Curr Phys Med Rehabil Rep DOI 10.1007/s40141-016-0138-1

REHABILITATION TECHNOLOGY (BE DICIANNO, SECTION EDITOR)

A Systematic Review of Telerehabilitation and mHealth Interventions for Spinal Cord Injury Claire A. Wellbeloved-Stone 1 & Justin L. Weppner 2 & Rupa S. Valdez 1

# Springer Science + Business Media New York 2016

Abstract Spinal cord injury (SCI) is a devastating and expensive diagnosis, requiring ongoing rehabilitation. Technological solutions including telerehabilitation and mobile health (mHealth) have the potential to support rehabilitation activities at home. This systematic review evaluates the previous decade of telerehabilitation and mHealth interventions for SCI. Twelve relevant articles were returned from eight databases. Of these studies, only two focused on mHealth interventions. The included studies were representative of SCI cases in terms of gender, age, and injury type but not geographic region. The heterogeneity of the included studies coupled with a lack of standardized reporting guidelines precluded the development of specific recommendations for future intervention development. Rather, recommendations from this review focus on the need for a wide of range of future research in this domain, with a stronger focus on mHealth. Moreover, the results demonstrate a need for clear reporting standards to facilitate future narrative reviews and meta-analyses.

Keywords mHealth . Telerehabilitation . Telehealth . Telemedicine . Rehabilitation . Spinal cord injury

This article is part of the Topical Collection on Rehabilitation Technology * Rupa S. Valdez [email protected] 1

Department of Public Health Sciences, University of Virginia, P.O. Box 800717, Charlottesville, VA 22908, USA

2

Department of Physical Medicine and Rehabilitation, University of Virginia, 545 Ray C. Hunt Drive, Charlottesville, VA 22908, USA

Introduction Given that the leading causes of spinal cord injuries (SCI) nationally and globally are motor vehicle crashes, falls, and acts of violence, any person can sustain such an injury at any time [1, 2]. In the USA, the annual incidence of SCI is approximately 40 cases per million people, with an estimated 236,000 to 327,000 persons living with SCI [1]. Every year, approximately 11,000 people in the USA are hospitalized due to SCI [3, 4]. A person living with SCI has increased dependence on others and is often unable to return to work or school [2, 5]. SCI also leads to an increased risk of premature death—people living with SCI are two to five times more likely to die prematurely than those without SCI [2]. This increased risk of premature death is due to a variety of factors, including an increased risk of and complications resulting from influenza, pneumonia, respiratory problems, heart disease, neurological problems, and urological complications and infection [2]. SCI leads to higher rates of depression, anxiety, posttraumatic stress, and suicide [2, 6, 7]. While 1 in 20 Americans suffers from depression, that rate increases to 1 in 5 for people with SCI [8]. Another impact of SCI is the daily burden of living with chronic pain [9]. Due to the fact that SCI affects multiple systems and requires complex care, it has been classified as one of the five most expensive diagnoses [10]. Recent estimates for the yearly healthcare and living expenses for persons with SCI average $69,204 per year with estimated lifetime costs of $1,517,806 to $4,543,182 depending on age at time of injury and level of injury [1]. First year costs can average over $200,000 and the average cost after the first year is almost $70,000 [11]. Additionally, the World Health Organization reports a trend toward increasing prevalence of SCI globally as survival rates increase in high-income countries. [2]. As advanced medical care improves survival rates, it is necessary to determine how to improve treatment options and

