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Introduction: Low back pain (LBP) remains the leading cause of disability. The Low Back Pain and Disability Drivers Management (PDDM) model aims to identify the domains driving pain and disability to guide clinical decisions. The objectives of this study were to determine the feasibility of conducting a pragmatic controlled trial of the PDDM model and to explore its effectiveness compared to clinical practice guidelines' recommendations for LBP management., Methods: A pilot cluster nonrandomised controlled trial. Participants included physiotherapists and their patients aged 18 years or older presenting with a primary complaint of LBP. Primary outcomes were the feasibility of the trial design. Secondary exploratory analyses were conducted on LBP-related outcomes such as pain severity and interference at 12-week follow-up., Results: Feasibility of study procedures were confirmed, recruitment exceeded our target number of participants, and the eligibility criteria were deemed suitable. Lost to follow-up at 12 weeks was higher than expected (43.0%) and physiotherapists' compliance rates to the study protocol was lower than our predefined threshold (75.0% vs. 57.5%). A total of 44 physiotherapists and 91 patients were recruited. Recommendations for a larger scale trial were formulated. The PDDM model group demonstrated slightly better improvements in all clinical outcome measures compared to the control group at 12 weeks., Conclusion: The findings support the feasibility of conducting such trial contingent upon a few recommendations to foster proper future planning to determine the effectiveness of the PDDM model. Our results provide preliminary evidence of the PDDM model effectiveness to optimise LBP management., Clinical Trial Registration: Clinicaltrial.gov, NCT04893369., (© 2023 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd.)

Purpose: A significant number of people will experience prolonged symptoms after COVID-19 infection that will greatly impact functional capacity and quality of life. The aim of this study was to identify trajectories of health-related quality of life (HRQOL) and their predictors among adults diagnosed with COVID-19., Methods: This is a retrospective analysis of an ongoing prospective cohort study (BQC-19) including adults (≥18y) recruited from April 2020 to March 2022. Our primary outcome is HRQOL using the EQ-5D-5L scale. Sociodemographic, acute disease severity, vaccination status, fatigue, and functional status at onset of the disease were considered as potential predictors. The latent class mixed model was used to identify the trajectories over an 18-month period in the cohort as a whole, as well as in the inpatient and outpatient subgroups. Multivariable and univariable regressions models were undertaken to detect predictors of decline., Results: 2163 participants were included. Thirteen percent of the outpatient subgroup (2 classes) and 28% in the inpatient subgroup (3 classes) experienced a more significant decline in HRQOL over time than the rest of the participants. Among all patients, age, sex, disease severity and fatigue, measured on the first assessment visit or on the first day after hospital admission (multivariable models), were identified as the most important predictors of HRQOL decline. Each unit increase in the SARC-F and CFS scores increase the likelihood of belonging to the declining trajectory (univariable models)., Conclusion: Although to different degrees, similar factors explain the decline in HRQOL over time among the overall population, people who have been hospitalized or not. Clinical functional capacity scales could help to determine the risk of HRQOL decline., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

The purpose of this study was to describe the acceptability of a stroke telerehabilitation platform from the perspective of both patients and therapists. Two public rehabilitation centers participated in a pilot telerehabilitation trial. A theoretical framework was used to conceptualize acceptability. Semi-structured individual interviews with patients and focus groups of therapists were conducted. Most participants and therapists were satisfied with the intervention. Participants emphasized the advantages of staying at home to get their treatments. Therapists were more skeptical at first about their self-efficacy to deliver therapy remotely. There was a consensus among therapists about the need for a combination of telerehabilitation and in-person visits to optimize treatments. While we found overall good acceptability, effectiveness of this technology could be improved via an accessible user interface, complementary rehabilitation material, and ongoing training and technical just-in-time support with therapists., Competing Interests: The authors declare that they have no competing interest., (Copyright © 2022 Isabelle Gaboury, Rosalie Dostie, Hélène Corriveau, Arnaud Demoustier, Michel Tousignant.)

Background: Children with disability face long wait times for rehabilitation services. Before the COVID-19 pandemic, telehealth adoption was low across pediatric rehabilitation. Owing to the COVID-19 pandemic restrictions, pediatric therapists were asked to rapidly shift to telehealth, often with minimal training. To facilitate the behavior changes necessary for telehealth adoption, provision of appropriate evidence-based training and support is required. However, evidence to support the effective implementation of such training is lacking. The successful real-world implementation of a training intervention and program of support (TIPS) targeting pediatric therapists to enhance the adoption of family-centered telerehabilitation (FCT) requires the evaluation of both implementation and effectiveness., Objective: This study aimed to evaluate TIPS implementation in different pediatric rehabilitation settings and assess TIPS effectiveness, as it relates to therapists' adoption, service wait times, families' perception of service quality, and costs., Methods: This 4-year, pan-Canadian study involves managers, pediatric occupational therapists, physiotherapists, speech-language pathologists, and families from 20 sites in 8 provincial jurisdictions. It will use a multimethod, prospective, hybrid type 3 implementation-effectiveness design. An interrupted time series will assess TIPS implementation. TIPS will comprise a 1-month training intervention with self-paced learning modules and a webinar, followed by an 11-month support program, including monthly site meetings and access to a virtual community of practice. Longitudinal mixed modeling will be used to analyze indicators of therapists' adoption of and fidelity to FCT collected at 10 time points. To identify barriers and facilitators to adoption and fidelity, qualitative data will be collected during implementation and analyzed using a deductive-inductive thematic approach. To evaluate effectiveness, a quasi-experimental pretest-posttest design will use questionnaires to evaluate TIPS effectiveness at service, therapist, and family levels. Generalized linear mixed effects models will be used in data analysis. Manager, therapist, and family interviews will be conducted after implementation and analyzed using reflective thematic analysis. Finally, cost data will be gathered to calculate public system and societal costs., Results: Ethics approval has been obtained from 2 jurisdictions (February 2022 and July 2022); approval is pending in the others. In total, 20 sites have been recruited, and data collection is anticipated to start in September 2022 and is projected to be completed by September 2024. Data analysis will occur concurrently with data collection, with results disseminated throughout the study period., Conclusions: This study will generate knowledge about the effectiveness of TIPS targeting pediatric therapists to enhance FCT adoption in pediatric rehabilitation settings, identify facilitators for and barriers to adoption, and document the impact of telehealth adoption on therapists, services, and families. The study knowledge gained will refine the training intervention, enhance intervention uptake, and support the integration of telehealth as a consistent pediatric rehabilitation service option for families of children with disabilities., Trial Registration: ClinicalTrials.gov NCT05312827; https://clinicaltrials.gov/ct2/show/NCT05312827., International Registered Report Identifier (irrid): PRR1-10.2196/40218., (©Karen Hurtubise, Isabelle Gaboury, Jade Berbari, Marie-Claude Battista, Tibor Schuster, Michelle Phoenix, Peter Rosenbaum, Olaf Kraus De Camargo, Stacey Lovo, Lesley Pritchard-Wiart, Jill G Zwicker, Audrée Jeanne Beaudoin, Mélanie Morin, Thomas Poder, Marie-Pierre Gagnon, Geneviève Roch, Danielle Levac, Michel Tousignant, Heather Colquhoun, Kimberly Miller, Jennifer Churchill, Paula Robeson, Andréa Ruegg, Martine Nault, Chantal Camden. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 28.10.2022.)

Background: Across most healthcare systems, patients are the primary focus. Patient involvements enhance their adherence to treatment, which in return, influences their health. The objective of this study was to determine the characteristics (ie, attributes) and associated levels (ie, values of the characteristics) that are the most important for patients regarding telerehabilitation (TR) healthcare to support a future discrete choice experiment (DCE) study design., Methods: A mixed-methods systematic review was conducted from January 2005 to the end of July 2020 and the search strategy was applied to five different databases. The initial selection of articles that met the eligibility criteria was independently made by one researcher, two researchers verified the accuracy of the extracted data, and all researchers discussed about relevant variables to include. Reporting of this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the study. A qualitative synthesis was used to summarize findings., Results: From a total of 928 articles, 11 (qualitative [n = 5], quantitative [n = 3] and mixed-methods [n = 3] design) were included, and 25 attributes were identified and grouped into 13 categories: Accessibility, Distance, Interaction, Technology experience, Treatment mode, Treatment location, Physician contact mode, Physician contact frequency, Cost, Confidence, Ease of use, Feeling safer, and Training session. The attributes levels varied from two to five. The DCE studies identified showed the main stages to undertake these types of studies., Conclusion: This study could guide the development of interview grid for individual interviews and focus groups to support a DCE study design in the TR field. By understanding the characteristics that enhance patients' preferences, healthcare providers can create or improve TR programs that provide high-quality and accessible care. Future research via a DCE is needed to determine the relative importance of the attributes., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

OBJECTIVE: To develop a clinical practice guideline covering the assessment, management, and return to work of adults with rotator cuff disorders. DESIGN: Clinical practice guideline. METHODS: Using systematic reviews, appraisal of the literature, and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the province of Quebec (Canada). RESULTS: Recommendations (n = 73) and clinical decision algorithms (n = 3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, nonsteroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return-to-work plan should be developed early, in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. CONCLUSION: This clinical practice guideline was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decisionmaking for diagnosis and treatment, and planning for successful return to work. J Orthop Sports Phys Ther 2022;52(10):647-664. Epub: 27 July 2022. doi:10.2519/jospt.2022.11306 .

