Economic Evaluation of Telerehabilitation: Systematic Literature Review of Cost-Utility Studies.

BACKGROUND: Telerehabilitation could benefit a large population by increasing adherence to rehabilitation protocols. OBJECTIVE: Our objective was to review and discuss the use of cost-utility approaches in economic evaluations of telerehabilitation interventions. METHODS: A review of the literature on PubMed, Scopus, Centres for Review and Dissemination databases (including the HTA database, the Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database), Cochrane Library, and ClinicalTrials.gov (last search on February 8, 2021) was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were defined in accordance with the PICOS (population, intervention, comparison, outcomes, and study design) system: the included studies had to evaluate patients in rehabilitation therapy for all diseases and disorders (population) through exercise-based telerehabilitation (intervention) and had to have a control group that received face-to-face rehabilitation (comparison), and these studies had to evaluate effectiveness through gain in quality of life (outcome) and used the design of randomized and controlled clinical studies (study). RESULTS: We included 11 economic evaluations, of which 6 concerned cardiovascular diseases. Several types of interventions were assessed as telerehabilitation, consisting in monitoring of rehabilitation at home (monitored by physicians) or a rehabilitation program with exercise and an educational intervention at home alone. All studies were based on randomized clinical trials and used a validated health-related quality of life instrument to describe patients' health states. Four evaluations used the EQ-5D, 1 used the EQ-5D-5L, 2 used the EQ-5D-3L, 3 used the Short-Form Six-Dimension questionnaire, and 1 used the 36-item Short Form survey. The mean quality-adjusted life years gained using telerehabilitation services varied from -0.09 to 0.89. These results were reported in terms of the probability that the intervention was cost-effective at different thresholds for willingness-to-pay values. Most studies showed results about telerehabilitation as dominant (ie, more effective and less costly) together with superiority or noninferiority in outcomes. CONCLUSIONS: There is evidence to support telerehabilitation as a cost-effective intervention for a large population among different disease areas. There is a need for conducting cost-effectiveness studies in countries because the available evidence has limited generalizability in such countries. TRIAL REGISTRATION: PROSPERO CRD42021248785; https://tinyurl.com/4xurdvwf.

Dry-land strength training vs. electrical stimulation in sprint swimming performance.

This study was undertaken to compare the effects of dry-land strength training vs. an electrical stimulation program on swimmers. Twenty-four national-level swimmers were randomly assigned to 3 groups: the dry-land strength training program (S), the electrical stimulation training program (ES), and the control (C) group. The training program lasted 4 weeks. The subjects were evaluated before the training, at the end of the training program, and 4 weeks later. The outcome values ascertained were peak torque during arm extension at different velocities (from -60 to 180°·s(-1)) using an isokinetic dynamometer and performance, stroke rate, and stroke length during a 50-m front crawl. A significant increase in swimming velocity and peak torque was observed for both S and ES at the end of the training and 4 weeks later. Stroke length increased in the S group but not in the ES group. However, no significant differences in swimming velocity between S and ES groups were observed. No significant changes occurred in the C group. Programs combining swimming training with dry-land strength or electrical stimulation programs led to a similar gain in sprint performance and were more efficient than swimming alone.

Effects of a physical training programme on cognitive function and walking efficiency in elderly persons with dementia.

OBJECTIVES: To study the effects of physical stimulation based on walking exercises, equilibrium and endurance on cognitive function and walking efficiency in patients with dementia. METHODS: Randomized controlled trial including 31 subjects suffering from dementia (age: 81.8 +/- 5.3 years). The intervention group (n = 16) benefited from a 15-week physical activity programme involving three 1-hour sessions per week. The control group (n = 15) did not practice any physical activities. Before and after rehabilitation, all subjects were evaluated with the Rapid Evaluation of Cognitive Functions test (ERFC French version) and walking analysis. RESULTS: After the 15 weeks of rehabilitation, the subjects from the intervention group improved their overall ERFC score (p < 0.01), while those in the control group decreased their overall ERFC score. Interactions were also observed between walking parameters and groups (p < 0.01); the intervention group improved walking capacities through heightened walking speed, stride length and a reduction in double limb support time. Lastly, the subjects from the control group presented a reduction in both walking speed and stride length. CONCLUSION: This study shows that a physical activity programme can slow cognitive decline and improve quality of walking in elderly persons suffering from dementia.

