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Look Before You Leap: Interventions Supervised via Telehealth Involving Activities in Weight-Bearing or Standing Positions for People After Stroke-A Scoping Review.
Ramage, ER, Fini, N, Lynch, EA, Marsden, DL, Patterson, AJ, Said, CM, English, C
Physical therapy. 2021;(6)
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Abstract
OBJECTIVE The COVID-19 pandemic has seen a rapid shift to telehealth-delivered physical therapy services. Common impairments after stroke create unique challenges when providing rehabilitation via telehealth, particularly when it involves activities undertaken in weight-bearing or standing positions, including walking training. Our scoping review maps the evidence regarding safety, efficacy, and feasibility of remotely supervised telehealth interventions involving activities undertaken in weight-bearing or standing positions for people after stroke. METHODS Searches of relevant databases for primary research studies were conducted using keywords relating to exercise and telehealth. Studies of stroke survivors undertaking interventions involving activities in weight-bearing or standing positions, supervised in real-time via telehealth were included. Two reviewers independently appraised all studies. Data were charted by one reviewer, checked by another, and results synthesized narratively. RESULTS Seven studies (2 randomized trials, 1 mixed-methods, and 4 pre-post studies) were included, involving 179 participants. Some studies included stroke survivors with cognitive impairment, and 2 (29%) studies included only participants who walked independently. Adherence (reported in 3 studies) and satisfaction (reported in 4 studies) were good, and no serious adverse events (data from 4 studies) related to interventions were reported. Strategies to overcome technological barriers were used to optimize intervention safety and feasibility, along with physiological monitoring, caregiver assistance, and in-person exercise prescription. However, there is limited high-quality evidence of efficacy. CONCLUSIONS We identified strategies used in research to date that can support current practice. However, urgent research is needed to ensure that stroke survivors are receiving evidence-based, effective services. IMPACT The COVID-19 pandemic has necessitated a rapid shift to telerehabilitation services for people with stroke, but there is little evidence to guide best practice. Our review provides practical guidance and strategies to overcome barriers and optimize safety and adherence for telehealth interventions involving activities in weight-bearing or standing positions.
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Better Knee, Better Me™: effectiveness of two scalable health care interventions supporting self-management for knee osteoarthritis - protocol for a randomized controlled trial.
Bennell, KL, Keating, C, Lawford, BJ, Kimp, AJ, Egerton, T, Brown, C, Kasza, J, Spiers, L, Proietto, J, Sumithran, P, et al
BMC musculoskeletal disorders. 2020;(1):160
Abstract
BACKGROUND Although education, exercise, and weight loss are recommended for management of knee osteoarthritis, the additional benefits of incorporating weight loss strategies into exercise interventions have not been well investigated. The aim of this study is to compare, in a private health insurance setting, the clinical- and cost-effectiveness of a remotely-delivered, evidence- and theory-informed, behaviour change intervention targeting exercise and self-management (Exercise intervention), with the same intervention plus active weight management (Exercise plus weight management intervention), and with an information-only control group for people with knee osteoarthritis who are overweight or obese. METHODS Three-arm, pragmatic parallel-design randomised controlled trial involving 415 people aged ≥45 and ≤ 80 years, with body mass index ≥28 kg/m2 and < 41 kg/m2 and painful knee osteoarthritis. Recruitment is Australia-wide amongst Medibank private health insurance members. All three groups receive access to a bespoke website containing information about osteoarthritis and self-management. Participants in the Exercise group also receive six consultations with a physiotherapist via videoconferencing over 6 months, including prescription of a strengthening exercise and physical activity program, advice about management, and additional educational resources. The Exercise plus weight management group receive six consultations with a dietitian via videoconferencing over 6 months, which include a very low calorie ketogenic diet with meal replacements and resources to support behaviour change, in addition to the interventions of the Exercise group. Outcomes are measured at baseline, 6 and 12 months. Primary outcomes are self-reported knee pain and physical function at 6 months. Secondary outcomes include weight, physical activity levels, quality of life, global rating of change, satisfaction with care, knee surgery and/or appointments with an orthopaedic surgeon, and willingness to undergo surgery. Additional measures include adherence, adverse events, self-efficacy, and perceived usefulness of intervention components. Cost-effectiveness of each intervention will also be assessed. DISCUSSION This pragmatic study will determine whether a scalable remotely-delivered service combining weight management with exercise is more effective than a service with exercise alone, and with both compared to an information-only control group. Findings will inform development and implementation of future remotely-delivered services for people with knee osteoarthritis. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12618000930280 (01/06/2018).
