A digital health home intervention for people within the Alzheimer's disease continuum: results from the Ability-TelerehABILITation pilot randomized controlled trial

Patient-Related Barriers to Digital Technology Adoption in Alzheimer Disease: Systematic Review

Background

Digital technology in dementia is an area of great development with varying experiences across countries. However, novel digital solutions often lack a patient-oriented perspective, and several relevant barriers prevent their use in clinics.

Objective

In this study, we reviewed the existing literature on knowledge, familiarity, and competence in using digital technology and on attitude and experiences with digital tools in Alzheimer disease. The main research question is whether digital competence and attitudes of patients and caregivers may affect the adoption of digital technology.

Methods

Following the PRISMA guidelines, a literature search was conducted by two researchers in the group. Inter-rater reliability was calculated with Cohen κ statistics. The risk of bias assessment was also recorded.

Results

Of 597 initial records, only 18 papers were considered eligible. Analyses of inter-rater reliability showed good agreement levels. Significant heterogeneity in study design, sample features, and measurement tools emerged across studies. Quality assessment showed a middle-high overall quality of evidence. The main factors affecting the adoption of digital technology in patients and caregivers are severity of cognitive deficits, timing of adoption, and the availability of training and support. Additional factors are age, type of digital device, and ease of use of the digital solution.

Conclusions

Adoption of digital technology in dementia is hampered by many patient-related barriers. Improving digital competence in patient-caregiver dyads and implementing systematic, patient-oriented strategies for the development and use of digital tools are needed for a successful incorporation of digital technology in memory clinics.

Effectiveness of Telehealth Interventions on Cognitive Function and Quality of Life in Adults With Neurological Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

Telehealth is an encouraging solution for the remote delivery of cognitive interventions. This review aimed to identify the characteristics and effectiveness of telehealth interventions on cognitive functions and related quality of life in adults with neurological disorders.

DESIGN

Systematic review and meta-analysis.

SETTINGS AND PARTICIPANTS

Community and residential, adults with neurological disorders.

METHODS

Six English and 2 Chinese databases were searched from inception to August 2024. Randomized controlled trials that evaluated telehealth interventions for cognitive function in adults with neurological disorders were eligible. The meta-analysis was conducted using R (Version 4.1.3). The Revised Cochrane risk of bias tool for randomized trials (RoB 2) tool was used for risk of bias assessment.

RESULTS

Sixteen studies with 952 participants were included, 14 of which were eligible for the meta-analysis. Asynchronous telehealth via apps/websites with regular online supervision was the most commonly used format. The pooled results suggested that telehealth interventions could significantly improve global cognitive function [standardized mean difference (SMD) = 0.95; 95% confidence interval (CI): 0.06∼1.83; P = .035], memory (SMD, 0.79; 95% CI: 0.36∼1.23; P = .0004), and quality of life (SMD, 0.57; 95% CI, 0.14∼1.00; P = .01) compared with controls. However, there was no statistically significant effect on attention (SMD, 0.12; 95% CI, -0.11∼0.35, P = .31), executive function (SMD, 0.06; 95% CI, -0.30∼0.42, P = .73), or language (SMD, 0.44; 95% CI, -0.01∼0.89, P = .054).

CONCLUSIONS AND IMPLICATIONS

Telehealth interventions are safe, feasible and acceptable for adults with neurological disorders, and could potentially reduce health care cost. They have beneficial effects on global cognitive function, memory, and quality of life. More exercise-based telehealth interventions with adequate statistical power and rigorous designs are needed to evaluate the long-term benefits and financial impact.

Effect of digital health corrective posture exercise program on head and shoulder posture in adolescents: A cluster randomized controlled trial

BACKGROUND

Poor posture, particularly forward head posture and rounded shoulders, has become increasingly prevalent among adolescents due to prolonged screen use and sedentary behaviors. This study aimed to investigate the effects of a 6-week digital health corrective posture exercise (DHCPE) program on head and shoulder posture in adolescents.

