Question: Does home-based telerehabilitation to improve arm movements have comparable efficacy to dose-matched in-clinic rehabilitation for people with stroke?
Design: Randomised controlled non-inferiority trial with concealed allocation and blinded outcome assessment.
Setting: Eleven sites in the National Institutes of Health StrokeNet clinical trials network in the United States.
Participants: Adults within 4 to 36 weeks of ischaemic or haemorrhagic stroke who had mild-to-severe upper limb deficits without major deficits in mood or cognition. Randomisation of 124 participants allocated 62 to home-based telerehabilitation and 62 to in-clinic rehabilitation.
Interventions: Both groups received 18 supervised and 18 unsupervised 70-minute sessions over 6 to 8 weeks, comprising arm exercises (based on the principles of task-specific training and the Accelerated Skill Acquisition Program), functional training and stroke education. The in-clinic group had supervised sessions at the research centre and performed unsupervised exercise sessions at home with an individualised exercise booklet. The home-based telerehabilitation group used videoconferencing for the supervised sessions. For this group, exercises were presented on the computer screen for both supervised and unsupervised sessions, and functional games were used for functional training.
Outcome measures: The primary outcome was change in Fugl-Meyer upper extremity score from baseline to 4 weeks after intervention. Secondary outcomes were change in Box and Block Test, hand domain of the Stroke Impact Scale, stroke knowledge, and enjoyment of the rehabilitation program.
Results: A total of 114 participants completed the study but intention-to-treat analysis with multiple imputation for missing data analysed all randomised participants. Participants were adherent to more than 93% of therapy sessions in each group. The adjusted mean change in Fugl-Meyer score was 0.06 points (95% CI −2.14 to 2.26) greater in the telerehabilitation group compared with the in-clinic group. The non-inferiority margin was 2.47 points and fell outside the 95% CI, indicating that telerehabilitation is not inferior to in-clinic care. Non-inferiority was also demonstrated in the Box and Block Test but not the Stroke Impact Scale, in which the in-clinic group demonstrated a larger improvement. Both groups improved stroke knowledge after treatment. The in-clinic group reported greater enjoyment and satisfaction.
Conclusion: Upper extremity rehabilitation provided by telerehabilitation is not inferior to the same intervention provided in the clinic for improving arm motor function after stroke, but may not be satisfying or enjoyable for participants.