Development and Evaluation of a Tele-Physiotherapy Exercise Program for Post-Stroke Rehabilitation

Thesis Abstract

This study addresses the access and effectiveness gaps in post-stroke rehabilitation by developing and evaluating a tele-physiotherapy exercise program designed to deliver evidence-based, patient-centered rehabilitation remotely. The problem centers on limited access to in-person therapy, variability in adherence, and inequities in outcomes among stroke survivors, particularly in rural and underserved urban settings. The aim is to design a scalable tele-physiotherapy intervention that concretely improves motor function, functional independence, and patient engagement, and to evaluate its efficacy, feasibility, and acceptability in routine care. Specific objectives include (1) to develop a Theory-informed tele-physiotherapy protocol grounded in self-determination theory and the biopsychosocial model, (2) to assess the efficacy of the program on upper and lower limb function using validated measures, (3) to evaluate changes in activities of daily living, mobility, and quality of life, (4) to examine adherence, satisfaction, and perceived barriers/facilitators to remote rehabilitation, and (5) to perform a cost-consequence analysis to compare economic implications with standard in-person care. A mixed-methods design was employed, incorporating a randomized controlled trial (n = 180 stroke survivors within six months post-event) to quantify functional outcomes, complemented by qualitative interviews (n = 30) and a pragmatic process evaluation. Participants were recruited from five metropolitan and regional rehabilitation centers and were randomly assigned to either the Tele-Physiotherapy Intervention (TPI) or Usual Care (UC) for twelve weeks. The TPI consisted of a structured, remotely supervised exercise program delivered via a secure videoconferencing platform, with weekly live sessions plus a portable home exercise kit and an asynchronous library of video-guided routines tailored to motor impairments. The intervention integrated behavioral support elements, including goal setting, feedback, and progress monitoring, consistent with self-determination theory to enhance autonomous motivation. Training content emphasized task-specific, high-intensity practice with progressive resistance and balance components, augmented by education on stroke self-management and adherence strategies. Data collection employed standardized instruments at baseline, post-intervention (12 weeks), and follow-up (24 weeks). Primary outcomes included the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) and the Fugl-Meyer Assessment for Lower Extremity (FMA-LE), as well as the Functional Independence Measure (FIM). Secondary outcomes encompassed the Stroke Impact Scale (SIS), the Timed Up and Go (TUG) test, and the 6-Minute Walk Test (6MWT). Adherence was quantified via platform usage metrics and home exercise completion rates, while satisfaction and usability were measured with the System Usability Scale (SUS) and a bespoke tele-physiotherapy satisfaction questionnaire. Cost data were collected from healthcare utilization records and patient-received resources to enable a cost-consequence analysis. Qualitative data were generated from semi-structured interviews with a purposive subsample of participants and care partners, analyzed using thematic analysis to elucidate mechanisms of change, perceived barriers, and contextual factors. Quantitative data were analyzed using mixed-model repeated measures ANOVA to evaluate group-by-time interactions, adjusted for baseline severity and age, with mediation analyses exploring whether adherence mediated functional outcomes. The qualitative data were then integrated with quantitative findings through a convergent design. Anticipated findings include statistically significant greater gains in FMA-UE and FMA-LE scores for the TPI group versus UC at 12 weeks, with sustained or further improved outcomes at 24 weeks; improved FIM and SIS domains reflecting enhanced independence and quality of life; higher adherence and satisfaction in the tele-physiotherapy group, moderated by technological usability and perceived social support. The process evaluation is expected to reveal key facilitators such as flexible scheduling, real-time feedback, and tailored progression, along with barriers including internet connectivity and digital literacy in older adults. The study contributes to knowledge by providing rigorous evidence on the clinical effectiveness and cost implications of a scalable tele-physiotherapy model for post-stroke rehabilitation, grounded in behavioral theory and patient-centered design. The theoretical framework integrating self-determination theory and the biopsychosocial model is empirically tested, offering insights into mechanisms of motivation, adherence, and functional recovery in remote rehabilitation. The main conclusion is that a well-structured tele-physiotherapy program can achieve clinically meaningful motor gains, enhance independence, and be cost-effective relative to standard care. Policy and practice recommendations include integration into standard stroke pathways, training for clinicians in remote-delivery competencies, and strategies for addressing digital disparities to maximize equitable access.