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quality of life while simultaneously decreasing financial burden on the patient and the healthcare system. Individuals living with SCI require ongoing rehabilitation. Much of this rehabilitation is coordinated by providers specializing in Physical Medicine and Rehabilitation, a medical specialty concerned with diagnosis, evaluation, and management of persons with physical and cognitive disabilities [5, 12]. The physiatrist leads an interdisciplinary healthcare team to carry out a comprehensive rehabilitation plan [5, 12]. The ongoing care plan aims to give the individual a sense of control over their situation in which the patient feels little initial independence [5, 12]. As functional status, level of independence, and medical stability improve, the patient returns home and rehabilitation continues through an outpatient clinical setting [5, 12]. Consequently, the vast majority of people in the USA with SCI remain in a private residence post-injury [1], creating opportunities for expansion of rehabilitation into the home setting. Many intersecting forces [13–21], including costs are leading to the transition of care from institutional to patients’ home and community settings [22, 23]. This transition encourages patients with multiple chronic conditions to actively engage in their own care [15, 24, 25]. Moreover, this transition has prompted both public and private agencies to encourage research and development of technologies supporting patients in this more active role [26–28]. Two such technological solutions relevant to SCI are telerehabilitation (remote provision of rehabilitation services) [29] and mobile health technology (mHealth) [30, 31] focused on rehabilitation activities. There is rapidly growing interest in the use of telemedicine [32] and mHealth [33] for supporting patients, including those requiring rehabilitative services [34], with managing their condition. Winters distinguishes between telemedicine (the delivery of clinical services) and telehealthcare (the management of disability and health) [35]. Schmeler et al. argue that telerehabilitation deserves to be distinguished as well, due to its focus on physical therapy, occupational therapy, audiology, speech-language pathology, and neuropsychology [36]. Telerehabilitation services are generally provided by telephone, text, email, videoconference, and/or other web-based technologies [37, 38] and often require at least a mediumbandwidth Internet connection [37]. Although 84 % of adults in the USA report using the Internet [39], only 69 % of adults report having a broadband connection at home [40]. Not having a broadband connection could be a significant barrier to receiving telerehabilitation. However, 68 % of adults report having a smartphone [41] and 13 % of adults who report having a smartphone do not have broadband at home [40]. Additionally, 45 % of adults own a tablet computer [41]. This opens up opportunities for mHealth as a means of supporting SCI patients at home. Specifically, there has been interest in using mHealth in rehabilitation to maintain therapy plans and receive help with home exercises, aid patients

during transitions of care, as well as monitor patients and provide feedback [34]. The objective of this paper is to determine how mHealth and telerehabilitation are being used to support people living with SCI at home. Such an understanding will enable us to determine gaps in the types and impact of technologies and interventions currently available. Identification of these gaps will facilitate the development of a research agenda at the intersection of telerehabilitation, mHealth, and SCI to improve management of SCI in home and community settings. Previously published reviews related to this topic have focused exclusively on the intersection of SCI and telecounseling. One systematic review on SCI and telecounseling was published in 2013 [42]. One meta-analysis that included SCI among other diagnoses was published in 2011 [43]. This meta-analysis only included three articles focused on SCI. In addition to a limited focus on telecounseling, both of these reviews limited their scope to psychosocial factors and consequently did not include physical rehabilitation. Our review broadens this previous scope to include the whole suite of telerehabilitation in addition to mHealth as related to SCI. Moreover, our review expands the focus to all aspects of rehabilitation, encompassing both psychosocial and physical factors.

Methods We conducted a systematic review of literature published between January 2006 and March 2016 to explicate the current state of mHealth and telerehabilitation interventions focused on SCI. Due to the heterogeneity of the articles returned, we were unable to conduct any meta-analyses. Instead, the review reported here is narrative in nature [44]. Search We searched the following databases for relevant records: Association for Computing Machinery (ACM), Computers and Applied Sciences Complete (CASC), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Reviews, Engineering Village, Institute of Electrical and Electronics Engineers, National Center for Biotechnology Information-PubMed (PubMed), and Web of Science. These searches were developed with the aid of two librarians at the University of Virginia School of Medicine. The final searches were conducted between March 30, 2016 and April 1, 2016. The search terms for each database may be found in Appendix Table 1. To the extent possible, search terms were identical across databases. However, when appropriate, we used search terms that matched the ontologies relevant to each database. The final search yielded a total of 104 records after duplicates were removed (see Fig. 1). Additionally, there were two papers that reported on the same study; these are distinguished in Fig. 1

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by the terms “study” and “record.” We reported on only one of these studies, as all the data were the same across both records.

&

Setting: any setting, as long as the intervention was ultimately intended for use in the home or community

Three individuals (CWS, JW, and a research assistant) were involved in screening articles for inclusion. If an article did not meet inclusion criteria, it was excluded from the review. There were no additional exclusion criteria. The inclusion criteria were as follows:

The same three individuals independently screened the records based on title and abstract using the above inclusion criteria. If fulfillment of inclusion criteria was unclear, articles were referred to full text. Two individuals (CWS and JW) independently screened full text of records that were included based on title and abstract. Any disagreements for both processes were resolved by consensus.

