Stroke survivors’ acceptance and satisfaction of telerehabilitation delivery of physiotherapy services: a systematic review

Figures & data

Figure 1. PRISMA flow diagram for search strategy [25].

Table 1. Eligibility criteria for inclusion in review.

	Inclusion criteria	Exclusion criteria
Population	Diagnoses of stroke (ischaemic or haemorrhagic) First or recurrent stroke ≥18 years Any amount of time post stroke Any level of disability Lives at home +/- caregiver at home	Currently residing in acute hospital or inpatient rehabilitation or residential care facility
Intervention	Completed remotely at home Physiotherapy/exercise-based intervention that includes weightbearing/standing/lower limb exercises Technology component Supervision/monitoring/feedback from physiotherapist throughout intervention	Completed remotely with health professional present Aimed at upper limb/arm function only Virtual reality or robotics only
Comparison	Any	Nil exclusion criteria
Outcome	Reported patient acceptance, usability, or satisfaction related outcomes Perceptions of patients	Perceptions of health professionals only
Publication type	Published primary research studies (quantitative or qualitative research designs) Published in English language Peer reviewed journal Published from 2010 onward	Systematic reviews Literature reviews Meta-analyses Conference papers Protocols Letters No full text available

Table 2. Quality appraisal of included studies using the Mixed methods appraisal Tool (MMAT) version 2018.²⁶.

Study	Qualitative		Methodological quality criteria
	Screening question	Screening question	1.1	1.2	1.3	1.4	1.5
	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the qualitative approach appropriate to answer the research question?	Are the qualitative data collection methods adequate to address the research question?	Are the findings adequately derived from	Is the interpretation of results sufficiently substantiated by data?	Is there coherence between qualitative data sources, collection, analysis and interpretation?
Tyagi et al. [15]	Yes	Yes	Yes	Yes	Yes	Yes	Yes
	Quantitative randomised controlled trials
	Screening question	Screening question	2.1	2.2	2.3	2.4	2.5
			Is randomization appropriately performed?	Are the groups comparable at baseline?	Are there complete outcome data?	Are outcome assessors blinded to the intervention provided?	Did the participants adhere to the assigned intervention?
Chumbler et al. [16]	Yes	Yes	Yes	Yes	Yes	No	Yes
	Quantitative non-randomised studies
	Screening question	Screening question	3.1	3.2	3.3	3.4	3.5
			Are the participants representative of the target population?	Are measurements appropriate regarding both the outcome and intervention (or exposure)?	Are there complete outcome data?	Are the confounders accounted for in the design and analysis?	During the study period, is the intervention administered (or exposure occurred) as intended?
Bellomo et al. [27]	Yes	Yes	Yes	Yes	No	Yes	Yes
Bernocchi et al. [23]	Yes	Yes	Yes	Yes	Yes	No	Yes
Galloway et al. [24]	Yes	Yes	Yes	Yes	Yes	No	Yes
Sarfo et al. [25]	Yes	Yes	Yes	Yes	Yes	No	Yes
Simpson et al. [26]	Yes	Yes	Yes	Yes	Yes	No	Yes
Torriani-Pasin et al. [3]	Yes	Yes	Yes	Yes	Yes	No	Yes

Table 3. Methodological characteristics of reviewed studies.

