicted with an earlier study30 reporting positive effects of STI (7 sessions over 1 year). The authors reported that treatment integrity was monitored in both studies and there was no dose-response effect. However, because of differences in TBI severity (ie, moderate-to-severe TBI for Bell et al30 and mild-to-severe for Bell et al39), and the need to adapt STI to participants' functional level, it is possible that there were variations in how STI was implemented across the studies. Process issues such as therapeutic alliance were not assessed. Brockway et al47 explored perceived benefits of telephone-based delivery after the PST intervention.33 Service members with mild TBI identified that key advantages included convenience, anonymity, and acceptability (ie, comfort of receiving support at home). Only 6% (ie, 5 of 80) stated a preference for face-to-face delivery of psychological support.
The efficacy of telerehabilitation has been compared with conventional delivery of the same intervention in other neurological populations.6 , 9 Yet, no studies of this nature were identified for adults with TBI. Fann et al35 evaluated in-person and telephone formats of CBT, but focused on the efficacy of CBT relative to usual care. Their choice-randomization strategy enabled participants to indicate their delivery mode preference; hence, comparisons between the 2 modes could not be reliably made.
Despite rapid advances in web-based platforms and their applications in stroke,6 multiple sclerosis,7 and pediatric TBI12–14 research, only 3 Internet-based intervention studies34 , 36 , 44 were identified for adults with TBI in the present review. Overall, these studies indicated that Internet-based interventions are generally feasible; however, their efficacy relative to usual care was not investigated. The RCTs that compared 2 different Internet-based interventions targeting memory (n = 14)34 and fatigue (n = 41)44 found no significant differences between the control and experimental interventions. Furthermore, a pre-/poststudy (n = 21) of an Internet-based CBT program36 reported that technological and cognitive barriers contributed to high attrition rates (38%).
Potential reasons for low usage of Internet platforms relate to practical barriers (eg, costs and broadband access) and TBI-related deficits. Thus, there is a need to pilot less familiar technology in clinical or research settings before home-based application and conducting clinical trials.18–20 Bergquist et al21 , 34 initially trained participants to use IM in the clinic before implementation in the home. Participants without reliable Internet access and those who could not independently log into the IM system after 2 hours of training were excluded. Some researchers have developed technology customized for people with cognitive and physical impairments, for example, the Home Care Activity Desk.48 Others have adapted face-to-face interventions for Internet-based delivery, providing participants with training and equipment (eg, noise-cancelling headsets) and support to download software and set up security settings and screen sharing.22–24
Overall, this review was limited by the small number of studies meeting the sample size requirement (≥10 participants). Furthermore, the findings are based on heterogeneous studies with respect to design, sample characteristics, interventions, outcomes, and methodological quality. Several studies reported outcomes at postintervention only or included relatively short follow-ups (eg, ≤3 months postintervention). Moreover, the evidence of positive outcomes of telephone-based support relative to usual care from 4 RCTs was limited to relatively short-term outcomes, with 2 of these RCTs33 , 35 indicating that the effects were not maintained at follow-up assessment, and the other 2 RCTs30 , 37 not examining durability of outcomes. Despite the comprehensive search strategy used to identify relevant literature across 4 databases, it is possible that different search strategies or databases may have yielded other eligible studies, including articles not published in English.
In future TBI research, there is a need to compare the clinical efficacy and cost-effectiveness of in-person and telephone-based delivery of interventions, as well as different telerehabilitation platforms, and include longer follow-up assessments. Such intervention trials need to be sufficiently powered to detect differences between active interventions, or to demonstrate noninferiority or equivalence of outcomes. Hence, multicenter recruitment may be necessary to achieve adequate sample sizes. With regard to Internet-based interventions, engagement of people with TBI, family members, and clinicians in the design, adaptation and trialing of technology are strongly advocated to enhance feasibility and acceptability before large-scale studies and translation into clinical practice.49 Supported by the evidence of efficacy in this review, telephone-based delivery has the potential to increase access to specialized interventions for people with TBI living outside metropolitan areas and enable extended follow-up and monitoring. However, given the finding that the positive effects were limited to short-term outcomes, further research on approaches (eg, booster sessions) for improving maintenance of gains over time is recommended. As evidence of efficacy increases for telerehabilitation, policy guidelines concerning privacy, credentialing, and reimbursement will be needed to support practice.10
This systematic review identified that telephone-based intervention has been most commonly used to deliver rehabilitation remotely to adults with TBI. Scheduled telephone support was found to improve particular outcomes for individuals with mild and moderate-to-severe TBI relative to usual care in 4 out of 5 RCTs. However, the durability of these effects was either not demonstrated or not examined by these studies. Only 3 Internet-based interventions were identified that focused mainly on feasibility. Future research priorities relate to engaging end users in the design and trialing of technology and comparing the clinical and cost-effectiveness of in-person therapy and different telerehabilitation platforms.
