Comparative Analysis of Tele-Rehabilitation vs In-Person Therapy Outcomes in Stroke Rehabilitation

Thesis Abstract

Stroke rehabilitation increasingly relies on remote delivery methods, yet evidence comparing tele-rehabilitation with conventional in-person therapy remains heterogeneous and context-dependent, potentially limiting scalable implementation for post-stroke motor recovery and functional independence. This study addresses the gap by evaluating equivalence and differential effects of tele-rehabilitation versus in-person therapy on motor outcomes, activities of daily living, and patient engagement within a real-world clinical setting. The aim is to determine whether tele-rehabilitation yields outcomes non-inferior to in-person therapy across functional domains, and to identify patient- and clinician-related factors that moderate or mediate treatment effects. Specific objectives include (1) comparing motor recovery trajectories over 12 weeks using standardized measures; (2) assessing changes in activities of daily living, quality of life, and caregiver burden; (3) evaluating adherence, satisfaction, and therapeutic alliance in both delivery modalities; (4) analyzing cost implications from a healthcare system perspective; and (5) exploring contextual moderators such as stroke severity, lesion location, and access to technology. The study tests the non-inferiority hypothesis for motor outcomes and explores potential superiority or equivalence across secondary outcomes. A mixed-methods, multi-site, non-inferiority trial is employed. The quantitative component adopts a prospective, randomized design enrolling 240 adults within six months post-stroke, allocated 11 to tele-rehabilitation or standard in-person therapy for 12 weeks, with follow-up at three months post-intervention. Primary outcome is motor recovery measured by the Fugl-Meyer Assessment–Upper Extremity (FMA-UE) and the Box and Block Test. Secondary outcomes include the Barthel Index, Stroke Impact Scale, and EuroQol-5D-5L, alongside adherence metrics captured via session attendance and home exercise completion rates. Data will be analyzed using linear mixed-effects models to estimate group-by-time interactions, with non-inferiority margins predefined based on established minimal clinically important differences. Cost-effectiveness will be assessed through incremental cost-utility analysis from the payer and societal perspectives. The qualitative component comprises semi-structured interviews with 40 patients and 20 therapists (10 per arm) to elucidate experiences, perceived barriers and facilitators, and the therapeutic alliance, with thematic analysis guided by the grounded theory approach. Integration of quantitative and qualitative data will occur through a convergent parallel design, enabling triangulation of outcomes and contextual interpretation of effect sizes. Ethical considerations include informed consent, data privacy compliance (HIPAA-equivalent standards appropriate to the setting), and risk mitigation for technology-related barriers. Validity and reliability of instruments will be ensured through validated scales, administrator training, and standard operating procedures for remote assessments. Analytic strategies include intention-to-treat principles for primary analyses, multiple imputation for missing data, and sensitivity analyses to examine robustness across subgroups defined by stroke subtype, baseline motor function, and access to technology. Expected findings anticipate that tele-rehabilitation will demonstrate non-inferiority to in-person therapy for primary motor outcomes, with comparable or improved adherence and patient satisfaction, particularly among individuals with transportation difficulties or rural residence. It is plausible that tele-rehabilitation may offer equal improvements in activities of daily living and quality of life, while demonstrating favorable cost-effectiveness in remote monitoring and reduced hospitalization rates. The study aims to advance knowledge by delineating the conditions under which tele-rehabilitation can match or exceed conventional therapy, clarifying the role of therapeutic alliance and technology usability as mediators, and providing policy-relevant data on sustainable models of stroke rehabilitation delivery. The contribution to knowledge lies in delivering robust, generalizable evidence on the clinical efficacy and economic viability of tele-rehabilitation for stroke, informing guidelines on patient selection, intervention design, and integration into multidisciplinary care pathways. The study would advocate a patient-centered, technology-enabled framework that accommodates diverse settings, reduces geographic disparities, and supports scaling of rehabilitation services without compromising outcomes. Based on findings, recommendations will target clinicians, health systems, and policymakers to optimize platform features, training programs, and reimbursement structures to foster high-quality tele-rehabilitation for stroke survivors.