OBJECTIVES: To present the methods used to develop a clinical practice guideline (CPG) with recommendations endorsed by key stakeholders for assessing, managing, and supporting return to work for adults with rotator cuff disorders. DESIGN: Clinical practice guideline development. METHODS: A steering committee composed of the research team of this project led the development of this CPG in 5 phases, which followed the standards of the NICE and AGREE II collaborations. During the preparation phase (I), a multidisciplinary working committee of experts in managing rotator cuff disorders (n = 20) determined the scope and objectives of the CPG. The recommendations development phase (II) included initial knowledge synthesis, development of preliminary recommendations, systematic consultations with a multidisciplinary panel of key stakeholders (n = 51) using a modified three-round Delphi approach and drafting of the original CPG. In the external evaluation phase (III), an external committee of experts evaluated the original CPG using the AGREE II tool. In the dissemination phase (IV), the strategy for disseminating the CPG was developed and implemented. During the update phase (V), the CPG was revised based on an update of the initial knowledge synthesis. RESULTS: Seventy-three preliminary recommendations were developed from the initial knowledge synthesis. During the Delphi consultation, all of these recommendations were endorsed, and one new recommendation was proposed by panelists. The original CPG received an overall AGREE II score of 83% from the external evaluators. In 2021, an update of the initial 2017 knowledge synthesis was conducted and 13 recommendations were revised. CONCLUSION: The 5-phase consensus methods approach guided the development of a high-quality CPG on assessing, managing, and supporting return to work for adults with rotator cuff disorders. J Orthop Sports Phys Ther 2022;52(10):665-674. Epub: 27 July 2022. doi:10.2519/jospt.2022.11307 .

Background: In Canada, stroke survivors have difficulty accessing community-based rehabilitation services because of a lack of resources. VirTele, a personalized remote rehabilitation program combining virtual reality exergames and telerehabilitation, was developed to provide stroke survivors an opportunity to pursue rehabilitation of their chronic upper extremity (UE) deficits at home while receiving ongoing follow-up from a clinician., Objective: We aimed to identify the behavioral and motivational techniques used by clinicians during the VirTele intervention, explore the indicators of empowerment among stroke survivors, and investigate the determinants of VirTele use among stroke survivors and clinicians., Methods: This multiple case study involved 3 stroke survivors with chronic UE deficits and their respective clinicians (physiotherapists) who participated in the VirTele intervention, a 2-month remote rehabilitation intervention that uses nonimmersive virtual reality exergames and telerehabilitation aimed at improving UE deficits in stroke survivors. Study participants had autonomous access to Jintronix exergames and were asked to use them for 30 minutes, 5 times a week. The VirTele intervention included 1-hour videoconference sessions with a clinician 1 to 3 times a week, during which the clinician engaged in motivational interviewing, supervised the stroke survivors' use of the exergames, and monitored their use of the affected UE through activities of daily living. Semidirected interviews were conducted with the clinicians and stroke survivors 4 to 5 weeks after the end of the VirTele intervention. All interviews were audiorecorded and transcribed verbatim. An abductive thematic analysis was conducted to generate new ideas through a dynamic interaction between data and theory., Results: Three stroke survivors (n=2, 67%, women and n=1, 33%, man), with a mean age of 58.8 (SD 19.4) years, and 2 physiotherapists participated in the study. Five major determinants of VirTele use emerged from the qualitative analyses, namely technology performance (usefulness and perception of exergames), effort (ease of use), family support (encouragement), facilitators (considerations of the stroke survivors' safety as well as trust and understanding of instructions), and challenges (miscommunication and exergame limits). During the VirTele intervention, both clinicians used motivational and behavioral techniques to support autonomy, competence, and connectivity. All these attributes were reflected as empowerment indicators in the stroke survivors. Lessons learned from using telerehabilitation combined with exergames are provided, which will be relevant to other researchers and contexts., Conclusions: This multiple case study provides a first glimpse into the impact that motivational interviewing can have on adherence to exergames and changes in behavior in the use of the affected UE in stroke survivors. Lessons learned regarding the supportive role caregivers play and the new responsibilities clinicians have when using the VirTele intervention may inform the use of exergames via telerehabilitation. These lessons will also serve as a model to guide the implementation of similar interventions., International Registered Report Identifier (irrid): RR2-10.2196/14629., (©Dorra Rakia Allegue, Shane Norman Sweet, Johanne Higgins, Philippe S Archambault, Francois Michaud, William C Miller, Michel Tousignant, Dahlia Kairy. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 15.09.2022.)

Introduction: Access to public rehabilitation services for patients with non-urgent conditions - which suffer mainly from musculoskeletal disorders - is problematic around the world. Remote rehabilitation services are recognized as effective means to increase accessibility. Patient acceptability is an important element in the successful implementation of such clinical innovations and has not yet been studied thoroughly in this context. Thus, the aim of this study was to evaluate and compare the acceptability of two remote consultation modalities - phone and teleconsultation - for patients waiting for public outpatient non-urgent rehabilitation services., Methods: We conducted a qualitative descriptive study nested within a randomized clinical trial in which participants received either phone or teleconsultation follow-ups with a physiotherapist after a first systematic face-to-face evaluation. Semi-structured interviews were conducted with participants of both groups selected with purposive sampling. Sekhon's acceptability metaframework was used and interviews were transcribed and coded with thematic analysis., Ethic Approval: The research protocol was approved by the Research Ethics Board of the Centre intégré universitaire de santé et de services sociaux - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie - CHUS) (#2019-2919)., Results: Twenty participants were recruited. Results show both follow-up modalities have a good level of acceptability for participants; however, teleconsultation stands out because its visual dimension offers higher quality human contact and satisfactorily meets greater needs for support., Conclusion: Systematic in-person assessment and advice combined with telephone or teleconsultation follow-up can contribute to diversifying the services offered in physiotherapy outpatient clinics. Offering a range of service modalities with different resource requirements may shorten wait times. Such an approach seems to be well accepted by patients, especially with teleconsultation., Clinicaltrials: gov ID: NCT03991858., (© 2022 John Wiley & Sons Ltd.)

Diverse challenges arise with research involving people with communication disorders while using remote methods for data collection. Ethical and methodological issues related to the inclusion of people with communication disorders in research, specifically qualitative research, are magnified by communication challenges specific to remote communication. Avenues are discussed to ensure that remote data collection processes can include people with a communication disorder, while limiting negative impacts on the validity of the data.