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Renewed: Protocol for a randomised controlled trial of a digital intervention to support quality of life in cancer survivors.
Krusche, A, Bradbury, K, Corbett, T, Barnett, J, Stuart, B, Yao, GL, Bacon, R, Böhning, D, Cheetham-Blake, T, Eccles, D, et al
BMJ open. 2019;(3):e024862
Abstract
INTRODUCTION Low quality of life is common in cancer survivors. Increasing physical activity, improving diet, supporting psychological well-being and weight loss can improve quality of life in several cancers and may limit relapse. The aim of the randomised controlled trial outlined in this protocol is to examine whether a digital intervention (Renewed), with or without human support, can improve quality of life in cancer survivors. Renewed provides support for increasing physical activity, managing difficult emotions, eating a healthier diet and weight management. METHODS AND ANALYSIS A randomised controlled trial is being conducted comparing usual care, access to Renewed or access to Renewed with brief human support. Cancer survivors who have had colorectal, breast or prostate cancer will be identified and invited through general practice searches and mail-outs. Participants are asked to complete baseline measures immediately after screening and will then be randomised to a study group; this is all completed on the Renewed website. The primary outcome is quality of life measured by the European Organization for Research and Treatment of Cancer QLQ-c30. Secondary outcomes include anxiety and depression, fear of cancer recurrence, general well-being, enablement and items relating to costs for a health economics analysis. Process measures include perceptions of human support, intervention usage and satisfaction, and adherence to behavioural changes. Qualitative process evaluations will be conducted with patients and healthcare staff providing support. ETHICS AND DISSEMINATION The trial has been approved by the NHS Research Ethics Committee (Reference 18/NW/0013). The results of this trial will be published in peer-reviewed journals and through conference presentations. TRIAL REGISTRATION NUMBER ISRCTN96374224; Pre-results.
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End Users Want Alternative Intervention Delivery Models: Usability and Acceptability of the REMOTE-CR Exercise-Based Cardiac Telerehabilitation Program.
Rawstorn, JC, Gant, N, Rolleston, A, Whittaker, R, Stewart, R, Benatar, J, Warren, I, Meads, A, Jiang, Y, Maddison, R
Archives of physical medicine and rehabilitation. 2018;(11):2373-2377
Abstract
OBJECTIVE Evaluate user experiences of an exercise-based cardiac telerehabilitation intervention (REMOTE-CR) that provided near universal access to real-time remote coaching and behavioral support from exercise specialists. DESIGN Secondary analysis (12-week follow-up) of a parallel group, single blind, randomized controlled noninferiority trial (ACTRN12614000843651). SETTING Community-based cardiac rehabilitation. PARTICIPANTS Adults (N=162) with coronary heart disease who were eligible for outpatient cardiac rehabilitation. Eighty-two of 162 trial participants were randomized to receive REMOTE-CR; 67 completed usability and acceptability assessment at 12-week follow-up. INTERVENTION REMOTE-CR comprised 12 weeks of individualized exercise prescription, real-time physiological monitoring, coaching, and behavioral support, delivered via a bespoke telerehabilitation platform. OUTCOMES Ease of use, satisfaction with the technology platform and intervention content, and demand for real-world implementation as an alternative to traditional center-based programs were assessed at 12-week follow-up. RESULTS Components of usability and acceptability were positively evaluated by most participants (44-66 of 67, 66%-99%). Fifty-eight of 67 (87%) would choose REMOTE-CR if it was available as a usual care service, primarily because it provides convenient and flexible access to real-time individualized support from exercise specialists. Technology challenges were rare and had little effect on user experiences or demand for REMOTE-CR. CONCLUSIONS REMOTE-CR can extend the reach and impact of existing cardiac rehabilitation services by overcoming traditional participation barriers while preserving expert oversight. Adoption of emerging technologies should be accelerated to support dynamic, engaging, individualized intervention delivery models, but optimizing overall cardiac rehabilitation participation rates will require multiple delivery models that are tailored to satisfy diverse participant preferences.