& &

Data Extraction

Screening

& & &

Publication date: January 2006–March 2016 Record type: journal article. Any language was permissible; however, all articles yielded from the search were published in English. The authors were able to obtain the full text of all screened articles Study focus: (1) mHealth or telemedicine, (2) rehabilitation, and (3) spinal cord injury (at least some of the participants in the study must have been diagnosed with SCI specifically) Intervention user: the mHealth or telemedicine intervention described must be for use by patients Method: the mHealth or telemedicine intervention must have been tested or evaluated with a patient population

Two individuals (CWS and JW) independently extracted data from included articles. The reviewers developed and used a standardized Excel document to record extracted data. All categories were inductively generated based on how the authors of the 12 included articles reported intervention characteristics. Differences in data extraction were resolved by consensus. The following were extracted: &

Category: Publication –

&

Category: Sample –

&

Data collected: Study setting (e.g., clinic, rehabilitation center, home), geographic location of study, data collection methods, standardized data collection tools (e.g., Mini-Mental State Examination (MMSE), Disabilities of the Arm, Shoulder, and Hand (DASH) Index), randomization of participants, type of study (e.g., RCT, case–control, case report), length of study, description of primary intervention and technology platform, secondary technologies used for the intervention (e.g., web cam, earpiece with accelerometer, magnetic tongue stud), discussion of HIPAA or data encryption

Category: Outcomes –

Fig. 1 PRISMA diagram

Data collected: Sample size, gender, age, condition/ injury (e.g., spina bifida, multiple sclerosis, spinal cord injury), SCI level, type of SCI (e.g., tetraplegia, paraplegia, complete, incomplete), comorbidities (e.g., pressure ulcers, depression, pain), attrition rate

Category: Study methods –

&

Data collected: First author, title, year

Data collected: List of outcomes measured, outcomes observed in study

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Included articles sometimes contained multiple subcategories for a given category. For example, several interventions included patients with multiple comorbidities. Consequently, the sum across subcategories for a given category sometimes exceeds the number of included articles. Examples of such categories include condition/injury, comorbidities, and standardized data collection tools used.

Results

injury level (C4, n = 1; C5, n = 2; C6, n = 2; C7, n = 1) [50, 56], and two reported ranges of nerve levels (c1–c8, n = 1; t1– t12, n = 1; l1–l2, n = 1; and C6–7, n = 1; T2–7, n = 1; T8 and below n = 1) [46, 54]. One of these studies also reported postpolio (n = 1) [54]. Another one of these also reported the American Spinal Injury Association (ASIA) Classification level, and one reported only the ASIA level (A5, n = 1; D3, n = 1; D6–D7, n = 1) [51, 56]. A fifth study reported the injury levels as high tetraplegia incomplete, low tetraplegia complete, and low tetraplegia incomplete (n = 1). [45]. Details about SCI level may be found in Appendix Table 2.

A total of 12 studies met our inclusion criteria [45–56]. Publication There were 12 unique first authors across each of the included papers. The earliest study included was published in 2008 [52], and the most recent studies included were published in 2016 [49, 55]. Details about publication information may be found in Appendix Table 2. Sample Sample Size The number of participants in the studies ranged from 1 [51] to 142 [46], with an average of 32.7 (standard deviation = 44.3) participants across all 12 studies. Details about sample size may be found in Appendix Table 2. Gender Participants in 10 of the 12 studies were predominantly male [45, 46, 48–52, 54–56]. Of the two remaining studies, one had an exclusively female sample [47], while another contained a sample that was approximately 75 % female [53]. This latter study, however, was not exclusively focused on SCI. Details about gender may be found in Appendix Table 2. Age Of the nine studies reporting mean age, this mean ranged from 36 to 57 [45–48, 50, 53–56]. One study reported approximate ages, 50s and 60s, for the two participants [52] and one study had only one participant who was 47 [51]. The remaining study [49] reported a median age of 37 and a range of 27– 56. Details about age may be found in Appendix Table 2. Condition/Injury Nine studies were focused solely on participants with SCI [45, 47, 49–52, 54–56]. The remaining three studies also included participants with traumatic brain injury (TBI) (n = 1) [48], multiple sclerosis (MS) (n = 2) [46, 53], spina bifida (n = 1) [53], cerebral palsy (n = 1) [53], stroke (n = 1) [53], and/or lupus (n = 1) [53]. Details about condition/ injury may be found in Appendix Table 2. SCI Level Only four studies reported specific SCI level [46, 50, 54, 56]. Two of these studies reported individual nerve