Question(s): How cost-effective is group-based pelvic floor muscle training (PFMT) for treating urinary incontinence in older women?, Design: Economic evaluation conducted alongside an assessor-blinded, multicentre randomised non-inferiority trial with 1-year follow-up., Participants: A total of 362 women aged ≥ 60 years with stress or mixed urinary incontinence., Intervention: Twelve weekly 1-hour PFMT sessions delivered individually (one physiotherapist per woman) or in groups (one physiotherapist per eight women)., Outcome Measures: Urinary incontinence-related costs per woman were estimated from a participant and provider perspective over 1 year in Canadian dollars, 2019. Effectiveness was based on reduction in leakage episodes and quality-adjusted life years. Incremental cost-effectiveness ratios and net monetary benefit were calculated for each of the effectiveness outcomes and perspectives., Results: Both group-based and individual PFMT were effective in reducing leakage and promoting gains in quality-adjusted life years. Furthermore, group-based PFMT was ≥ 60% less costly than individual treatment, regardless of the perspective studied: -$914 (95% CI -970 to -863) from the participant's perspective and -$509 (95% CI -523 to -496) from the provider's perspective. Differences in effects between study arms were minor and negligible. Adherence to treatment was high, with low loss to follow-up and no between-group differences., Conclusion: Compared with standard individual PFMT, group-based PFMT was less costly and as clinically effective and widely accepted. These results indicate that patients and healthcare decision-makers should consider group-based PFMT to be a cost-effective first-line treatment option for urinary incontinence., Trial Registration: ClinicalTrials.govNCT02039830., (Copyright © 2022 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: Exergames are increasingly being used among survivors of stroke with chronic upper extremity (UE) sequelae to continue exercising at home after discharge and maintain activity levels. The use of virtual reality exergames combined with a telerehabilitation app (VirTele) may be an interesting alternative to rehabilitate the UE sequelae in survivors of chronic stroke while allowing for ongoing monitoring with a clinician., Objective: This study aimed to determine the feasibility of using VirTele in survivors of chronic stroke at home and explore the impact of VirTele on UE motor function, quantity and quality of use, quality of life, and motivation in survivors of chronic stroke compared with conventional therapy., Methods: This study was a 2-arm feasibility clinical trial. Eligible participants were randomly allocated to an experimental group (receiving VirTele for 8 weeks) or a control group (receiving conventional therapy for 8 weeks). Feasibility was measured from the exergame and intervention logs completed by the clinician. Outcome measurements included the Fugl-Meyer Assessment-UE, Motor Activity Log-30, Stroke Impact Scale-16, and Treatment Self-Regulation Questionnaire-15, which were administered to both groups at four time points: time point 1 (T1; before starting the intervention), time point 2 (after the intervention), time point 3 (1 month after the intervention), and time point 4 (T4; 2 months after the intervention)., Results: A total of 11 survivors of stroke were randomized and allocated to an experimental or a control group. At the onset of the COVID-19 pandemic, participants pursued the allocated treatment for 3 months instead of 8 weeks. VirTele intervention dose was captured in terms of time spent on exergames, frequency of use of exergames, total number of successful repetitions, and frequency of videoconference sessions. Technical issues included the loss of passwords, internet issues, updates of the system, and problems with the avatar. Overall, most survivors of stroke found the technology easy to use and useful, except for 9% (1/11) of participants. For the Fugl-Meyer Assessment-UE and Motor Activity Log-30, both groups exhibited an improvement in >50% of the participants, which was maintained over time (from time point 3 to T4). Regarding Stroke Impact Scale-16 scores, the control group reported improvement in activities of daily life (3/5, 60%), hand function (5/5, 100%), and mobility (2/5, 40%), whereas the experimental group reported varied and inconclusive results (from T1 to T4). For the Treatment Self-Regulation Questionnaire-15, 75% (3/4) of the experimental group demonstrated an increase in the autonomous motivation score (from T1 to time point 2), whereas, in the control group, this improvement was observed in only 9% (1/11) of participants., Conclusions: The VirTele intervention constitutes another therapeutic alternative, in addition to conventional therapy, to deliver an intense personalized rehabilitation program for survivors of chronic stroke with UE sequelae., International Registered Report Identifier (irrid): RR2-10.2196/14629., (©Dorra Rakia Allegue, Johanne Higgins, Shane N Sweet, Philippe S Archambault, Francois Michaud, William Miller, Michel Tousignant, Dahlia Kairy. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 22.06.2022.)

Objectives: To evaluate the scale-up of the OPUS-AP program to improve the care of residents at long-term care (LTC) centers through the systematic implementation of resident-centered approaches to care, the application of nonpharmacologic interventions for the management of behavioral and psychological symptoms of dementia (BPSD), and the deprescribing of antipsychotics where these are not clinically indicated., Design: Prospective, closed cohort., Setting and Participants: Residents with major neurocognitive disorder (MNCD) from 24 (phase 1) and 129 (phase 2) publicly funded LTC centers in Quebec, Canada., Methods: The primary outcome was antipsychotic deprescribing (cessation or dose reduction). Secondary outcomes included changes in benzodiazepine and antidepressant prescriptions, BPSD, and falls. Comparisons were made between assessments at baseline and after 9 months., Results: OPUS-AP phase 2 was conducted from March to December 2019 in 329 clinical wards at 129 LTC centers. At baseline, the 10,601 included residents had a mean age of 82.9: 64.6% were of female sex, 73.7% had a diagnosis of MNCD, and 47.0% had an antipsychotic prescription. These characteristics were similar to those of the 1054 residents at the 24 LTC centers in phase 1. In phase 2, successful antipsychotic deprescribing was achieved for 77.1% of residents in whom this approach was attempted, compared to 85.5% in phase 1. Phase 1 and 2 showed statistically significant improvements in the Cohen-Mansfield Agitation Inventory score and reduced use of benzodiazepines in residents with successful antipsychotic deprescribing. These improvements were of a smaller magnitude in phase 2. Statistically significant reductions in falls were observed in phase 2., Conclusions and Implications: The scale-up of the OPUS-AP program from 24 to 129 LTC centers was successful and resulted in a significant reduction in antipsychotic use, as well as improvement in BPSD, and reductions in benzodiazepine use and falls in residents with successful antipsychotic deprescribing., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

As telecommunications technology progresses, telehealth frameworks are becoming more widely adopted in the context of long-term care (LTC) for older adults, both in care facilities and in homes. Today, robots could assist healthcare workers when they provide care to elderly patients, who constitute a particularly vulnerable population during the COVID-19 pandemic. Previous work on user-centered design of assistive technologies in LTC facilities for seniors has identified positive impacts. The need to deal with the effects of the COVID-19 pandemic emphasizes the benefits of this approach, but also highlights some new challenges for which robots could be interesting solutions to be deployed in LTC facilities. This requires customization of telecommunication and audio/video/data processing to address specific clinical requirements and needs. This paper presents OpenTera, an open source telehealth framework, aiming to facilitate prototyping of such solutions by software and robotic designers. Designed as a microservice-oriented platform, OpenTera is an end-to-end solution that employs a series of independent modules for tasks such as data and session management, telehealth, daily assistive tasks/actions, together with smart devices and environments, all connected through the framework. After explaining the framework, we illustrate how OpenTera can be used to implement robotic solutions for different applications identified in LTC facilities and homes, and we describe how we plan to validate them through field trials., Competing Interests: Conflicts of interestThe authors declare that they have no conflict of interest., (© The Author(s) under exclusive licence to International Union for Physical and Engineering Sciences in Medicine (IUPESM) 2022.)

Purpose: Falls among persons with Parkinson's disease (PD) decrease health-related quality of life (HRQOL) and are a risk factor for hospitalization. Although physiotherapy can decrease falls and improve functional capacity, people living in remote areas have limited access to such services. This pilot study aimed to document the feasibility of a physiotherapy telerehabilitation intervention for patients with PD and to estimate the change over time in functional capacity, HRQOL, and the rate of falls. Methods: Eleven persons with PD participated in an 8-week physiotherapy telerehabilitation intervention. We assessed feasibility by computing retention rate and assiduity, number of undesirable health events, and technical problems. We assessed functional capacity, HRQOL, and falls at baseline, after the intervention, and at the 3-month follow-up. Results: Retention rate and assiduity were 91% and 100%. We resolved all technical problems (21.9% of sessions). No undesirable health events occurred. Point estimates suggest an improvement in functional capacity (Mini-BESTest) and HRQOL. Forty percent of participants fell during the intervention phase. Conclusion: Physiotherapy telerehabilitation is feasible and safe for persons with PD. Improvements in functional capacity and HRQOL must be confirmed with an appropriate design., (© Canadian Physiotherapy Association.)

Background: Strong evidence supports beginning stroke rehabilitation as soon as the patient's medical status has stabilized and continuing following discharge from acute care. However, adherence to rehabilitation treatments over the rehabilitation phase has been shown to be suboptimal., Objective: The aim of this study is to assess the impact of a telerehabilitation platform on stroke patients' adherence to a rehabilitation plan and on their level of reintegration into normal social activities, in comparison with usual care. The primary outcome is patient adherence to stroke rehabilitation (up to 12 weeks), which is hypothesized to influence reintegration into normal living. Secondary outcomes for patients include functional recovery and independence, depression, adverse events related to telerehabilitation, use of services (up to 6 months), perception of interprofessional shared decision making, and quality of services received. Interprofessional collaboration as well as quality of interprofessional shared decision making will be measured with clinicians., Methods: In this interrupted time series with a convergent qualitative component, rehabilitation teams will be trained to develop rehabilitation treatment plans that engage the patient and family, while taking advantage of a telerehabilitation platform to deliver the treatment. The intervention will be comprised of 220 patients who will take part in stroke telerehabilitation with an interdisciplinary group of clinicians (telerehabilitation group) versus face-to-face standard of care (control group: n=110 patients)., Results: Our Research Ethics Board approved the study in June 2020. Data collection for the control group is underway, with another year planned before we begin the intervention phase., Conclusions: This study will contribute to the minimization of both knowledge and practice gaps, while producing robust, in-depth data on the factors related to the effectiveness of telerehabilitation in a stroke rehabilitation continuum. Findings will inform best practice guidelines regarding telecare services and the provision of telerehabilitation, including recommendations for effective interdisciplinary collaboration regarding stroke rehabilitation., Trial Registration: ClinicalTrials.gov NCT04440215; https://clinicaltrials.gov/ct2/show/NCT04440215., International Registered Report Identifier (irrid): DERR1-10.2196/32134., (©Isabelle Gaboury, Michel Tousignant, Hélène Corriveau, Matthew Menear, Guylaine Le Dorze, Christian Rochefort, Brigitte Vachon, Annie Rochette, Sylvie Gosselin, François Michaud, Jessica Bollen, Sarah Dean. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 28.10.2021.)