METHODS

A total of 36 subjects were recruited and randomly allocated to 3 groups: the DHCPE group, the face-to-face exercise (FTFE) group, and a control group. The DHCPE and FTFE groups participated in the same corrective posture exercise programs. The DHCPE group conducted the digital health intervention remotely through a monitored screen, while the FTFE group engaged in corrective posture exercises on-site with therapists. Each intervention lasted 50 minutes and was conducted 3 times a week over a period of 6 weeks for both groups. The outcome measurements included protracted head and shoulder distances, trunk lean (the angle of shoulder inclination relative to the pelvis), trunk deviation, shoulder and pelvic height levels, and the absolute differences and inequality ratios between both sides. All assessments were conducted both preintervention and postintervention.

RESULTS

Both the DHCPE and FTFE groups demonstrated significant improvements in protracted head, left protracted shoulder, and trunk lean following the intervention. The interaction effect revealed that both the DHCPE and FTFE groups exhibited significant improvements in these measurements compared with the control group. Furthermore, no significant differences were found between the improvements observed in the DHCPE group and those in the FTFE group.

CONCLUSION

DHCPE and FTFE were effective in improving head and shoulder posture in adolescents. The improvements in the DHCPE group were comparable to those achieved in the FTFE group. DHCPE has the potential to serve as a viable alternative to FTFE for enhancing head and shoulder posture in this population.

Timely and Personalized Interventions and Vigilant Care in Neurodegenerative Conditions: The FIT4TeleNEURO Pragmatic Trial

Parkinson's disease (PD) and multiple sclerosis (MS) are two chronic neurological diseases (CNDs) that have a high demand for early and continuous rehabilitation. However, accessing professional care remains a challenge, making it a key priority to identify sustainable solutions for ensuring early rehabilitation availability. Objective: The FIT4TeleNEURO pragmatic trial proposes to investigate, in real-life care settings, the superiority in terms of the effectiveness of early rehabilitation intervention with harmonized, mix-model telerehabilitation (TR) protocols (TR single approach, task-oriented-TRsA; TR combined approach, task-oriented and impairment-oriented-TRcA) compared to conventional management (control treatment, CeT) in people with PD and MS. Design, and Methods: This multicenter, randomized, three-treatment arm pragmatic trial will involve 300 patients with CNDs (PD, N = 150; MS, N = 150). Each participant will be randomized (1:1:1) to the experimental groups (20 sessions of TRsA or TRcA according to a mix-model-3 asynchronous + 1 synchronous session/week) or the control group (20 sessions of CeT). Primary and secondary outcome measures will be obtained at the baseline (T0), post-intervention (T1, 5 weeks after baseline), and follow-up (T2, 3 months after the end of the treatment). A multidimensional evaluation (cognitive, motor, and quality of life domains) will be conducted at each time point of assessment (T0; T1; T2). The primary outcome measures will be the assessment of change (T0 vs. T1 vs. T2) in static and dynamic balance, measured using the Mini-Balance Evaluation Systems Test. Usability and acceptability assessment will be also investigated. Expected Results: Implementing TR protocols will enable a more targeted and efficient response to the growing demand for rehabilitation in the early stages of CNDs. Both the TRsA and TRcA approaches are expected to be more effective than CeT, with the combined approach likely providing greater benefits in secondary outcome measures. Finally, the acceptability of the asynchronous modality could open the door to scalable solutions, such as digital therapeutics.

Smart Digital Solutions for EARLY Treatment of COGNitive Disability (EARLY-COGN^3): A Study Protocol