Type of SCI Eight of the studies reported on the type of SCI [48, 53–55]. Of these, three reported on tetraplegia alone [49, 50, 56], one reported on paraplegia alone [51], one reported on a participant with tetraplegia and a participant with an unspecified case of SCI [52], and the remaining three reported on both tetraplegia and paraplegia [45–47]. Of these eight studies, four reported on type of SCI by whether it was complete or incomplete [45, 46, 50, 52]. In three of these studies, incomplete injuries were more common than complete [46, 50, 52]. In the remaining study, more participants had complete injuries [45]. Details about type of SCI may be found in Appendix Table 2. Comorbidities Seven studies reported comorbidities [45, 46, 52–56]. Comorbidities reported include pressure ulcers (n = 2) [45, 46], depressed mood or past diagnosis of depression (n = 2) [46, 52], substance abuse (n = 1) [52], BMI over 25 (n = 1) [53], pain (n = 2) [54, 55], bladder and bowel complications (n = 1) [55], diabetes (n = 1) [55], hypertension (n = 1) [55], and tooth decay (n = 1) [56]. Details about comorbidities may be found in Appendix Table 2. Attrition Rate Of the nine studies [46–51, 53, 54, 56] that reported attrition, the rates ranged from 0 to 47.6 %. Details about attrition rate may be found in Appendix Table 2. Study Methods Study Setting Six of the studies took place in home or community settings [46, 47, 51–53, 55]. Three of the studies took place in hospital or lab settings [45, 48, 49]. The remaining three studies took place in both a lab or hospital and home or community setting [50, 54, 56]. Details about study setting may be found in Appendix Table 3. Geographic Location Eight of the studies were based in the USA [45, 46, 49, 52–56]. Of these eight, four involved more than one state and region [46, 49, 53, 55]. There were two studies from Canada [47, 48], one study from Canada and Australia [50], and one study from France [51]. Details about geographic location may be found in Appendix Table 3.

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Data Collection Methods The data collection methods included clinical assessment (n = 5) [45, 50, 54–56], observations (n = 3) [48, 49, 51], interviews (n = 5) [46–48, 55, 56], surveys (n = 1) [54], questionnaires (n = 1) [46], focus groups (n = 1) [47], and health appraisals (n = 1) [53]. Details about data collection methods may be found in Appendix Table 3. Standardized Data Collection Tools Used Six studies reported on the use of one or more standardized data collection tools [46, 47, 53–56]. Tools used in the studies included Pressure Ulcer Scale for Healing (PUSH) version 3.0 (n = 1) [46], Patient Health Questionnaire (n = 1) [46], Cornell Services Index (n = 1) [46], Craig Hospital Inventory of Environmental Factors-Short Form version 3.0 (n = 1) [46], CareCall log (n = 1) [46], Participatory development tools (n = 1) [47], Mini-Mental State Examination (MMSE) (n = 1) [53], Wheelchair User’s Shoulder Pain Index (WUSPI) (n = 1) [54], Shoulder Rating Questionnaire (SRQ) (n = 1) [54], Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure (n = 1) [54], Duke Severity of Illness Checklist (DUSOI) (n = 1) [55], Short Form-8 (SF-8) Health Survey (n = 1) [55], Loe-Silness Gingival Index (LSGI) (n = 1) [56], and Oral Home Telecare Questionnaire (OHTQ) (n = 1) [56]. Details about standardized data collection tools used may be found in Appendix Table 3. Randomization Participants were randomized in three of the included studies [3, 46, 50]. In one additional study, the evaluators, rather than participants, were randomized [45]. Details about randomization may be found in Appendix Table 3. Type of Study The types of study represented in this review include RCTs (n = 3) [46, 50, 53], case studies (n = 3) [48, 51, 52], pre-post studies (n = 2) [54, 56], case–control studies (n = 1) [49], community-based participatory research (n = 1) [47], cohort studies (n = 1) [45], and pilot studies (n = 1) [55]. Details about type of study may be found in Appendix Table 3. Length of Study Eight studies reported on study length [46, 47, 49, 50, 53–56]. Of these, the study length ranged from 210 days to 20 months. Details about length of study may be found in Appendix Table 3.