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Physiotherapy breathing retraining for asthma: a randomised controlled trial.
Bruton, A, Lee, A, Yardley, L, Raftery, J, Arden-Close, E, Kirby, S, Zhu, S, Thiruvothiyur, M, Webley, F, Taylor, L, et al
The Lancet. Respiratory medicine. 2018;(1):19-28
Abstract
BACKGROUND Despite effective pharmacotherapy, asthma continues to impair quality of life for most patients. Non-pharmacological approaches, including breathing retraining, are therefore of great interest to patients. However, clinicians rarely advocate breathing retraining and access to this intervention is restricted for most patients due to the limited availability of suitable physiotherapists and poor integration of breathing retraining into standard care. We aimed to assess the effectiveness of a digital self-guided breathing retraining intervention. METHODS In this randomised controlled trial, we recruited patients from 34 general practices in the UK. Eligibility criteria for patients with asthma were broad, comprising a physician diagnosis of asthma, age of 16-70 years, receipt of at least one anti-asthma medication in the previous year, and impaired asthma-related quality of life (Asthma Quality of Life Questionnaire [AQLQ] score of <5·5). We developed a self-guided intervention, which was delivered as a DVD plus a printed booklet (DVDB). Participants were randomly assigned to receive either the DVDB intervention, three face-to-face breathing retraining sessions, or standard care, in a 2:1:2 ratio, for 12 months. Randomisation was achieved using the Southampton Clinical Trials Unit telephone randomisation service by use of random number generators. The primary outcome was the AQLQ score in the intention-to-treat population at 12 months. The trial was powered to show equivalence between the two active intervention groups, and superiority of both intervention groups over usual care. Secondary outcomes included patient-reported and physiological measures of asthma control, patient acceptability, and health-care costs. This trial was registered with International Standard Randomised Controlled Trial Number registry, number ISRCTN88318003. FINDINGS Between Nov 5, 2012 and Jan 28, 2014, invitations to participate in the study were sent to 15 203 patients with general practitioner-diagnosed asthma, of whom 655 were recruited into the study. AQLQ scores at 12 months were significantly higher in the DVDB group (mean 5·40, SD 1·14) than in the usual care group (5·12, SD 1·17; adjusted mean difference 0·28, 95% CI 0·11 to 0·44), and in the face-to-face group (5·33, SD 1·06) than in the usual care group (adjusted mean difference 0·24, 95% CI 0·04 to 0·44); AQLQ scores were similar between the DVDB group and the face-to-face group (0·04, 95% CI -0·16 to 0·24). There were no significant differences between the randomisation groups in FEV1 or fraction of exhaled nitric oxide. 744 adverse events occurred in 272 patients: 101 (39%) of 261 patients in the DVDB group, 55 (42%) of 132 patients in the face-to-face group, and 132 (50%) of 262 in the usual care group, with patients reporting one or more event. 11 (4%) patients in the DVDB group, four (3%) patients in the face-to-face group, and 20 (8%) patients in the usual care group had a serious adverse event. INTERPRETATION Breathing retraining programmes improve quality of life in patients with incompletely controlled asthma despite having little effect on lung function or airway inflammation. Such programmes can be delivered conveniently and cost-effectively as a self-guided digital audiovisual programme, so might also reduce health-care costs. FUNDING UK National Institute of Health Research.
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Medium-Term Effectiveness of a Comprehensive Internet-Based and Patient-Specific Telerehabilitation Program With Text Messaging Support for Cardiac Patients: Randomized Controlled Trial.