Background: Healthy cognitive functioning is a primary component of well-being, independence, and successful aging. Cognitive deficits can arise from various conditions, such as brain injury, mental illness, and neurological disorders. Rehabilitation is a highly specialized service limited to patients who have access to institutional settings. In response to this unmet need, telehealth solutions are ideal for triggering the migration of care from clinics to patients' homes. Objectives: The aim of EARLY-COGN^3 will be threefold: (1) to test the efficacy of a digital health at-home intervention (tele@cognitive protocol) as compared to an unstructured cognitive at-home rehabilitation in a cohort of patients with Chronic Neurological Diseases (CNDs); (2) to investigate its effects on the biomolecular and neurophysiological marker hypothesizing that people with CNDs enrolled in this telerehabilitation program will develop changes in biological markers and cortical and subcortical patterns of connectivity; (3) to analyze potential cognitive, neurobiological, and neurophysiological predictors of response to the tele@cognitive treatment. Method: In this single-blind, randomized, and controlled pilot study, we will assess the short- and long-term efficacy of cognitive telerehabilitation protocol (tele@cognitive) as compared to an unstructured cognitive at-home rehabilitation (Active Control Group-ACG) in a cohort of 60 people with Mild Cognitive Impairment (MCI), Subjective Cognitive Complaints (SCCs), or Parkinson's Disease (PD). All participants will undergo a clinical, functional, neurocognitive, and quality of life assessment at the baseline (T0), post-treatment (5 weeks, T1), and at the 3-month (T2) follow-up. Neurophysiological markers and biomolecular data will be collected at T0 and T1. Conclusions: EARLY-COGN^3 project could lead to a complete paradigm shift from the traditional therapeutic approach, forcing a reassessment on how CNDs could take advantage of a digital solution. (clinicaltrials.gov database, ID: NCT06657274).

Enhancing the effect of rehabilitation on multiple sclerosis: A randomized clinical trial investigating the impact of remotely-supervised transcranial direct current stimulation and virtual reality telerehabilitation training

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease characterized by balance and gait impairment, fatigue, anxiety, depression, and diminished quality of life. Transcranial direct current stimulation (tDCS) has emerged as an effective intervention for managing these symptoms.

OBJECTIVE

This study aims to investigate the efficacy of remotely supervised tDCS (RS-tDCS) applied to the left dorsolateral prefrontal cortex, in conjunction with a telerehabilitation (TR) program, on motor (balance and gait), cognitive (executive functions), and participation outcomes (fatigue, anxiety, depression, and quality of life) in persons with MS (pwMS).

METHODS

In this multicenter interventional randomized controlled trial, pwMS were randomly assigned to: TR with active tDCS (TR RS-AtDCS, n = 20) or TR with sham tDCS (TR RS-StDCS, n = 21). Two additional groups of historical controls were represented by comparable TR (TR, n = 35) or usual care (UC, n = 35). The TR RS-tDCS program comprised a 6 weeks of rehabilitation intervention delivered through a hybrid mix model TR, five sessions a week each lasting 45 min with additional 20 min of tDCS during the first week.

RESULTS

The subjects underwent to TR treatments (TR; TR RS-AtDCS; TR RS-StDCS) exhibited post-treatment improvements compared to UC group in Mini-BESTest global score (p = 0.013, T0 vs T1 ̶ UC group: p = 0.429, TR groups: p < 0.001), anterior postural control (p = 0.028, T0 vs T1 ̶ UC group: p = 0.860, TR groups: p < 0.001), and dynamic walking (p = 0.010, T0 vs T1 ̶ UC group: p = 0.269, TR groups: p = 0.012). The TR RS-AtDCS group showed improvement in the 12-item MSWS (p = 0.006) and STAI-Y (p = 0.032) compared to UC, TR and TR RS-StDCS.

CONCLUSIONS

This study underscores the benefits of TR in addressing motor challenges (balance and gait) among pwMS. The incorporation of RS-tDCS positively impacted on participants' perceived walking difficulties and reduced anxiety. The novelty of this study lies in its comprehensive evaluation of motor, quality of life, and emotional outcomes within home-based interventions. These findings highlight the potential of combined interventions to enhance well-being in pwMS.

A systematic review of cognitive telerehabilitation in patients with cognitive dysfunction

Introduction

One of the possible treatment options for patient with cognitive dysfunction is cognitive telerehabilitation. Previous systematic reviews on cognitive telerehabilitation have focused on specific disease groups and the analysis of intervention methods did not differentiate between traditional face-to-face cognition treatment and usual care. In this systematic review, we aim to analyze randomized controlled trials (RCTs) that compare telerehabilitation with face-to-face treatment or usual care for improving cognitive function in elderly individuals with cognitive dysfunction or patients with acquired brain injury.

Methods

We conducted this systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). In this systematic review, we searched 7 electronic databases (PubMed, Cochrane, EMbase, CINAHL, Web of Science, Scopus, KMbase) to identify relevant studies published through December 10, 2024. We conducted a meta-analysis to assess the quality of the studies and synthesize the evidence. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method.