Decreasing subthalamic deep brain stimulation frequency reverses cognitive interference during gait initiation in Parkinson's disease.

OBJECTIVE: Freezing of gait (FOG) represents a major burden for Parkinson's disease (PD) patients. High-frequency (130-Hz) subthalamic deep-brain-stimulation (STN-DBS) has been reported to aggravate FOG whereas lowering the frequency to 60-80 Hz improves FOG. To further understand the effects of STN-DBS on FOG, we assessed the effects of 80-Hz and 130-Hz STN-DBS on gait initiation performance, in relation to motor and executive function processing. METHODS: Gait initiation was recorded in 19 PD patients and 20 controls, combined or not with a cognitive interference task with a modified Stroop paradigm. PD patients were recorded before surgery with and without dopaminergic treatment, and after surgery with 80-Hz and 130-Hz STN-DBS in a randomised double-blind crossover study. RESULTS: In the absence of cognitive interference, PD patients exhibited significant gait initiation improvement with dopaminergic treatment, 80-Hz and 130-Hz STN-DBS. Nine patients performed the cognitive interference task. With 130-Hz STN-DBS, all gait initiation parameters were significantly degraded, whereas the cognitive interference task induced no major changes before surgery and with 80-Hz STN-DBS, as in controls. CONCLUSIONS: High-frequency STN-DBS leads to an inability to simultaneously process motor and cognitive information while this ability seems preserved with low-frequency STN-DBS. SIGNIFICANCE: This study supports the potential benefit of 80-Hz STN-DBS on FOG.

Repetitive transcranial magnetic stimulation combined with cognitive training for the treatment of Alzheimer's disease.

OBJECTIVE: To assess the efficacy of a combination of cognitive training (COG) and repetitive transcranial magnetic stimulation (rTMS), on cognitive performance, locomotor activity, apathy, caregiver burden and dependence of patients with Alzheimer's disease (AD). METHODS: A combination of COG and rTMS was performed in 10 patients with AD (NeuroAD procedure) for a period of 5weeks (one session per day, 5days a week), without maintenance sessions. Patients were evaluated at the end of the treatment (D45) and 6months later (M6) by the Mini Mental State Examination (MMSE), the Alzheimer disease assessment scale - cognitive subscale (ADAS-Cog), various neuropsychological tests and clinical scores specific for locomotor activity, apathy, caregiver burden, and dependence, recorded before the study (baseline). RESULTS: The primary endpoint was the improvement of the ADAS-Cog score at D45, which was reached. Six months after the end of the treatment, the ADAS-Cog score returned to baseline value, except for the best responders who remained significantly improved. The other main result was the improvement of apathy and dependence scores at both D45 and M6 for the entire series of patients. No serious adverse events occurred and all patients completed the study. CONCLUSIONS: The results of this open-label study confirm the feasibility of the rTMS-COG procedure in AD patients, and suggest that these patients can benefit from the procedure, in terms of cognitive performances, apathy and dependence, even in the long term. These promising results remain to be confirmed in controlled studies based on a larger population size, which could also help identify the prognostic factors associated with good outcome, in order to optimize patient selection.

Rehabilitation of the psychomotor consequences of falling in an elderly population: A pilot study to evaluate feasibility and tolerability of virtual reality training.

BACKGROUND: A fall in elderly subjects can lead to serious psychological consequences. These symptoms can develop into Fear of Falling with behavioural disorders comparable to PTSD that may severely limit autonomy. Virtual reality training (VRT) could be seen as a worthwhile therapeutic approach for this syndrome since it has been shown to be a useful tool for motor rehabilitation or combat-related PTSD. We thus developed a training scenario for VRT with psychomotor therapists. OBJECTIVE: To test the feasibility and acceptability of VRT when used by elderly adults for fall rehabilitation. METHODS: Our population of 8 patients older than 75 years, with a Mini Mental Score Examination greater than 18/30 performed sessions of VRT and answered a questionnaire on the feasibility and acceptability of it. RESULTS: This sample showed a highly favourable response to the prototype of VRT. They found it easy to use, enjoyed the experience, and thought it realistic and helpful. CONCLUSION: The conclusions of our study are limited by sample size. However, applications with VRT can offer the potential of an acceptable technique for elderly subjects. The next step will be to show the efficacy of this method in the management of post-fall PTSD.