Frederix, I, Hansen, D, Coninx, K, Vandervoort, P, Vandijck, D, Hens, N, Van Craenenbroeck, E, Van Driessche, N, Dendale, P
Journal of medical Internet research. 2015;(7):e185
Abstract
BACKGROUND Cardiac telerehabilitation has been introduced as an adjunct or alternative to conventional center-based cardiac rehabilitation to increase its long-term effectiveness. However, before large-scale implementation and reimbursement in current health care systems is possible, well-designed studies on the effectiveness of this new additional treatment strategy are needed. OBJECTIVE The aim of this trial was to assess the medium-term effectiveness of an Internet-based, comprehensive, and patient-tailored telerehabilitation program with short message service (SMS) texting support for cardiac patients. METHODS This multicenter randomized controlled trial consisted of 140 cardiac rehabilitation patients randomized (1:1) to a 24-week telerehabilitation program in combination with conventional cardiac rehabilitation (intervention group; n=70) or to conventional cardiac rehabilitation alone (control group; n=70). In the telerehabilitation program, initiated 6 weeks after the start of ambulatory rehabilitation, patients were stimulated to increase physical activity levels. Based on registered activity data, they received semiautomatic telecoaching via email and SMS text message encouraging them to gradually achieve predefined exercise training goals. Patient-specific dietary and/or smoking cessation advice was also provided as part of the telecoaching. The primary endpoint was peak aerobic capacity (VO2 peak). Secondary endpoints included accelerometer-recorded daily step counts, self-assessed physical activities by International Physical Activity Questionnaire (IPAQ), and health-related quality of life (HRQL) assessed by the HeartQol questionnaire at baseline and at 6 and 24 weeks. RESULTS Mean VO2 peak increased significantly in intervention group patients (n=69) from baseline (mean 22.46, SD 0.78 mL/[min*kg]) to 24 weeks (mean 24.46, SD 1.00 mL/[min*kg], P<.01) versus control group patients (n=70), who did not change significantly (baseline: mean 22.72, SD 0.74 mL/[min*kg]; 24 weeks: mean 22.15, SD 0.77 mL/[min*kg], P=.09). Between-group analysis of aerobic capacity confirmed a significant difference between the intervention group and control group in favor of the intervention group (P<.001). At 24 weeks, self-reported physical activity improved more in the intervention group compared to the control group (P=.01) as did the global HRQL score (P=.01). CONCLUSIONS This study showed that an additional 6-month patient-specific, comprehensive telerehabilitation program can lead to a bigger improvement in both physical fitness (VO2 peak) and associated HRQL compared to center-based cardiac rehabilitation alone. These results are supportive in view of possible future implementation in standard cardiac care.
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Telerehab III: a multi-center randomized, controlled trial investigating the long-term effectiveness of a comprehensive cardiac telerehabilitation program--rationale and study design.
Frederix, I, Hansen, D, Coninx, K, Vandervoort, P, Van Craenenbroeck, EM, Vrints, C, Dendale, P
BMC cardiovascular disorders. 2015;:29
Abstract
BACKGROUND Telerehabilitation has been proposed as an adjunct/alternative to standard center-based cardiac rehabilitation. Two recent systematic reviews showed non-inferiority and/or superiority of this remote approach for cardiac rehabilitation. However, these trials focused only on one core component of cardiac rehabilitation and telemonitoring, rather than implementing a more comprehensive approach. The aim of Telerehab III is to investigate the long-term effectiveness of the addition of a patient-tailored, internet-based telerehabilitation program implementing multiple cardiac rehabilitation core components and using both telemonitoring and telecoaching strategies to standard cardiac rehabilitation. METHODS/DESIGN In this prospective, multi-center randomized, controlled trial 140 patients with coronary artery disease and/or chronic heart failure patients will be recruited between February 2013 and February 2015. Patients will be randomized 1:1 to an intervention group (receiving an internet-based telerehabilitation program in addition to standard cardiac rehabilitation) or to standard cardiac rehabilitation alone. The mean follow-up is at least 6 months. The primary endpoint is peak oxygen consumption (VO2 peak). Secondary endpoints include measured and self-reported daily physical activity, cardiovascular risk factor control, health-related quality of life, days lost due to (non)cardiovascular rehospitalizations and time to first (non)cardiovascular rehospitalization. A clinical event committee blinded to treatment allocation assesses causes of rehospitalizations. DISCUSSION Telerehab III will be one of the first studies to examine the added value of a more comprehensive cardiac telerehabilitation program, focusing on multiple cardiac rehabilitation core components. It has the potential to augment current standard center-based cardiac rehabilitation practices and to be used as a model for other disease prevention programs. TRIAL REGISTRATION Current controlled trials ISRCTN29243064. Registration date 21 January 2015.