Background: In Canada, only 11% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program., Objective: This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment., Methods: A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment-upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week., Results: The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels., Conclusions: VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising., International Registered Report Identifier (irrid): RR2-10.2196/14629., (©Dorra Rakia Allegue, Dahlia Kairy, Johanne Higgins, Philippe S Archambault, Francois Michaud, William C Miller, Shane N Sweet, Michel Tousignant. Originally published in JMIR Serious Games (https://games.jmir.org), 31.08.2021.)

Purpose: Telerehabilitation could prevent sequelae from COVID-19. We aimed to assess the feasibility of telerehabilitation; describe pulmonary and functional profiles of COVID-19 patients; and explore the effect of telerehabilitation on improving pulmonary symptoms and quality of life., Methods: We conducted a pre-experimental, pre-post pilot study. We recruited COVID-19 patients who had returned home following hospitalization. The intervention included eight weeks of supervised physiotherapy sessions. We documented technological issues, success of recruitment strategies, and participants' attendance to supervised sessions. We measured the impact of pulmonary symptoms on quality of life and functional health., Results: We scheduled 64 supervised sessions with seven participants with few technological issues. Initial scores showed that pulmonary symptoms moderately to highly impacted quality of life. At eight weeks, all patients had improved from 10 to 45 points on the EuroQol-Visual Analog Scale (EQ-VAS) instrument, indicating clinical significance., Conclusion: We developed and administered a telerehabilitation intervention during a global pandemic that targets key symptoms of the relevant disease., (Copyright © 2021 Pamela Tanguay, Nicole Marquis, Isabelle Gaboury, Dahlia Kairy, Matthieu Touchette, Michel Tousignant, Simon Décary.)

Background: Subacromial pain syndrome (SAPS) is a common complaint in orthopaedics. Subacromial corticosteroid injections (CSI) can relieve pain in the short term. Anodal transcranial direct current stimulation (a-tDCS) has been used for symptomatic pain relief in a variety of chronic pain conditions. The aim of this pilot study was to assess whether the application a-tDCS could enhance the symptomatic relief provided by CSI in patients affected by SAPS., Methods: Thirty-eight participants (18 to 65-year-old) suffering from SAPS were recruited to have a CSI and randomly allocated to receive, 1 weeks post CSI, real a-tDCS (r-tDCS), sham tDCS (s-tDCS) or no intervention (Control). Upper limb function was measured 1 week prior to the CSI, at the 2- and 4-week follow-ups using self-administered questionnaires and physical measures. Self-reported pain and activity during each day were logged by the participants using visual analog scales (VAS). Differences between groups were tested using repeated-measures ANOVAs., Results: Pain VAS and the Single Assessment Numeric Evaluation scale (SANE) showed significant improvement from baseline 2 weeks and 4 weeks after CSI in all groups (p < 0.05). There were no significant group X time interaction 2 weeks following tDCS treatment in any of the variables., Conclusion: All groups showed significant improvement in pain VAS and SANE scores following the CSI. One session of a-tDCS treatment 2 weeks following CSI did not result in any additive or potentializing effects when compared to a s-tDCS or a control group., Trial Registration: ClinicalTrials.gov, NCT03967574 . Registered 30 May 2019 - Retrospectively registered.

Purpose: The purpose of this article is to describe the development of a new Web platform to optimize self-management after pulmonary rehabilitation (PR) for persons living with a chronic respiratory disease (CRD) and to present data on its usability. Method: The Web platform is informed by a theoretical framework of behaviour changes and concepts of self-management and self-efficacy. It uses breathing exercises and a logbook and is meant to be a self-management tool. Usability was tested for 8 months after PR with a group consisting of five patients with chronic obstructive pulmonary disease and one with pulmonary fibrosis. We evaluated adherence (e.g., number of exercise/weeks), quality of life, dyspnoea, and functional capacity. We measured frequency count for adherence and pre-post differences per patient for clinical outcomes. Results: Four participants' adherence was higher than 50% of completed exercises (72 exercise/weeks). Five of six participants showed maintenance of functional capacity (6-minute walk test) 8 months after PR. Four participants showed maintenance of their quality of life. Four participants showed a deterioration in dyspnoea on the Borg Scale of Perceived Exertion. Conclusions: We developed a new theory-informed Web platform to optimize self-management after PR for persons living with a CRD. The pilot Web platform appears to optimize adherence to self-management techniques and possibly stabilize people's health outcomes., (© Canadian Physiotherapy Association.)

Aims: To compare the effects of group-based and individual physiotherapy for stress or mixed urinary incontinence (UI) on pelvic floor morphometry, pelvic floor muscle (PFM) function, and related self-efficacy, immediately after treatment and at 1 year., Methods: This is a planned secondary analysis of the group rehabilitation or individual physiotherapy study, an assessor-blinded, randomized, noninferiority trial. Eligible participants included 362 community-dwelling older women with symptoms of stress/mixed UI. After learning how to contract PFMs, participants completed 12 weeks of PFM training, either individually (one-on-one) or as part of a group (eight women). Pelvic floor transperineal ultrasound volumes (morphometry), PFM intravaginal dynamometric data (function), and self-efficacy in performing PFM exercises were acquired at baseline, posttreatment, and at 1 year., Results: Groups were comparable at all time points. Immediately posttreatment, both groups demonstrated significant changes in pelvic floor morphometry during coughs, and in PFM function during contractions and coughs. Participants also reported improved self-efficacy in performing PFM exercises. Results were sustained at 1 year. When participants coughed, pelvic floor structures were better supported (reflected by less caudal movement of the puborectalis sling and a smaller opening of the levator hiatus) in a pattern consistent with the "knack" strategy. Furthermore, both interventions resulted in stronger, faster, more coordinated, and more endurant PFMs., Conclusion: In older women with stress or mixed UI, both individual and group-based PFM training resulted in comparable improvements in overall PFM function, pelvic floor morphometry during coughs, and related self-efficacy in performing PFM exercises, which were sustained at 1 year., (© 2020 Wiley Periodicals LLC.)

Purpose: To describe the characteristics and effectiveness of pediatric telerehabilitation interventions offered to children 0-12 years old or to their families. Methods: A systematic review was conducted on randomized control trials published between 2007 and 2018 involving at least one rehabilitation professional who provided services remotely. Information was extracted about key study, participants and intervention characteristics. The percentage of outcomes that improved were computed per study, and per intervention characteristic. Results: Out of 4472 screened articles, 23 were included. Most studies were published after 2016 and evaluated outcomes related to the child's behavior (n = 12, 52.2%) or to the parent (n = 10, 43.5%), such as parental skills or stress. Overall, 56.1% (SD: 38.5%) of evaluated outcomes improved following telerehabilitation. A great diversity of population and teleintervention characteristics was observed. Effective interventions tended to target parents, centered around an exercise program, used a coaching approach, focused on improving children's behavioral functioning, lasted >8 weeks and were offered at least once a week. Conclusions: Intervention characteristics that appear to yield better outcomes should inform the development of future telerehabilitation studies, especially in populations for whom telerehabilitation is currently understudied (e.g., children's with physical functioning difficulties). Future trials should compare telerehabilitation interventions to well-described evidence-based face-to-face interventions, and document their cost-effectiveness.Implications for RehabilitationDespite a great variety in practices, telerehabilitation might be as effective as face-to-face interventions, across disciplines, for a variety of clinical outcomes.Telerehabilitation might be more effective when coaching approaches are used, especially to achieve outcomes related to children's behavior or parental skills.Further research is required to better understand the characteristics of effective telerehabilitation interventions, and to determine how these characteristics may differ for specific populations and outcomes.

