Comparative Effectiveness of Tele-Rehabilitation vs In-Person Care in Stroke Recovery

Thesis Abstract

This study investigates the comparative effectiveness of tele-rehabilitation versus in-person care on functional recovery, reintegration, and quality of life among adults in the subacute to chronic stages of stroke. The problem addressed is the persistent gap in access to high-quality rehabilitation services and the uncertain equivalence of remote modalities to conventional therapy across diverse settings. The aim is to determine whether tele-rehabilitation yields non-inferior, superior, or context-dependent outcomes relative to standard in-person rehabilitation, with a focus on motor function, activities of daily living, cognitive function, and psychosocial well-being. Specific objectives are (1) to compare motor recovery trajectories using standardized measures over a 12-week intervention period; (2) to evaluate activities of daily living, participation, and health-related quality of life; (3) to assess adherence, patient satisfaction, and technology usability; (4) to identify moderators and mediators of treatment effects, including lesion characteristics, time since stroke, and comorbidity burden; and (5) to explore cost implications from a societal perspective. A mixed-methods design is employed, combining a multicenter, parallel-group randomized controlled trial (n = 240 participants) with an embedded qualitative study (n = 40) to capture patient, caregiver, and clinician perspectives. The trial adopts a non-inferiority framework with a 6-point non-inferiority margin on the Fugl-Meyer Assessment for upper and lower extremity function, and a 10-point margin on the Stroke Impact Scale. Theoretical underpinnings integrate the Biopsychosocial Model to account for interaction effects among physical impairment, psychological state, and social support, and Social Cognitive Theory to elucidate self-efficacy and adherence in tele-rehabilitation. Participants are adults aged 18–85 years, within six months post-stroke, with mild-to-moderate impairment, randomized to either tele-rehabilitation or in-person therapy for 12 weeks, delivered thrice weekly by trained therapists. Data collection uses standardized instruments motor function via Fugl-Meyer Assessment (upper and lower extremities), functional independence via the Barthel Index, participation through the Stroke Impact Scale, cognitive status via Montreal Cognitive Assessment, mood via the Hospital Anxiety and Depression Scale, and health-related quality of life via the EQ-5D-5L. Intervention-specific instruments include a validated tele-rehabilitation usability questionnaire and adherence-tracking logs. Economic evaluation adopts a cost-utility analysis from the healthcare system and societal perspectives, collecting direct and indirect costs through patient diaries and administrative data. Quantitative analysis employs intention-to-treat principles. Primary analysis uses non-inferiority testing with mixed-effects repeated measures models to compare functional outcomes over time, adjusting for baseline scores and stratification factors. Secondary analyses include ANCOVA for post-intervention outcomes, time-to-event analyses for adherence, and subgroup analyses to identify effect modifiers (age, sex, stroke subtype, time since onset, and digital literacy). Mediation analyses examine whether adherence and self-efficacy mediate outcome differences. The embedded qualitative component uses semi-structured interviews, analyzed by thematic analysis, to identify factors influencing engagement, perceived barriers, and facilitators of tele-rehabilitation. Triangulation integrates quantitative and qualitative findings to contextualize differential effects and mechanisms. Expected findings anticipate that tele-rehabilitation will achieve non-inferior motor and functional outcomes compared with in-person care, with comparable improvements in activities of daily living and quality of life. It is anticipated that higher accessibility and patient satisfaction may accompany tele-rehabilitation, while adherence may depend on digital literacy and caregiver support. Subgroup analyses may reveal greater benefits for participants in rural or underserved areas and for those with transportation barriers. The study contributes to knowledge by providing robust, multicenter evidence on the comparative effectiveness and cost implications of tele-rehabilitation versus conventional therapy, clarifying moderators of success and offering actionable guidance for policy and clinical practice. It also informs the design of scalable rehabilitation pathways that optimize resource allocation, access, and patient-centered outcomes in stroke recovery. Recommendations include prioritizing integrated tele-rehabilitation platforms with user-centered interfaces, targeted training for clinicians and patients, hybrid models combining remote sessions with periodic in-person visits, and ongoing monitoring frameworks to sustain adherence and outcomes beyond the trial period.