Results

Finally, 16 studies were included in the analysis. For comparing telerehabilitation with face-to-face cognition treatment, the meta-analysis included 2 RCTs for global cognition (immediate outcome), 2 RCTs for attention (immediate outcome), 2 RCTs for visuospatial function (immediate outcome). For comparing telerehabilitation with usual care, the meta-analysis included 7 RCTs for global cognition (immediate outcome), 3 RCTs for global cognition (persistence outcome), 4 RCTs for attention (immediate outcome), 3 RCTs for executive function (immediate outcome), 3 RCTs for working memory (immediate outcome), 3 RCTs for visuospatial function (immediate outcome).

Discussion

Telerehabilitation has been shown to be more effective than usual care in improving global cognitive function, and its effectiveness is not inferior to that of traditional face-to-face cognitive treatment. By overcoming the limitations of traditional cognition rehabilitation and providing continuous treatment, telerehabilitation can offer effective treatment in specific situations.

Effectiveness of telerehabilitation on the International Classification of Functioning, Disability, and Health framework outcomes during the COVID-19 pandemic: A systematic review and meta-analysis of randomized controlled trials

Objective

This study aimed to synthesize and analyze the evidence on the effectiveness of telerehabilitation categorized according to the International Classification of Functioning, Disability, and Health (ICF) outcomes for physical therapy (PT) during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Studies were identified using the Physiotherapy Evidence Database (PEDro), Scopus, PubMed, EMBASE, and other sources of data. Randomized controlled trials comparing telerehabilitation with the control group (i.e., no treatment/usual care) were included. Standard meta-analysis techniques were applied to assess the effectiveness of telerehabilitation. Outcome measures were categorized according to the domains of the ICF.

Results

Among the 134 studies that met the eligibility criteria, the majority of findings demonstrated significant improvements across all domains of the ICF following telerehabilitation as compared to the control group, regardless of participant groups. Only 9 of 134 studies were included in the meta-analysis. Six studies enrolled individuals with COVID-19 and the remaining three enrolled individuals with knee osteoarthritis (OA) who were unable to access services at the clinic. Compared with the control group, the Borg-Rating-of-Perceived-Exertion scale, as reflected in an impairment domain, was significantly lower in individuals with COVID-19 who received telerehabilitation (3 studies, n = 135; standardized mean difference (SMD) -1.82, 95% CI -2.77 to -0.86). Compared with that in the control group, 30-second sit-to-stand test (3 studies, n = 122; SMD 0.88, 95% CI 0.52-1.25) and 6-minute-walking test (4 studies, n = 221; SMD 0.83, 95% CI 0.42-1.24), as reflected to an activity domain, showed significant improvement in the telerehabilitation group. Conversely, there was no effectiveness of telerehabilitation on an activity domain as measured by the timed up and go test in people with knee OA (3 studies, n = 111; SMD -0.45, 95% CI -1.19 to 0.30).

Conclusion

This study provides evidence supporting the effectiveness of telerehabilitation across all domains of the ICF, with significant improvements observed in the impairment and activity domains for individuals with COVID-19. These improvements are particularly evident in the meta-analysis findings such as perceived exertion, leg strength, and functional capacity.

The effect of visual education aimed at the basic needs of individuals with disabilities on the health literacy and life quality of caregivers

The aim of this research is to evaluate the effect of visual education for the basic needs of people with disabilities on the health literacy and life quality of caregivers. The study sample comprised 268 caregivers evaluated in a pretest-posttest pattern. The data were collected using a Personal Information Form, the Health Literacy Scale, and the World Health Organization [WHO] Life Quality Scale-Short Form. Data were evaluated with the Wilcoxon test and Spearman correlation analysis. Following the education given to caregivers, an increase was determined in the Health Literacy Scale sub-dimension of information comprehension and in the WHO Life Quality Scale-Short Form sub-dimension of social relations. Thus it was seen that the visual education increased the health literacy and life quality of the caregivers.