Importance: Urinary incontinence is one of the most prevalent health concerns experienced by older women (aged ≥60 years). Individual pelvic floor muscle training (PFMT) is the recommended first-line treatment for stress or mixed urinary incontinence in women, but human and financial resources limit its delivery. Whether group-based PFMT performs as well as individual PFMT in this population remains unclear., Objective: To assess the efficacy of group-based PFMT relative to individual PFMT for urinary incontinence in older women., Design, Setting, and Participants: The Group Rehabilitation or Individual Physiotherapy (GROUP) study is a single-blind, randomized, noninferiority trial conducted in 2 Canadian research centers, from July 1, 2012, to June 2, 2018. A total of 362 community-dwelling women aged 60 years or older with symptoms of stress or mixed urinary incontinence were enrolled., Interventions: After an individual session conducted to learn how to contract pelvic floor muscles, participants completed 12-week PFMT as part of a group of 8 women (n = 178) or in individual sessions (n = 184)., Main Outcomes and Measures: The primary outcome measure was the percentage reduction in urinary incontinence episodes at 1 year, as reported in a 7-day bladder diary and relative to pretreatment baseline. Secondary outcomes included lower urinary tract-related signs, symptoms, and quality of life immediately following treatment and at 1 year. Per-protocol analysis was used., Results: Among 362 women who were randomized (mean [SD] age, 67.9 [5.8] years), 319 women (88%) completed the 1-year follow-up and were included in the per-protocol analysis. Median percentage reduction in urinary incontinence episodes was 70% (95% CI, 44%-89%) in individual PFMT compared with 74% (95% CI, 46%-86%) in group-based PFMT. The upper boundary of the 95% CI for the difference in the percentage reduction in urinary incontinence episodes at 1 year was lower than the prespecified margin for noninferiority of 10% (difference, 4%; 95% CI, -10% to 7%; P = .58), confirming noninferiority. Individual PFMT and group-based PFMT had similar effectiveness for all secondary outcomes at 1 year. Adverse events were minor and uncommon., Conclusions and Relevance: Results of the GROUP study suggest that group-based PFMT is not inferior to the recommended individual PFMT for the treatment of stress and mixed urinary incontinence in older women. Widespread use in clinical practice may help increase continence-care affordability and treatment availability., Trial Registration: ClinicalTrials.gov Identifier: NCT02039830.

Objectives: To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults., Data Sources: A systematic bibliographic search was conducted up until May 2018 in Medline, Embase, and Physiotherapy Evidence Database, or PEDro, databases, in addition to 12 clinical guidelines search engines listed on the Appraisal of Guidelines for Research and Evaluation (AGREE) website., Study Selection: Nine CPGs on the management of rotator cuff disorders in adults or workers, available in English or French, and published from January 2008 onward, were included and screened by 2 independent reviewers., Data Extraction: CPG methodology was assessed with the AGREE II checklist. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following 4 levels: "essential," "recommended," "may be recommended," and "not recommended.", Data Synthesis: Methodological quality was considered high for 3 CPGs and low for 6. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen or nonsteroidal anti-inflammatory drug prescriptions and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return-to-work strategies included intervening early, use of a multidisciplinary approach, and adaptation of work organization., Conclusions: Only 3 CPGs were of high quality. The development of more rigorous CPGs is warranted., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Exergames have the potential to provide an accessible, remote approach for poststroke upper extremity (UE) rehabilitation. However, the use of exergames without any follow-up by a health professional could lead to compensatory movements during the exercises, inadequate choice of difficulty level, exercises not being completed, and lack of motivation to pursue exercise programs, thereby decreasing their benefits. Combining telerehabilitation with exergames could allow continuous adjustment of the exercises and monitoring of the participant's completion and adherence. At present, there is limited evidence regarding the feasibility or efficacy of combining telerehabilitation and exergames for stroke rehabilitation., Objective: This study aims to (1) determine the preliminary efficacy of using telerehabilitation combined with exergames on UE motor recovery, function, quality of life, and motivation in participants with chronic stroke, compared with conventional therapy (the graded repetitive arm supplementary program; GRASP); (2) examine the feasibility of using the technology with participants diagnosed with stroke at home; and (3) identify the obstacles and facilitators for its use by participants diagnosed with stroke and stroke therapists and understand the shared decision-making process., Methods: A mixed methods study protocol is proposed, including a randomized, blinded feasibility trial with an embedded multiple case study. The intervention consists of the provision of a remote rehabilitation program, during which participants will use the Jintronix exergame for UE training and the Reacts Application to conduct videoconferenced sessions with the therapists (physical or occupational therapists). We plan to recruit 52 participants diagnosed with stroke, randomly assigned to a control group (n=26; 2-month on-paper home exercise program: the GRASP with no supervision) and an experimental group (n=26; 2-month home program using the technology). The primary outcome is the Fugl-Meyer UE Assessment, a performance-based measure of UE impairment. The secondary outcomes are self-reported questionnaires and include the Motor Activity Log-28 (quality and frequency of use of the UE), Stroke Impact Scale-16 (the quality of life), and Treatment Self-Regulation Questionnaire (motivation). Feasibility data include process, resources, management, and scientific outcomes. Qualitative data will be collected by interviews with both participants and therapists., Results: At present, data collection was ongoing with one participant who had completed the exergame- telerehabilitation based intervention. We expect to collect preliminary efficacy data of this technology on the functional and motor recovery of the UE, following a stroke; collect feasibility data with users at home (adherence, safety, and technical difficulties); and identify the obstacles and facilitators for the technology use and understand the shared decision-making process., Conclusions: This paper describes the protocol underlying the study of a telerehabilitation-exergame technology to contribute to understanding its feasibility and preliminary efficacy for UE stroke rehabilitation., Trial Registration: ClinicalTrials.gov NCT03759106; http://clinicaltrials.gov/show/NCT03759106., International Registered Report Identifier (irrid): DERR1-10.2196/14629., (©Dorra Rakia Allegue, Dahlia Kairy, Johanne Higgins, Philippe Archambault, Francois Michaud, William Miller, Shane Norman Sweet, Michel Tousignant. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 21.05.2020.)

Objective: To determine the prevalence of no-show patients in 4 family medicine teaching units (FMTUs) and to investigate the reasons given by patients for past missed appointments in order to identify factors that could be acted on to improve access to care., Design: Retrospective data collection through electronic medical records and a self-administered survey., Setting: Four FMTUs at the University of Montreal in Quebec., Participants: Patients older than 18 years of age (or younger patients' guardians) who were able to read French and had visited the clinic at least once., Main Outcomes Measures: No-show prevalence among patients scheduled to see different types of health care professionals, and patients' reasons for past missed appointments and for not notifying the clinic before missing an appointment., Results: The overall prevalence of no-show patients was 7.8% (2700 missed appointments of 34 619 scheduled appointments), ranging from 6.3% to 9.0% among the 4 FMTUs. The survey participation rate was 91.0% (1757 completed surveys of 1930 distributed surveys). A total of 19.1% of respondents acknowledged previous no-show behaviour. Resolved issues (22.9%) and work obligations (19.4%) were the most frequent personal reasons for missing an appointment, whereas inconvenient timing of the appointment (17.0%), delay before the appointment (14.6%), and lack of confirmation (13.7%) were the most frequent organizational reasons. The most frequent reason for not notifying the clinic of the absence was forgetting to call (55.2%)., Conclusion: The no-show phenomenon, although not very prevalent in our clinics, is present and can potentially affect access to care. Reasons for missing an appointment without notifying the clinic are varied and point toward different potential solutions to reduce no-shows. Educating patients about the importance of informing the clinic when they cannot come, offering a wider range of appointment dates and times, systematically confirming appointments, improving telephone service, and offering different methods to communicate with the clinic could all be solutions to improve access to care., (Copyright© the College of Family Physicians of Canada.)

Objective : To explore the effects of a web platform, aiming to support parents of children 5-12 years old with suspected or diagnosed developmental coordination disorder (DCD), on parental knowledge and skills. Method : A randomized pilot trial was undertaken (Clinical trial NCT03141333). Parents of the intervention group (n = 15) had access to a web platform (including resources, forum and virtual interactions) for three months. The control group (n = 13) only had access to resources. The primary outcome was measured pre- and post-intervention with the Parent Knowledge and Skills Questionnaire. Pre- post-questionnaires evaluated secondary outcomes (parents' sense of competence, children's strenghts and difficulties, and occupational performance). Results and discussion : All outcome measures improved over time for the intervention group. However, those improvements were not clinically or statistically significant ( p 0.08-0.41). Conclusion : Web platforms supporting parents of children with DCD need further evaluation. Especially, usability of web platforms and new outcome measures should be explored.