Ankle dorsiflexion delay can predict falls in the elderly.

The aim of this study was to investigate the kinematic and kinetic characteristics of walking in healthy non-faller elderly in order to develop predictive parameters for falls. A 1-year prospective trial was completed on a walking circuit with two integrated force platforms and an optoelectronic system for three-dimensional movement analysis. Gait was investigated in 54 volunteers who were healthy people over 60 who had not fallen in the previous year. The subjects were contacted 2-monthly over a period of 1 year. The results showed that 16 of the 54 people tested had fallen. There was no significant age difference between the group of fallers and the group of non-fallers. Fallers walked more slowly and tended to use a double support for a longer period of time. Fallers were less powerful but mainly showed fewer power and moment variations. The range of motion at the ankle and the hip was reduced. We noticed a change in the walking pattern, showing a delay in the dorsiflexion of the ankle at the swing phase. In conclusion, subclinical gait parameters occur in older people. The advent of neuromotor pattern alterations when walking is related to the tendency to fall. Ankle dorsiflexion delays, in particular, appear to be predictive of falls.

The Walking Trail-Making Test is an early detection tool for mild cognitive impairment.

BACKGROUND: Executive function impairment (in particular, mental flexibility) in the elderly, and in patients with mild cognitive impairment (MCI), is strongly correlated with difficulties in performing complex walking tasks. The aim of this study was to determine if the adaptation of a neuropsychological test (the Trail-Making Test), to evaluate executive functions during walking, can be an early detection tool for cognitive impairment. METHODS: Fifty subjects (15 young, 20 older, presumably healthy, and 15 MCI) were first evaluated for cognitive functions (Mini-Mental State Examination, Frontal Assessment Battery, and Trail-Making Test) and motor functions (10-meter walking test). All subjects then performed a spatial navigation, or a complex walking test (the Walking Trail-Making Test: [WTMT]), and their spatiotemporal walking variables were analyzed using cluster analysis. RESULTS: Following evaluation of WTMT locomotor performance, cluster analysis revealed three groups that were distinctly different in age and cognitive abiliTIES: a group of young subjects, a group of healthy older subjects, MCI subjects with amnestic impairment, and a group of MCI subjects with executive function impairment. The WTMT enabled early detection, (ie, borderline MCI) of dysexecutive impairment, with 78% sensitivity and 90% specificity. CONCLUSION: The WTMT is of interest in that it can help provide early detection of dysexecutive cognitive impairment.

Cognitive Impairment Assessment through Visuospatial Memory Can Be Performed with a Modified Walking Corsi Test Using the 'Magic Carpet'.

BACKGROUND: Subjects with mild cognitive impairment (MCI) have disturbances in their spatial navigation abilities and exhibit early deficits in visuospatial short-term memory. The purpose of the present study was to determine whether a quantitative (span score) and qualitative (evaluating navigation strategies used) analysis of the Corsi test (usual condition and complex navigation task) would be useful to reveal cognitive decline. METHODS: We evaluated the performance of 15 young adults, 21 healthy elderly subjects and 15 subjects with MCI using the electronic version of the Corsi test (the Modified Corsi Block-Tapping Test, MCBT) and the complex navigation task (the Modified Walking Corsi Test, MWCT). The MWCT, which is an adaptation of the Corsi test, assesses spatial memory when the subject walks in a complex environment. We used Richard et al.'s model [Cogn Sci 1993;17:497-529] to investigate problem-solving strategies during the Corsi tests. RESULTS: The span scores obtained on the MCBT and the MWCT were significantly lower in the healthy elderly subjects (MCBT = 5.0 ± 0.7; MWCT = 4.0 ± 0.7) and the subjects with MCI (MCBT = 4.7 ± 0.8; MWCT = 4.1 ± 0.9) than in the younger adults (MCBT = 6.2 ± 0.6; MWCT = 5.3 ± 1.0). The visuospatial working memory was more impaired in the complex navigation task (MWCT = 4.3 ± 0.9) than in the modified Corsi test (MCBT = 5.3 ± 0.8). Finally, the subjects with greater cognitive impairment were more likely to have inadequate or absence of problem-solving strategies. CONCLUSIONS: Investigating the problem-solving strategies used during the MWCT appears to be a promising way to differentiate between the subjects with MCI and the healthy elderly subjects.