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APPENDIX. Quality criteria for telerehabilitation RCTs (based on Cicerone et al29) Internal validity
- A. Eligibility criteria: Inclusion and exclusion criteria were specified.
- B. (i) Method of randomization: Described how participants were randomized (eg, stratified according to certain variables, in blocks, and use of computer-generated sequence).
- (ii) Allocation concealment: The allocation sequence was concealed from the researchers using methods such as (a) randomization was conducted by a person independent of the researchers involved in the intervention (eg, statistician), (b) a centralized randomization program, or (c) predetermined and sequentially numbered or coded sealed opaque envelopes or similar.
- C. Similarity of baseline characteristics: A comparison was made between the treatment groups on demographic and clinical variables (including outcome measures) at preintervention or baseline. Descriptive data were presented and/or the results of between-group comparisons are presented. No point is given if postintervention outcomes differ between groups and the groups were not equivalent on this outcome at baseline.
- D. Description of interventions: An adequate description of both treatment and control interventions was provided concerning what was involved and how these were delivered. The duration and intensity of treatment (number of sessions, frequency, and average length) are specified to enable an approximate calculation of the total hours of therapy received. If studies employed a usual care condition, they briefly described what this entailed (eg, provision of an educational booklet and standard outpatient care) and over what period.
- E. Cointerventions avoided or equivalent: Details on concurrent professional support or treatment (eg, medication) received during the study intervention are provided for both conditions. Credit was also given if authors specified that participants did not receive a specific form of therapy related to the experimental treatment.
- F. Outcome measurement blinded: This required 2 conditions to be met: (1) the person conducting the assessment was unaware (blinded or masked) of the condition to which participants were allocated; and (2) at least one outcome measure needed to be an objective test (ie, assessor-rated, performance-based, or requiring clinical judgment such as a clinical interview for depression).
- G. Outcome measures relevant to the intended outcome of the intervention. Depending on the focus of the intervention, this may include standardized tests of cognitive function, self and significant other reports of neurobehavioral or psychosocial function (eg, cognition, mood, and quality of life), assessment of everyday function (activity limitations, role participation, independence).
- H. Withdrawal and dropout rates were described for participants who were included in the study at baseline assessment but did not complete all assessments at postintervention and/or follow-up, and the reasons for withdrawal are provided. The percentage of withdrawal or dropouts between baseline and post-intervention assessment did not exceed 20% for short-term and 30% for long-term.
- I. Short-term outcomes were measured and reported at the end of the treatment period at or within 3 months of treatment cessation.
- J. Long-term outcomes were measured and reported more than 3 months after completion of treatment.
- K. Timing of outcome measures with respect to the baseline assessment was equivalent for all intervention groups and on all key outcome measures.
- L. Sample size for each group at randomization and/or at baseline assessment was described using numerical data.
- M. ITT analysis: Authors specified that analyses were conducted on an intention-to-treat basis, or it was clear that all participants receiving the baseline assessment were included in the postintervention analysis and analyzed in the groups to which they were originally allocated. Alternative analysis may also be conducted to minimize bias, particularly if dropout was greater than 20%.
- N. Point estimates (M, n[%]) and variability (SD, CI) were presented for one or more key outcome measure for each intervention group. Dichotomous or frequency data included range or confidence intervals. Mean change scores and SD were acceptable if baseline data on these outcomes were also presented.
- O. Statistical comparison of treatment effects included a direct comparison between treatment conditions. If significant differences existed at baseline, a group × time interaction or between-group comparison controlling for baseline functioning was conducted for the primary outcome at least. If no primary outcome was specified, statistical comparisons were reported for all outcomes identified as relevant to the treatment. A between-group comparison of mean change scores was acceptable if there were no significant differences at baseline.
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adults; systematic review; technology; telerehabilitation; traumatic brain injury