Background: Shoulder pain secondary to rotator cuff tendinopathy affects a large proportion of patients in orthopedic surgery practices. Corticosteroid injections are a common intervention proposed for these patients. The clinical evaluation of a response to corticosteroid injections is usually based only on the patient's self-evaluation of his function, activity, and pain by multiple questionnaires with varying metrological qualities. Objective measures of upper extremity functions are lacking, but wearable sensors are emerging as potential tools to assess upper extremity function and activity., Objective: This study aimed (1) to evaluate and compare test-retest reliability and sensitivity to change of known clinical assessments of shoulder function to wrist-based accelerometer measures and visual analog scales (VAS) of shoulder activity during daily living in patients with rotator cuff tendinopathy convergent validity and (2) to determine the acceptability and compliance of using wrist-based wearable sensors., Methods: A total of 38 patients affected by rotator cuff tendinopathy wore wrist accelerometers on the affected side for a total of 5 weeks. Western Ontario Rotator Cuff (WORC) index; Short version of the Disability of the Arm, Shoulder, and Hand questionnaire (QuickDASH); and clinical examination (range of motion and strength) were performed the week before the corticosteroid injections, the day of the corticosteroid injections, and 2 and 4 weeks after the corticosteroid injections. Daily Single Assessment Numeric Evaluation (SANE) and VAS were filled by participants to record shoulder pain and activity. Accelerometer data were processed to extract daily upper extremity activity in the form of active time; activity counts; and ratio of low-intensity activities, medium-intensity activities, and high-intensity activities., Results: Daily pain measured using VAS and SANE correlated well with the WORC and QuickDASH questionnaires (r=0.564-0.815) but not with accelerometry measures, amplitude, and strength. Daily activity measured with VAS had good correlation with active time (r=0.484, P=.02). All questionnaires had excellent test-retest reliability at 1 week before corticosteroid injections (intraclass correlation coefficient [ICC]=0.883-0.950). Acceptable reliability was observed with accelerometry (ICC=0.621-0.724), apart from low-intensity activities (ICC=0.104). Sensitivity to change was excellent at 2 and 4 weeks for all questionnaires (standardized response mean=1.039-2.094) except for activity VAS (standardized response mean=0.50). Accelerometry measures had low sensitivity to change at 2 weeks, but excellent sensitivity at 4 weeks (standardized response mean=0.803-1.032)., Conclusions: Daily pain VAS and SANE had good correlation with the validated questionnaires, excellent reliability at 1 week, and excellent sensitivity to change at 2 and 4 weeks. Daily activity VAS and accelerometry-derived active time correlated well together. Activity VAS had excellent reliability, but moderate sensitivity to change. Accelerometry measures had moderate reliability and acceptable sensitivity to change at 4 weeks., (©Samuel Larrivée, Frédéric Balg, Guillaume Léonard, Sonia Bédard, Michel Tousignant, Patrick Boissy. Originally published in JMIR Rehabilitation and Assistive Technology (http://rehab.jmir.org), 03.12.2019.)

Background: Advanced practice physiotherapists (APP) have helped improve accessibility to orthopaedic outpatient care. Several studies have validated the APP practice model in orthopaedic care, demonstrating high agreement between APPs and orthopaedic surgeons (OS) regarding diagnosis and management. However, as APPs tend to be experienced senior physiotherapists, such a study involving physiotherapy students (PS) has not yet been explored. The objective of this study was to evaluate the agreement for orthopaedic diagnoses and surgical triage between a PS and OSs., Methods: A prospective study involving a final year PS and seven OSs was conducted in a university hospital, after the PS had undergone a three-week intensive training. Eighty-six adult patients referred to OSs for knee osteoarthritis, hip osteoarthritis or shoulder problem were independently evaluated by the PS, and then re-evaluated by an OS. The diagnoses and surgical triage recommendations of both clinicians were analyzed for agreement using raw percent agreement and Cohen's kappa. Patient satisfaction with the outpatient clinic experience was noted using a modified version of the Visit-Specific Satisfaction Instrument., Results: Our sample consisted of 86 patients (mean age = 63.4 years). Reasons for consultation included shoulder problems (36%), knee osteoarthritis (52%) and hip osteoarthritis (12%). The raw percent agreement for diagnosis was 95.3%. The agreement for surgical triage was high (κ = 0.86, 95% CI: 0.74-0.98) with a raw agreement of 94.2%. Patient satisfaction was high., Conclusions: The PS and OSs made similar diagnoses and triage recommendations suggesting that clinical experience alone is not a prerequisite for physiotherapists to help increase accessibility to orthopaedic care.

Objectives . To determine the feasibility of recruiting families of children with suspected or diagnosed developmental coordination disorder (sdDCD) and explore their satisfaction with a web-based intervention Design . A feasibility randomized trial was conducted. Participants were the parents of 5-12-year-old children with sdDCD. The intervention group had access to online resources, group and private forums, and videoconferencing with a therapist. Main outcomes were recruitement and retention rates. Satisfaction was documented through a post-intervention survey and interview. Results . The recruitment rate was seven participants per month ( n  = 28 participants) and retention rate was 68%. Satisfaction was moderate. No differences in use and satisfaction were observed between groups. Participants formulated recommendations for improving the intervention, including targeting families earlier in the diagnosis process, and pre-scheduling meetings with therapists. Conclusions . This study demonstrated the feasibility of future trials, and highlighted avenues for improvement. Parent involvement during the development of the intervention is discussed at length. Abbreviations: DCD: Developmental Coordination Disorder; sdDCD: suspected or diagnosed Developmental Coordination Disorder; RCT: randomized-controled trial.

Background: Integrating biomedical sensors to a telerehabilitation platform allowed clinicians to receive real-time transmissions of the electrocardiogram (ECG) signal, oxygen saturation, and heart rate during an exercise program. These clinical data could be helpful to adjust and personalize the intensity of exercises to each patient's condition. The purpose of this study was to evaluate the feasibility and usefulness of biomedical sensors in telerehabilitation in patients with heart failure (HF)., Methods: Four participants with HF (mean age 66 years) followed the 12-week cardiac program using telerehabilitation, including sensors to monitor real-time vital signs during sessions. The exercise program included cardiovascular, strengthening and flexibility exercises. Participants were evaluated before the intervention and one month after the end of the program. Functional capacity was measured with Cardiopulmonary Exercise Testing (CPX), the 6-minute walk test (6MWT), and the sit to stand test (STST). Quality of life was objectified using the Kansas City Cardiomyopathy Questionnaire (KCCQ)., Results: Our main objective demonstrated that real-time biomedical sensors can be safely used by clinicians during a telerehabilitation session. Most participants showed a tendency to improve their physical capacities such as walking distance and lower limb muscular strength. As a main outcome of cardiac rehabilitation (CR), quality of life seems to improve after the 12-week intervention., Conclusions: This study proved the feasibility of using telerehabilitation with real-time biomedical sensors as an alternative or a complement to the conventional CR program. Use of sensors allowed a safe environment for the patient and an adequate and personalized exercise prescription. Limitation in one-to-one supervision must be challenged in future clinical trials to demonstrate that telerehabilitation could be efficient for cardiac patients requiring more individual supervision than group sessions in a gymnasium., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Urinary incontinence (UI), one of the most prevalent health concerns confronting women aged over 60 years, affects up to 55% of older community-dwelling women-20-25% with severe symptoms. Clinical practice guidelines recommend individualized pelvic floor muscle training (PFMT) as a first-line treatment for stress or mixed UI in women, although lack of human and financial resources limits delivery of this first-line treatment. Preliminary data suggest that group-based treatments may provide the answer. To date, no adequately powered trials have evaluated the effectiveness or cost-effectiveness of group compared to individual PFMT for UI in older women. Given demographic projections, high prevalence of UI in older women, costly barriers, and group PFMT promising results, there is a clear need to rigorously compare the short- and long-term effectiveness and cost-effectiveness of group vs individual PFMT., Methods/design: The study is designed as a non-inferiority randomized controlled trial, conducted in two facilities (Montreal and Sherbrooke) in the Canadian province of Quebec. Participants include 364 ambulatory, community-dwelling women, aged 60 years and older, with stress or mixed UI. Randomly assigned participants will follow a 12-week PFMT, either in one-on-one sessions or as part of a group, under the supervision of a physiotherapist. Blinded assessments at baseline, immediately post intervention, and at one year will include the seven-day bladder diary, the 24-h pad test, symptoms and quality of life questionnaires, adherence and self-efficacy questionnaire, pelvic floor muscle function, and cost assessments. Primary analysis will test our main hypothesis that group-based treatment is not inferior to individualized treatment with respect to the primary outcome: relative (%) reduction in the number of leakages., Discussion: Should this study find that a group-based approach is not less effective than individual PFMT, and more cost-effective, this trial will impact positively continence-care accessibility and warrant a change in clinical practice., Trial Registration: ClinicalTrials.gov, NCT02039830 . Registered on 12 December 2013; Study protocol version 2; 21 November 2013.

Objective: To predict suicidal ideation in people with schizophrenia, certain studies have measured its relationship with the variables of defeat and entrapment. The relationships are positive, but their interactions remain undefined. To further their understanding, this research sought to measure the relationship between suicidal ideation with the variables of loss, entrapment, and humiliation., Method: The convenience sample included 30 patients with schizophrenia spectrum disorders. The study was prospective (3 measurement times) during a 6-month period. Results were analyzed by stepwise multiple regression., Results: The contribution of the 3 variables to the variance of suicidal ideation was not significant at any of the 3 times (T1: 16.2%, P = 0.056; T2: 19.9%, P = 0.117; T3: 11.2%, P = 0.109). Further analyses measured the relationship between the variables of stigmatization, perceived cognitive dysfunction, symptoms, depression, self-esteem, reason to live, spirituality, social provision, and suicidal ideation. Stepwise multiple regression demonstrated that the contribution of the variables of stigmatization and perceived cognitive dysfunction to the variance of suicidal ideation was significant at all 3 times (T1: 41.7.5%, P = 0.000; T2: 35.2%, P = 0.001; T3: 21.5%, P = 0.012). Yet, over time, the individual contribution of the variables changed: T1, stigmatization (β = 0.518; P = 0.002); T2, stigmatization (β = 0.394; P = 0.025) and perceived cognitive dysfunction (β = 0.349; P = 0.046). Then, at T3, only perceived cognitive dysfunction contributed significantly to suicidal ideation (β = 0.438; P = 0.016)., Conclusion: The results highlight the importance of the contribution of the variables of perceived cognitive dysfunction and stigmatization in the onset of suicidal ideation in people with schizophrenia spectrum disorders.