Long-lasting improvements in episodic memory among subjects with mild cognitive impairment who received transcranial direct current stimulation combined with cognitive treatment and telerehabilitation: a multicentre, randomized, active-controlled study

Background

In recent years, an increasing number of studies have examined the potential efficacy of cognitive training procedures in individuals with normal ageing and mild cognitive impairment (MCI).

Objective

The aims of this study were to (i) evaluate the efficacy of the cognitive Virtual Reality Rehabilitation System (VRRS) combined with anodal transcranial direct current stimulation (tDCS) applied to the left dorsolateral prefrontal cortex compared to placebo tDCS stimulation combined with VRRS and (ii) to determine how to prolong the beneficial effects of the treatment. A total of 109 subjects with MCI were assigned to 1 of 5 study groups in a randomized controlled trial design: (a) face-to-face (FTF) VRRS during anodal tDCS followed by cognitive telerehabilitation (TR) (clinic-atDCS-VRRS+Tele@H-VRRS); (b) FTF VRRS during placebo tDCS followed by TR (clinic-ptDCS-VRRS+Tele@H-VRRS); (c) FTF VRRS followed by cognitive TR (clinic-VRRS+Tele@H-VRRS); (d) FTF VRRS followed by at-home unstructured cognitive stimulation (clinic-VRRS+@H-UCS); and (e) FTF cognitive treatment as usual (clinic-TAU).

Results

An improvement in episodic memory was observed after the end of clinic-atDCS-VRRS (p < 0.001). We found no enhancement in episodic memory after clinic-ptDCS-VRRS or after clinic-TAU.Moreover, the combined treatment led to prolonged beneficial effects (clinic-atDCS-VRRS+Tele@H-VRRS vs. clinic-ptDCS-VRRS+Tele@H-VRRS: p = 0.047; clinic-atDCS-VRRS+Tele@H-VRRS vs. clinic-VRRS+Tele@H-VRRS: p = 0.06).

Discussion

The present study provides preliminary evidence supporting the use of individualized VRRS combined with anodal tDCS and cognitive telerehabilitation for cognitive rehabilitation.

Clinical trial registration

https://clinicaltrials.gov/study/NCT03486704?term=NCT03486704&rank=1, NCT03486704.

Effects of home-based and telerehabilitation exercise on mental and physical health, and disease cost in people with Alzheimer's disease: A meta-analysis

BACKGROUND

Alzheimer's disease (AD) is a very disabling long-term disease that requires continuous regular care. A cost-effective and sustainable means of such care may be physical activity or exercise delivered at home or through telerehabilitation. The aim of this study is to determine the effects of home-based or telerehabilitation exercise in people with AD.

METHOD

PubMED, Embase, Web of Science (WoS), PEDro, and CENTRAL were searched for randomized controlled trials until January 2024. The data extracted include the characteristics of the participants, the interventions used for both experimental and the control groups, the baseline, post-intervention and follow-up mean and standard deviation values on the outcomes assessed and the findings of the included studies. Cochrane risks of bias assessment tool and PEDro scale were used to assess the risks of bias and methodological quality of the studies. The results were analyzed using narrative and quantitative syntheses.

RESULT

Eleven articles from nine studies (n=550) were included in the study. The results showed that, only global cognitive function (SMD = 0.72, 95% CI = 0.19-1.25, p=0.007), neuropsychiatric symptom (MD = -5.28, 95% CI =-6.22 to -4.34, p<0.0001) and ADL (SMD =3.12, 95% CI =0.11-6.13, p=0.04) improved significantly higher in the experimental group post-intervention. At follow-up, the significant difference was maintained only in neuropsychiatric symptoms (MD =-6.20, 95% CI =-7.17 to -5.23, p<0.0001).

CONCLUSION

There is a low evidence on the effects of home-based physical activity or exercise on global cognitive function, neuropsychiatric symptoms and ADL.