Author (year) journal	Title/study design	Participant characteristics	Telerehabilitation system/technology	Intervention parameters and contents
Bellomo et al. [27] (2020) Journal of Central Nervous System Disease	The WeReha Project for an Innovative Home-Based Exercise Training in Chronic Stroke Patients: A Clinical Study.	25 chronic stroke patients from outpatient neurological service. Inclusion: 18 to 85 years of age First episode of ischaemic stroke Able to walk indoors independently or with supervision Exclusion: Previous strokes Bilateral UL weakness Modified Ashworth Scale (MAS) >2 Aphasia/ communication difficulties Mini Mental State Examination (MMSE) <24)	Sensors/biofeedback technology WeReha device: Android tablet with dedicated software, inertial Bluetooth sensors, kit of elastic bands with Velcro pocket and assortment of smart objects. Video guided exercise and visual/voiced/ringing biofeedback. Voice calls with physiotherapist.	Intervention duration/frequency/length 12-week physiotherapy program.At least 3 × 15 min (minimum) sessions per week. Contents of intervention Balance exercises, upper and lower limb exercises in sitting or standing with specific motor tasks using WeReha device. Weekly phone review with physiotherapist. Informative training session held with patient and caregiver (30–60 min).
Bernocchi et al. [23] (2016) Topics in Stroke Rehabilitation	Home-based telesurveillance and rehabilitation after stroke: a real-life study. Single group pre-post pilot study.	26 post stroke patients: 15 subacute (time since stroke 112 ± 39 days), 11 chronic (time since stroke 470 ± 145 days). Inclusion: >18 years of age Ischaemic or haemorrhagic stroke Functional UL deficit Exclusion: Cognitive deficits and/or absence of caregiver	Pre-recorded exercises on video Videoconferencing and/or voice calls with physiotherapist. Voice calls with nurse-tutor.	Intervention duration/frequency/length 3-month physiotherapy program.Individual prescribed daily activities/time allocated. Contents of intervention Functional exercises including sit-to-stand, stairs, turning, ADLs. Physiotherapist supervised patient’s program at least once per week through videoconference. Nurse tutor provided structured phone support and monitoring of disease status.
Chumbler et al. [16] (2015) Journal of Telemedicine and Telecare	A randomized controlled trial on Stroke telerehabilitation: The effects on falls self-efficacy and satisfaction with care. Randomised, multisite, single-blinded trial.	52 veterans /stroke survivors. Inclusion: Ischaemic or haemorrhagic stroke in past two years	Voice calls with physiotherapist or occupational therapist. In-Home Messaging Device (IHMD)	Intervention duration/frequency/length 3 month home based exercise program. Randomised to STeleR (n = 23) or usual care. Contents of intervention Intervention group. STeleR home based training in exercises and adaptive strategies following standard stroke rehabilitation. 3 x home televisits, 5 telephone calls, daily in-home messaging device over 3 months to instruct patients in home exercises. Control group. Usual care: not contacted other than for initial recruitment and to obtain data. Could receive any services provided as part of usual care.
Galloway et al. [24] (2019) International Journal of Telerehabilitation	The Feasibility of a Telehealth Exercise Program Aimed at Increasing Cardiorespiratory Fitness for People After Stroke. Single group pre-post clinical trial.	21 stroke survivors. Inclusion: Ambulant Mild-moderate impairments >3months post stroke (On average many years post stroke)	Videoconferencing supervision of all exercise sessions by physiotherapist.	Intervention duration/frequency/length 8-week exercise program.3 days per week, 10–20 min sessions. Contents of intervention Participated in a home-based telehealth-supervised aerobic exercise program. individually prescribed, moderate-vigorous intensity including a variety of whole body, lower and upper body aerobic exercises. Home visit prior to commencement of intervention for risk assessment of the identified exercise space and to teach how to access video-conferencing software.