Background: Tai chi (TC) has been reported as being beneficial for improving balance post stroke, yet its utility in upper limb rehabilitation remains unknown. Methods: Twelve chronic stroke survivors with persistent paresis of an upper limb underwent 60 minutes of adapted TC twice a week for eight weeks, with a 4-week follow up. A 10-min TC home program was recommended for the days without sessions. TC level of performance, attendance to the sessions, duration of self-practice at home, and adapted TC movements used were recorded. Results: Eleven participants completed the study. A clinical reasoning algorithm underlying the adaptation of TC was elaborated throughout the trial. Participants with varying profiles including a severely impaired upper limb, poor balance, shoulder pain, and severe spasticity were not only capable of practicing the adapted TC, but attended all 16 sessions and practiced TC at home for a total of 16.51 ± 9.21 h. The degree of self-practice for subgroups with low upper limb function, shoulder pain, or moderate-to-severe spasticity was similar to that of subgroups with greater upper limb function, no shoulder pain, and minimal-to-no spasticity. Conclusion: Adapted TC seems feasible for upper limb rehabilitation post stroke. Although the study was based on a small sample size and requires confirmation, low upper limb function, insufficient balance, spasticity, and shoulder pain do not appear to hinder the practice of TC., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Background: Although the use of telepractice in speech-language therapy for assessment purposes is well documented, its effectiveness and potential for rehabilitation in poststroke aphasia remain largely unknown. The purpose of this study was to investigate the effectiveness of a remotely delivered synchronous pragmatic telespeech language therapy for improving functional communication in aphasia., Methods: A pre-/post-test design was chosen in which each participant was his or her own control. Using a telerehabilitation platform and software (Oralys TeleTherapy) based on the Promoting Aphasics' Communicative Effectiveness (PACE) approach, 20 participants with chronic poststroke aphasia received 9 speech therapy sessions over a 3-week period., Results: Teletreatment with the PACE pragmatic rehabilitation approach led to improvements in functional communication, marked by (a) an increase in communication effectiveness, reflecting significantly improved autonomy in functional communication; (b) a decrease in communication exchange duration, meaning that the treatment made communication faster and more efficient; (c) a decrease in the number of communication acts, meaning that, after treatment, less information was needed to be efficiently understood by the communication partner; and (d) an increase in the number of different communication strategies used, meaning that the treatment fostered the use of a variety of alternative communication modes., Conclusions: This study provides additional arguments about the benefits of telerehabilitation for poststroke patients with aphasia. It showed that multimodal language therapy delivered through synchronous telerehabilitation had positive effects on functional communication in chronic aphasia.

Introduction: This study aimed at exploring the perceived benefits and drawbacks of practicing tai chi, an alternative therapy that can be implemented in the community, as part of upper-limb rehabilitation following stroke., Methodology: Semistructured interviews were carried out with participants with chronic stroke (>6 months). The participants took part in 16 tai chi sessions over 8 weeks. Interviews were conducted in person using an interview guide based on the theory of planned behavior (TPB), and a thematic analysis was conducted., Results: Eight interviews were carried out with participants at various stages of motor recovery. Participants perceived a number of physical, functional, and psychological benefits. They found tai chi to be a global exercise, including both physical and mental aspects, and suggested that it can be included as part of rehabilitation for stroke patients. Many participants expressed a desire to continue practicing tai chi after completion of the study because it exceeded their expectations, among other reasons., Conclusion: This study can serve to guide future tai chi interventions and research on tai chi for rehabilitation in terms of the characteristics of the intervention and the various areas to assess in order to measure the overall benefits. IMPLICATIONS FOR REHABILITATION Tai chi was perceived as a good way of integrating various skills learned during rehabilitation. Despite having different functional abilities, all the participants noted various physical, functional, and psychological benefits from participating in the tai chi sessions. Tai chi seems to be a form of exercise that stroke patients would perform more long-term since all the participants in this study expressed the desire to continue practicing tai chi.

Optimal physical activity (PA) interventions are needed to increase PA in individuals with severe obesity, and optimize the results of bariatric surgery (BS). The aim of this study was to assess the feasibility and effect of Pre-Surgical Exercise Training (PreSET) delivered in-home via telehealth (TelePreSET) in subjects awaiting BS. Six women following the TelePreSET were compared to the women from a previous study (12 performing the PreSET in a gymnasium and 11 receiving usual care). In-home TelePreSET (12-weeks of endurance and strength training) was supervised twice weekly using videoconferencing. Physical fitness, quality of life, exercise beliefs, anthropometric measures and telehealth perception were assessed before and after 12-weeks. Satisfaction was evaluated with questionnaires at the end of the intervention. The TelePreSET participants attended 96% of the exercise sessions, and were very satisfied by the TelePreSET. The baseline telehealth perception score was high, and increased significantly after the intervention. The TelePreSET group significantly increased their physical fitness compared to the usual care group. No significant change was noted in other outcomes. The TelePreSET is feasible and seems effective to improve the physical fitness of women awaiting BS. Further studies are needed to confirm beneficial effects of this innovative mode of delivery.

Background and Introduction: Telerehabilitation after total knee arthroplasty (TKA) is supported by strong evidence on the effectiveness of such intervention and from a cost-benefit point of view. Satisfaction of patients toward in-home telerehabilitation after TKA has not yet been examined thoroughly in large-scale clinical trials. This study aims to compare satisfaction level of patients following in-home telerehabilitation (TELE) after TKA to one of the patients following a usual face-to-face home visit (STD) rehabilitation. Secondarily, to determine if any clinical or personal variables were associated to the level of satisfaction., Materials and Methods: This study was embedded in a multicenter randomized controlled trial with 205 patients randomized into two groups. Rehabilitation intervention was the same for both groups; only approach for service delivery differed (telerehabilitation or home visits). Participants were assessed at baseline (before TKA), at hospital discharge, and at 2 and 4 months postdischarge (E4) using functional outcomes. Patient satisfaction was measured using the validated Health Care Satisfaction Questionnaire (HCSQ) at E4., Results: Characteristics of all participants were similar at baseline. Satisfaction level of both groups did not differ and was very high (over 85%). It was neither correlated to personal characteristics nor to improvements of functional level from preoperative to E4. Satisfaction was rather found associated to walking and stair-climbing performances., Conclusions: These results, in conjunction with evidences of clinical effectiveness and cost benefits demonstrated in the same sample of patients, strongly support the use of telerehabilitation to improve access to rehabilitation services and efficiency of service delivery after TKA.

Background: Proximal humerus fractures can be treated surgically (eg: pinning, plate and screws) or conservatively by wearing a splint or a cast. Following both of these approaches, rehabilitation has proven effective to prevent functional limitations and to re-establish normal shoulder function. However, access to these rehabilitation services and compliance tends to be limited in elderly patients due to travelling difficulties caused by their precarious health status and, in some cases, social and marital status. Since the majority of patients with a proximal humerus fracture are elderly, it becomes relevant to find a new way to offer quick, simple and suitable rehabilitation service. Thus, the use of promising alternative approaches, as in-home telerehabilitation, can enhance access to rehabilitation services for such population. The main objective of the study is to compare the clinical effects of the innovative telerehabilitation approach (TELE group) compared to face-to-face visits to a clinic (CLINIC group) for patients treated for a proximal humerus fracture., Methods/design: In this randomized controlled trial, individuals who have had a proximal humerus fracture treated conservatively at the Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie CHUS), and who are returning home will be included. Participants will be recruited during their visit to the emergency ward or outpatient clinic by the medical or research team and will then sign the informed consent form if they are interested to participate in the study. We expect to recruit 52 participants (26 per group). Randomization will be done by a random number generator with sealed envelopes. Each patient will be evaluated before the beginning of the rehabilitation (T1), and immediately after the 2-month intervention (T2). The following outcomes will be measured: 1) upper extremity function (Constant Shoulder Score and Disability of the Arm, Shoulder and Hand questionnaire [DASH]); 2) range of motion (conventional goniometer); 3) user satisfaction (Health Care Satisfaction questionnaire); and 4) cost of services to the public healthcare system. The difference between the two groups will be compared using a t-test or a chi-squared test, and through a cost-effectiveness economic analysis., Discussion: We hypothesize that in-home telerehabilitation will provide a good alternative to conventional rehabilitation, in terms of its efficacy, simplicity, patient satisfaction, and low associated costs., Trial Registration: ClinicalTrials.gov: NCT02425267. April 22(nd), 2015.