Exploring cognitive reserve's influence: unveiling the dynamics of digital telerehabilitation in Parkinson's Disease Resilience

Telerehabilitation is emerging as a promising digital method for delivering rehabilitation to Parkinson's Disease (PD) patients, especially in the early stages to promote brain resilience. This study explores how cognitive reserve (CR), the brain's ability to withstand aging and disease, impacts the effectiveness of telerehabilitation. It specifically examines the influence of lifelong cognitive activities on the relationship between neural reserve and improved functional abilities following rehabilitation. In the study, 42 PD patients underwent a 4-month neuromotor telerehabilitation program. CR proxies were assessed using the Cognitive Reserve Index questionnaire (CRIq), brain changes via 3T-MRI, and functional response through changes in the 6-Minute Walk Distance (6MWD). Participants were divided into responders (n = 23) and non-responders (n = 19) based on their 6MWD improvement. A multiple regression model was run to test significant predictors of 6MWD after treatment in each group. The results revealed a significant correlation between 6MWD and CRIq scores, but only among responders. Notably, the CRIq Leisure-Time sub-index, along with baseline 6MWD, were predictors of post-treatment 6MWD. These findings highlight CR's role in enhancing the benefits of telerehabilitation on PD patients' neuromotor functions. Clinically, these results suggest that neurologists and clinicians should consider patients' lifestyles and cognitive engagement as important factors in predicting and enhancing the outcomes of telerehabilitation. The study underscores the potential of CR as both a predictor and booster of telerehabilitation's effects, advocating for a personalized approach to PD treatment that takes into account individual CR levels.

Cognitive telerehabilitation: an expert consensus paper on current evidence and future perspective

The progressive improvement of the living conditions and medical care of the population in industrialized countries has led to improvement in healthcare interventions, including rehabilitation. From this perspective, Telerehabilitation (TR) plays an important role. TR consists of the application of telemedicine to rehabilitation to offer remote rehabilitation services to the population unable to reach healthcare. TR integrates therapy-recovery-assistance, with continuity of treatments, aimed at neurological and psychological recovery, involving the patient in a family environment, with an active role also of the caregivers. This leads to reduced healthcare costs and improves the continuity of specialist care, as well as showing efficacy for the treatment of cognitive disorders, and leading to advantages for patients and their families, such as avoiding travel, reducing associated costs, improving the frequency, continuity, and comfort of performing the rehabilitation in its own spaces, times and arrangements. The aim of this consensus paper is to investigate the current evidence on the use and effectiveness of TR in the cognitive field, trying to also suggest some recommendations and future perspectives. To the best of our knowledge, this is the first consensus paper among multiple expert researchers that comprehensively examines TR in different neurological diseases. Our results supported the efficacy and feasibility of TR with good adherence and no adverse events among patients. Our consensus summarizes the current evidence for the application of cognitive TR in neurological populations, highlighting the potential of this tool, but also the limitations that need to be explored further.

Efficacy of telerehabilitation with digital and robotic tools for the continuity of care of people with chronic neurological disorders: The TELENEURO@REHAB protocol for a randomized controlled trial

Context

Chronic Neurological Disorders (CNDs) are among the leading causes of disability worldwide, and their contribution to the overall need for rehabilitation is increasing. Therefore, the identification of new digital solutions to ensure early and continuous care is mandatory.

Objective

This protocol proposes to test the usability, acceptability, safety, and efficacy of Telerehabilitation (TR) protocols with digital and robotic tools in reducing the perceived level of disability in CNDs including Parkinson's Disease (PD), Multiple Sclerosis (MS), and post-stroke patients.

Design Setting and Subjects

This single-blinded, multi-site, randomized, two-treatment arms controlled clinical trial will involve PD (N = 30), MS (N = 30), and post-stroke (N = 30). Each participant will be randomized (1:1) to the experimental group (20 sessions of motor telerehabilitation with digital and robotic tools) or the active control group (20 home-based motor rehabilitation sessions according to the usual care treatment). Primary and secondary outcome measures will be obtained at the baseline (T0), post-intervention (T1, 5 weeks after baseline), and at follow-up (T2, 2 months after treatment).

Main Outcome Measures

a multifaceted evaluation including quality of life, motor, and clinical/functional measures will be conducted at each time-point of assessment. The primary outcome measures will be the change in the perceived level of disability as measured by the World Health Organization Disability Assessment Schedule 2.0.

Conclusion

The implementation of TR protocols will enable a more targeted and effective response to the growing need for rehabilitation linked to CNDs, ensuring accessibility to rehabilitation services from the initial stages of the disease.