Sarfo et al. [25] (2018) Journal of the Neurological Sciences	Pilot trial of a tele-rehab intervention to improve outcomes after stroke in Ghana: A feasibility and user satisfaction study. Prospective, single-arm, pre-post pilot trial.	20 stroke survivors, average time post stroke 6 months. Inclusion: Modified Rankin Scale (mRS) score of 1–4. Exclusion: Serious medical comorbidities Pre-existing neurological disorders Severe uncontrolled psychiatric illness Uncontrolled HT History of alcoholism or drug abuse in last 6 months Severe arthritis or orthopaedic problems limiting passive ROM Unable to ambulate at least 50 m prior to stroke Intermittent claudication while walking <200 m	Pre-recorded exercises on video Mobile phone application 9zest Stroke Rehabilitation App© delivered exercises. Video calls with physiotherapist.	Intervention duration/frequency/length 12 weeks individualised, goal targeted exercise program.5 days a week, 30–60 min videos. Contents of intervention 4 categories of program: (1) mobility, upper and lower limb strengthening, (2) dexterity to improve fine motor movements, (3) seated and standing balance exercise and (4) walking endurance. Monitored weekly by a tele-therapist via videoconference after data review.
Simpson et al. [26] (2020) Topics in Stroke Rehabilitation	Connecting patients and therapists remotely using technology is feasible and facilitates exercise adherence after stroke. Single group pre-post feasibility study.	10 stroke survivors. Inclusion: Experienced a stroke in the past two years > 18 years of age Living in the community Able to stand up from a chair independently (with or without arms) Therapy goals related to STS exercise Exclusion: Living in residential care Unable to follow simple instructions Not medically stable enough to exercise	Sensors/biofeedback technology Custom application (app) on a tablet connected via Bluetooth to a chair-based sensor. Application Allowed therapist to prescribe repetitions, update goals, send feedback messages.	Intervention duration/frequency/length 4 weeks, daily exercise intervention. Individual daily prescribed repetitions. Contents of intervention Functional sit-to-stand exercise. Therapist remotely monitored and provided weekly individual feedback regarding progress via the app.
Torriani-Pasin et al. [3] (2021) Frontiers in Psychology	Adherence Rate, Barriers to Attend, Safety, and Overall Experience of a Remote Physical Exercise Program During the COVID-19 Pandemic for Individuals After Stroke. Longitudinal study.	36 stroke survivors. Inclusion: Already attended a face-to-face physical exercise program for at least 6 months Diagnosis of stroke (ischaemic or haemorrhagic) in chronic phase >18 years of age No orthopaedic, other neurological, and cardiac risk factors to exercise MOCA >14 Walking speed >0.4 m/s (home walker) Exclusion: Cardiovascular or respiratory condition impairing performance training and/or health safety during exercise	Pre-recorded exercise sessions on video Videoconferencing and/or voice calls with a member of research team.	Intervention duration/frequency/length 22 weeks remote physical exercise program.2 days per week for 22 weeks, with a total of 44 sessions approximately 40 min duration. Contents of intervention Exercise protocol: to reduce physical inactivity, to increase physical function, such as aerobic capacity, muscle resistance, mobility, balance, and gait, and to improve balance confidence and cognition. Weekly voice or video calls to monitor and adapt exercises.
Tyagi et al. [15] (2018) Archives of Physical Medicine and Rehabilitation	Acceptance of Tele-Rehabilitation by Stroke Patients: Perceived Barriers and Facilitators. Qualitative study.	13 stroke survivors. Inclusion: >21 years (mostly aged between 43 and 79) Able to understand and follow instructions Caregiver support Completed the TR program. (Also included their caregivers and tele-therapists)	Sensors/biofeedback technology Exercises delivered via iPad-based system. TR system consists of (1) hardware-iPad, exercise bands, portable sensors, and BP monitoring machine, (2) software: data management system, (3) exercises and resistance bands. Follow exercises displayed on screen and get instant feedback. Videoconferencing with physiotherapist.	Intervention duration/frequency/length 12 weeks program.5 times per week. Contents of intervention Intervention group. STARS (Singapore Tele-technology Aided Rehabilitation in Stroke) trial: home based physical therapy telerehabilitation program-set of exercises for different levels of functional ability. Weekly facetime session with tele-therapist to provide feedback and modify exercise prescription.