Background: Audio/video-mediated communication between patients and clinicians using videoconferencing over telecommunication networks is a key component of providing teletreatments in rehabilitation., Objective: The objectives of this study were to (1) document the conditions of use, performance, and reliability of videoconferencing-based communication in the context of in-home teletreatment (TELE) following total knee arthroplasty (TKA) and (2) assess from the perspective of the providers, the quality attributes of the technology used and its impact on clinical objectives., Materials and Methods: Descriptive embedded study in a randomized controlled trial using a sample of 97 post-TKA patients, who received a total of 1,431 TELE sessions. Technical support use, service delivery reliability, performance, and use of network connection were assessed using self-report data from a costing grid and automated logs captured from videoconferencing systems. Physical therapists assessed the quality and impact of video-mediated communications after each TELE session on seven attributes., Results: Installation of a new Internet connection was required in 75% of the participants and average technician's time to install test and uninstall technology (including travel time) was 308.4 min. The reliability of service delivery was 96.5% of planned sessions with 21% of TELE session requiring a reconnection during the session. Remote technical support was solicited in 43% of the sessions (interventions were less than 3-min duration). Perceived technological impacts on video-mediated communications were minimal with quality of the overall technical environment evaluated as good or acceptable in 96% of the sessions and clinical objectives reached almost completely or completely in 99% of the sessions., Conclusions: In-home rehabilitation teletreatments can be delivered reliably but requires access to technical support for the initial setup and maintenance. Optimization of the processes of reliably connecting patients to the Internet, getting the telerehabilitation platform in the patient's home, installing, configuring, and testing will be needed to generalize this approach of service delivery.

Over the last few years, the number of remote patient monitoring (RPM) products and of videoconferencing systems has exploded. There is also a significant number of research initiatives addressing the use of service robots for assistance in daily living activities. From a technological standpoint, providing telehomecare services is certainly feasible. However, one technological barrier is to have access to a telecommunication platform that can be adapted to address the broad range of specifications and requirements of clinical and telehealth applications. Handling the full spectrum of possibilities requires a telecommunication framework that can transmit vital sign data from patients to clinicians, bidirectional audio-video from a standard computing device, and also multiple video streams and bidirectional transmission of control data. This paper presents a framework that integrates such capabilities. It also illustrates the versatility of the framework by presenting custom-designed devices allowing integration of capabilities ranging from RPM to video visits and robot telepresence.

Biomechanical evidence is needed to determine to what extent the use of a mobility assistance dog (AD(Mob)) may minimize mechanical loads and muscular demands at the upper limbs among manual wheelchair users. This study quantified and compared upper limb efforts when propelling up a ramp with and without an AD(Mob) among manual wheelchair users. Ten manual wheelchair users with a spinal cord injury who own an AD(Mob) ascended a ramp with and without their AD(Mob). The movements of the wheelchair and upper limbs were captured and the forces applied at the pushrims were recorded to compute shoulder mechanical loading. Muscular demand of the pectoralis major, anterior deltoid, biceps, and the triceps was normalized against the maximum electromyographic values. The traction provided by the AD(Mob) significantly reduced the total force applied at the pushrim and its tangential component while the mechanical effectiveness remained similar. The traction provided by the AD(Mob) also resulted in a significant reduction in shoulder flexion, internal rotation, and adduction moments. The muscular demands of the anterior deltoid, pectoralis major, biceps, and triceps were significantly reduced by the traction provided by the AD(Mob). The use of AD(Mob) represents a promising mobility assistive technology alternative to minimize upper limb mechanical loads and muscular demands and optimize performance during wheelchair ramp ascent.

Background and Aim: Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients., Methods: We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process., Results: We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists' perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources., Conclusion: Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.

Background: Meniscus lesions are common musculoskeletal knee injuries which often lead to pain, limitation and compensations during functional tasks, such as descending stairs. This study investigated the effect of patellar taping with tension and without tension on three-dimensional (3D) kinematics of the knee during a slow step descent task in patients with meniscal lesions., Methods: Ten patients diagnosed with a meniscal lesion, confirmed by magnetic resonance imaging, underwent five, step descent movements at slow speed under three different conditions: 1) no taping; 2) tension-free taping; and 3) patellar taping with medial tension. 3D kinematic data were recorded from the injured knee using an eight-camera infrared Vicon motion analysis system. Maximum and minimum angle values and total range of motion (maximum/minimum value) in three movement planes during single-limb stance were compared using a repeated measure ANOVA., Findings: Results showed a significant increase in the maximum and minimum angle value in the sagittal plane (mean differences=2.4° and 4.2°, respectively) and a decrease in the transverse plane (-6.3° and -2.2°, respectively) for the patellar taping condition compared to the no taping condition. A decreased rotational angle range when comparing the patellar taping to the no taping (-4.1°) and tension-free taping (-3.1°) conditions was also observed. These changes remained significant when pain was considered as a covariate in the analysis. The tension applied to the patellar tape played a role in controlling the sagittal and transverse plane step-down movement among patients in our study., Interpretation: These results support the use of patellar taping with a medially oriented tension to help to reduce the transversal plane movement of the knee in this population and they bring new light to the taping effect., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Pulmonary rehabilitation (PR) has proven effective in improving exercise tolerance and quality of life in patients with chronic obstructive pulmonary disease (COPD). In Canada, however, there are insufficient rehabilitation services. New strategies such as telerehabilitation must be deployed to increase accessibility. This study aims to investigate the effect of telerehabilitation on exercise tolerance and quality of life and to document patient satisfaction and adherence., Materials and Methods: Twenty-six patients with moderate to very severe COPD participated in this pre-/postintervention study. They received 15 in-home teletreatment sessions over 8 weeks via videoconference from a service center to their home. Education was provided via self-learning health capsules. Assessments were carried out twice before (T0 and T1; 8 weeks apart) and immediately after the intervention (T2). Primary outcome measures were changes in exercise tolerance (6-min walk test [6MWT] and cycle endurance test [CET]) and quality of life (Chronic Respiratory Questionnaire [CRQ])., Results: There were significant improvements between pre- and postintervention (T2-T1) on the 6MWT (32 m; p<0.001), CET (41 s; p=0.005), and three of four CRQ domains (dyspnea [p<0.001], fatigue [p=0.002], and emotion [p=0.002]). Improvements in the CET and fatigue during the 8-week intervention period were greater than changes over 8 weeks of maturation (T1-T0) (p=0.004 and 0.02, respectively). Participants' satisfaction and adherence rate with telerehabilitation were very high., Conclusions: Using telehealth technology to deliver in-home PR is a feasible and practical solution for patients with moderate to very severe COPD. The telerehabilitation program was associated with beneficial effects on exercise tolerance and quality of life and was well received by users.

Background: The availability of less resource-intensive alternatives to home visits for rehabilitation following orthopaedic surgeries is important, given the increasing need for home care services and the shortage of health resources. The goal of this trial was to determine whether an in-home telerehabilitation program is not clinically inferior to a face-to-face home visit approach (standard care) after hospital discharge of patients following a total knee arthroplasty., Methods: Two hundred and five patients who had a total knee arthroplasty were randomized before hospital discharge to the telerehabilitation group or the face-to-face home visit group. Both groups received the same rehabilitation intervention for two months after hospital discharge. Patients were evaluated at baseline (before total knee arthroplasty), immediately after the rehabilitation intervention (two months after discharge), and two months later (four months after discharge). The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire at the last follow-up evaluation. Secondary outcome measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, functional and strength tests, and knee range of motion. The noninferiority margin was set at 9% for the WOMAC., Results: The demographic and clinical characteristics of the two groups of patients were similar at baseline. At the last follow-up evaluation, the mean differences between the groups with regard to the WOMAC gains, adjusted for baseline values, were near zero (for 182 patients in the per-protocol analysis): -1.6% (95% confidence interval [CI]: -5.6%, 2.3%) for the total score, -1.6% (95% CI: -5.9%, 2.8%) for pain, -0.7% (95% CI: -6.8%, 5.4%) for stiffness, and -1.8% (95% CI: -5.9%, 2.3%) for function. The confidence intervals were all within the predetermined zone of noninferiority. The secondary outcomes had similar results, as did the intention-to-treat analysis, which was conducted afterward for 198 patients., Conclusions: Our results demonstrated the noninferiority of in-home telerehabilitation and support its use as an effective alternative to face-to-face service delivery after hospital discharge of patients following a total knee arthroplasty., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)