Comparative Effectiveness of Tele-Rehabilitation in Post-Stroke Recovery Outcomes

Thesis Abstract

This study addresses the growing challenge of optimizing post-stroke rehabilitation in the context of rising telehealth adoption by examining whether tele-rehabilitation (tele-RT) yields comparable or superior recovery outcomes relative to conventional in-person therapy. The aim is to determine the comparative effectiveness of tele-RT for functional, cognitive, and psychosocial recovery in adults within six months post-stroke, and to identify patient and programmatic factors associated with differential outcomes. Specific objectives are (1) to compare motor function, activities of daily living, and mobility gains between tele-RT and conventional rehabilitation; (2) to examine cognitive and mood outcomes (executive function, attention, depression, and quality of life) across modalities; (3) to explore adherence, engagement, and satisfaction with tele-RT; (4) to assess cost-effectiveness from a healthcare system perspective; and (5) to identify moderators (age, stroke severity, lesion location, access to technology, socio-economic status) and mediators (therapist contact time, supervision quality) of treatment effectiveness. The study adopts a multi-center, prospective, randomized controlled trial complemented by an embedded mixed-methods design. The sample comprises 320 adults (aged 40–85) with first-ever ischemic or hemorrhagic stroke, recruited from five urban stroke centers within three months of onset and followed for six months post-randomization. Participants are randomized 11 to tele-RT or conventional rehabilitation, with stratification by baseline severity and time since stroke. Data collection uses standardized instruments motor function via the Fugl-Meyer's Upper/Lower Extremity Scales, functional independence via Barthel Index, mobility via the Timed Up and Go test, cognitive function via the Montreal Cognitive Assessment and Trail Making Tests, mood via the Patient Health Questionnaire-9, and health-related quality of life via the Stroke-Specific Quality of Life Scale. Adherence is tracked through digital logs, session attendance, and caregiver reports; satisfaction is measured with the Client Satisfaction Questionnaire. A health economics component collects direct and indirect costs to evaluate cost-effectiveness. The quantitative analysis employs mixed-effects linear models to compare trajectory differences between groups, adjusting for covariates. A predefined per-protocol analysis assesses dose-response relationships. Mediation and moderation analyses test hypothesized pathways (e.g., therapist contact time mediating outcomes; technology access moderating effect). Multiple imputation addresses missing data, and sensitivity analyses examine robustness of findings. Qualitative data are collected from a purposeful subsample of 40 participants and 20 therapists through semi-structured interviews, analyzed using thematic analysis within a phenomenological framework, with credibility enhanced by triangulation and member checking. Theoretical underpinnings integrate the International Classification of Functioning, Disability and Health (ICF) framework to interpret outcomes across body structure, activity, participation, and environmental factors, and the Self-Determination Theory to understand motivation and adherence within tele-RT. Expected findings include non-inferiority of tele-RT for motor and functional outcomes at six months, with potential superiority in accessibility-related domains and motivational engagement for participants facing transportation barriers. Cognitive and mood outcomes are anticipated to show parallel improvement across modalities, contingent on intensity and cognitive load of therapy programs. Higher adherence and satisfaction are hypothesized to accompany tele-RT when paired with user-friendly interfaces, real-time feedback, and caregiver involvement. The study contributes to knowledge by providing rigorously generated evidence on the effectiveness and cost-effectiveness of tele-RT for post-stroke rehabilitation, clarifying the conditions under which tele-RT may be preferred or restricted, and informing guidelines for scalable tele-rehabilitation programs. The findings are expected to offer actionable recommendations for clinicians, policymakers, and rehabilitation program designers regarding technology-enabled care pathways, resource allocation, and training needs. The main conclusion anticipates that tele-RT constitutes a viable alternative to conventional rehabilitation in appropriately selected patients, with comparable functional outcomes and potential gains in accessibility and satisfaction, while highlighting the importance of optimized program design, patient selection, and ongoing monitoring to maximize benefit. Recommendations include the development of standardized tele-RT protocols, integration of remote supervision and caregiver support, investment in user-centered telehealth platforms, and policy initiatives to ensure equitable access to technology and broadband services for stroke survivors.