Table 4. Outcome measures and main findings of reviewed studies.

Author	Outcome measure	Main findings	Limitations
Bellomo et al. [27]	Relevant Technology Acceptance Model (TAM) questionnaire. Other Berg Balance Scale (BBS) Barthel Index (BI) Fugl-Meyer scale (FM) Modified Rankin scale (mRS)	Results 22/25 completed the study. Technology acceptance Technology Acceptance Model (TAM) questionnaire:Mean scores for subscales TAM A (perceived ease of use): 42/49 TAM B: (perceived utility): 35/42 TAM C: (attitude toward new technologies): 23/35 TAM D: (attitude towards the use of new technologies): 23/28 TAM A (ease of use) highest average value. TAM A and TAM C were also significantly related to the BI scores.	Lack of control group, therefore no comparison. No satisfaction outcome measure.
Bernocchi et al. [23]	Relevant Ad hoc 10 item satisfaction questionnaire focusing on: quality of overall program, acceptance of technology used, efficiency of nurse-tutor and physiotherapist. Other Tinetti scale BBS Motricity Index NHPT 6MWT Modified Barthel Index Beck Depression Inventory (BDI) Family Strain Questionnaire (FSQ-SF)	Results 23/26 completed the study. Satisfaction outcomes Questionnaire on satisfaction: Overall patient evaluation of the service 100% satisfaction (60% very satisfied, 40% satisfied). The relationship with nurse tutor was excellent for 67% and good for 33% of patients. Access to the service was considered to have helped the patient and their family very much (27%), a lot (40%), and enough (27%).	Lack of control group, therefore no comparison. Not a formal standardised satisfaction outcome measure or reported results.
Chumbler et al. [16]	Relevant Stroke-Specific Patient Satisfaction with Care (SSPSC) scale to measure the participant satisfaction. Telephone exit interviews with participants (in-depth questionnaires) regarding satisfaction with components of study/program. Other Falls Efficacy Scale (FES)	Results of 52 patients enrolled, 48 completed baseline assessments, 44 completed 3-month survey, and 40 completed 6-month survey. Satisfaction outcomes SSPSC:Total score increased from 9.3 to 11 in the intervention group and declined in the UC group, a difference approaching significance. Exit interviews: 22 of 23 respondents in intervention group were satisfied with the in-home intervention-convenient, comfortable being videotaped and talking with their therapists via videoconference. All 23 felt the exercise training was useful. 17 of 23 indicated they applied what they learned from the exercise training daily. The IHMD was reported by some to be too repetitive, confusing, not useful.	Compared period of telerehabilitation following a period of usual care as opposed to telerehabilitation versus usual care comparison. Study sample predominantly males. Only intervention participants examined in qualitative study.
Galloway et al. [24]	Relevant Participant satisfaction questionnaire regarding telehealth delivery, content of exercise sessions and participant’s preferred dose at completion of trial. Technical familiarity questionnaire. Telehealth usability and satisfaction questionnaire.	Results 21 participants completed this study. Technology related outcomes Technical familiarity questionnaire: Mean familiarity score was 66 (out of 100). Internet issues occurred during 5% of all sessions. Usability Telehealth usability questionnaire: Most participants agreed or strongly agreed that the TH system was easy to use (95%), and easy to use after the first few sessions (95%). 75% participants agreed that they were able to use the system by themselves. Of the 6 participants who reported not being able to use the system by themselves, 4 scored <50 in the technical familiarity scale, and the remaining 2 had a higher level of physical impairment. Satisfaction outcomes All participants would use telehealth supervised exercise again. All participants agreed or strongly agreed that they felt safe during sessions. Most (95%) would recommend telehealth exercise session to other people who have had a stroke. Over half the participants preferred exercising at home even if transport has been available, and most disagreed that they would have preferred to do some of the sessions without telehealth supervision. Comments on what participants liked about telehealth: 38% of comments were related to perceived benefits including motivation to exercise, self-confidence, improved fitness, and computer skills. Convenience was also rated highly (20% of comments). Comments on what participants disliked: 81% reported there was nothing they didn’t like. The remainder disliked some aspect of technology, particularly HR monitors or reported issues with internet speed and reliability.	Lack of control group, therefore no comparison. Sample included ambulant people with mild-moderate impairments who were on average many years post stroke therefore may not be representative of all stroke survivors. 42 of 66 people who expressed an interest were declined or ineligible as per criteria. Telehealth delivery impacted on recruitment for the trial.
Sarfo et al. [25]	Relevant Satisfaction assessed using a telehealth satisfaction instrument designed for the study: 12 items corresponding to aspects of the TR experience with 11 items using 5-point Likert rating scales, and one item using ‘yes’ or ‘no’ response. Other Stroke Levity Scale (SLS) mRS BI National Institute of Health Stroke Scale (NIHSS) MOCA Fatigue severity scale VAS (pain) Feasibility outcomes	Results All 20 subjects completed the survey on satisfaction with the telerehabilitation intervention. Satisfaction outcomes High levels of patient satisfaction reported with telerehabilitation program. (60% reported ‘excellent’) satisfaction with the TH system, 30% reported ‘very good’, 5% reported ‘good’ and 5% ‘fair’ experience. All subjects reported that would use the TR intervention in the future. Internet connectivity and stability of streaming of audio-visuals was a major challenge reported by 12/20 (60%) subjects.	Lack of control group, therefore no comparison. General, structured survey that did not allow for discussion.
Simpson et al. [26]	Relevant ‘System Usability Scale’ completed at the final visit rating the usability of the technology across 10 items. ‘Physical Activity Enjoyment Scale’ rated participant enjoyment across 18 items using a 7-point Likert-scale. ‘Perceived benefit of activity’ was rated across 5 questions using a simple 5-point Likert scale. Other Short Physical Performance Battery (SPPB) Timed 2 min repeated STS test	Results Usability System Usability Scale:Participants rated the system usability (79%). Satisfaction outcomes Physical Activity Enjoyment Scale and perceived benefit of activity: Participants rated enjoyment at 71% Perceived benefit of activity score rated at 80%	Pre-post study design-lack of control group, therefore no comparison. Short intervention duration (4 weeks).
Torriani-Pasin et al. [3]	Relevant Two questionnaires (via weekly telephone calls) to identify attendance, barriers, safety, and overall experience related to the program.	Results 40 participants completed this study Attendance and adherence Adherence rate was 86.9%. Average individual attendance rate was 19/48 sessions. Mean participation rate was less than half of sessions. 10 (25%) participants attended 80% or more sessions, 13 (32.5%) attended <20% of the sessions. The main barriers for attendance were largely health condition-related barriers: Lack of motor skills and physical fitness (20.6%). Health condition appointments (9.5%). Difficulty performing exercise (8%). Lack of time (7.7%). Presence of pain (7.2%). Environmental related barriers: No exercise companion (11.3%). Problems with communication and lack of knowledge to use internet devices and tools (5.4%).	Convenience sample. Lack of control group, therefore no comparison.
Tyagi et al. [15]	Relevant Semi-structured in-depth interviews and focus group discussions regarding barriers and facilitations of TR.	Results 13 stroke survivors participated in this study. Technology acceptance and satisfaction outcomes Facilitators identified: Affordability (relative advantage for not so well off). Accessibility (eliminating need to travel and flexible nature of program). Barriers identified: Equipment setup-related difficulties (lack of clear instructions, inconvenience associated with frequent adjustments/equipment setup routine). Limited scope of exercises (exercises were repetitive). Connectivity issues (almost half participants encountered). Preferred choice: Majority chose no clear option. Varied responses favouring TR and DR. Most patients preferring TR were relatively younger with mixed disability, participants choosing DR were older and generally had a severe disability.	Included only participants who had consented to and participated in the RCT. Purposive sampling for a diverse representation makes these results more transferrable to other settings.

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