Estimation of the risk factors for falls in the elderly: can meta-analysis provide a valid answer?

The objective of this study was to analyze whether a meta-analysis could allow us to draw useful conclusions about the risk factors for falls in the elderly. A systematic review was carried out of various databases and completed manually. To satisfy the inclusion criteria, an article had to examine a population of subjects aged over 60 years to pertain to falls occurring during daily living activities, and to involve observational or interventional studies. This review identified 4405 indexed articles published between 1981 and 2011. Of the 220 studies with available data that were included in the final study, just 4% were interventional. Among these 220 studies, just 45% offered a satisfactory level of scientific proof. In total, 88 meta-analyses were carried out on the 156 potential protectors or risk factors that were identified. Our systematic review and meta-analyses ensured that high-quality results were obtained from this comprehensive literature search and included a detailed assessment of the quality of the included studies. Several factors appeared to be disproportionately represented in the literature, a fact that likely reflects the objective and precise assessment of these factors rather than their importance in the falls of the elderly. Thus, we cannot be certain that we obtained the most comprehensive analysis of the risk factors for falling with this method. Meta-analyses can help to define the association between falls and various risk factors, but they have to be used complementary to systematic review for the assessment of risk factors.

Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis.

OBJECTIVE: To carry out meta-analyses on psychotropic drugs and to provide an update of the risk of falling in the elderly people related to psychotropic drugs. DESIGN: Meta-analyses of studies on psychotropic drugs. RESULTS: 177 studies are included, of which 71 have data on risk factors associated with psychotropic drugs. The odds ratio and 95% Cl for associations between use of psychotropic drugs and fall are 1.78 and 1.57-2.01, respectively. This result is statistically heterogeneous. This heterogeneity disappears in the group of very old participants for each class. CONCLUSION: Our study confirms the association between falls in the elderly people and psychotropic drugs. These results are similar to those of former meta-analyses but with different methods. It shows that these meta-analyses on psychotropic drugs have a small impact on prescribing habits. They only give evidence to support the association between psychotropic drugs and falls even if there is no proven link.

Laxatives as a risk factor for iatrogenic falls in elderly subjects: myth or reality?

BACKGROUND: The multifactorial nature of falls is well known, and several studies on falls in the elderly have reported that laxatives can be a risk factor, but without attempting to discuss possible mechanisms to explain this role. OBJECTIVE: We aimed to isolate studies in which the risk factors for falls in the elderly related to laxatives have been evaluated and to carry out a meta-analysis combining the results of all identified good-quality studies. METHODS: Systematic literature review using the keywords 'accidental fall/numerical data' and 'risk factors'. This was followed by a manual search for articles cited in the previously identified publications. Articles were analysed if they had study populations aged ≥60 years, reported on falls occurring in everyday life, were observational or interventional studies that identified laxatives as a risk factor for falls, and were written in French or English. Articles of this type that were considered to be of good quality were included in the meta-analysis. RESULTS: 3747 indexed articles published between 1981 and 2007 were identified. Of these, seven articles met all inclusion criteria and were analysed. The odds ratio (95% CI) for the association between use of laxatives and fall occurrence in subjects participating in the good-quality trials (n = 4) included in the meta-analysis was 2.03 (1.52, 2.72). This result was statistically homogeneous (percentage of the total variation across studies due to heterogeneity [I2] = 0). CONCLUSIONS: Elderly subjects treated with laxatives were twice as likely to fall compared with non-laxative users. The causal relationship was probably not directly attached to a side effect of the substance used, but rather a reflection of other pathologies (e.g. older age, confinement to bed, concomitant Parkinson's disease) that may themselves cause falls.