conferencing equipment [48]. Four of the nine studies focused on telephone interventions [46, 47, 52, 53]. Three of these studies used standard phone systems [47, 52, 53], while the remaining study used the CareCall system, which was developed for the study [46]. One of the nine studies had both phone and video interventions [45]. This study used a standard phone system and the Aviva 1010XR and American Telecare systems for videoconferencing [45]. Of the remaining three studies, one used a standalone data messaging system [55] and two used smartphone applications [49, 51]. The standalone data messaging system, Health Buddy, is commercially available [55]. Of the two smartphone applications, one was a dedicated system for use in the study [48], while the other, Wegoto, is available in the App Store [51]. Details about the intervention technology platforms may be found in Appendix Table 3. Secondary Technology Used for Intervention The interventions reported in five of the studies included additional technologies beyond computers or telephones [45, 49, 50, 54, 56]. The technologies reported include videoconferencing equipment (n = 2) [45, 54]; a technology bundle including eTDS headset, TDS-PWCsmartphone interface, magnetic sensor board, magnetic tongue stud, USB transceiver, and control unit of the eTDS headset (not yet commercially available) (n = 1) [49]; a technology bundle including ReJoyce workstation, fingerless glove, earpiece with accelerometer (commercially available) (n = 1) [50]; and a technology bundle including a powered toothbrush, adapted flosser, and/or oral irrigator (n = 1) [56]. Details about secondary technology used for intervention may be found in Appendix Table 3. Discussion of HIPAA or Data Encryption None of included studies discussed HIPAA or data encryption. Details about the discussion of HIPAA or data encryption may be found in Appendix Table 3. Outcomes

Description of Intervention Technology Platform Nine of the studies involved communicating with the participant via a phone or video call [45–48, 50, 52–54, 56]. Of these nine phone or video interventions, one system was automated [46], five were with physical or mental health providers [45, 48, 52, 54, 56], two were with telephone coaches or telesupervisors [50, 53], and one was with a variety of guest speakers [47]. Furthermore, of these nine studies, four were focused on video interventions [6, 48, 50, 54]. Two studies used Skype [50, 54], one used Scopia [56], and one used Tandberg

List of Outcomes Measured Nine of the included studies reported patient outcome measures, including change in pressure ulcers, depression severity, healthcare utilization, and CareCall usage (CareCall is an interactive automated call system that uses branching logic to create an individualized phone call about health and wellness) (n = 1) [46]; whether telerehabilitation did or did not become part of routine use, factors that enabled or constrained telerehabilitation use, and if the identified factors related to the structure or the agent, as defined in the conceptual framework (n = 1) [48]; proficiency

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in unidirectional tapping, multidirectional tapping, and wheelchair driving tasks, as well as completion time for phone dialing and weight shifting tasks (n = 1) [49]; accessibility index as measured by accelerometer values (n = 1) [51]; and pain and function measured with the WUSPI, DASH Index, and SRQ. Secondary outcomes included isometric strength and static fatigue (n = 1) [54]; body weight, BMI, barriers to physical activity (B-PADS) score, aerobic exercise (min/ week), strength exercise (min/week), total exercise (min/ week), fat score, fiber score, and fruit/vegetable score (n = 1) [53]; gingival inflammation in LSGI scores (baseline, 6 months, 12 months), frequency of brushing, flossing and oral irrigator use, and tooth brushing time (n = 1) [56]; individualized patient outcomes and progress toward treatment goals (n = 1) [55]; and Action Research Arm Test (ARAT) and ReJoyce automated hand function scores (n = 1) [50]. Two of the studies were qualitative in nature and did not set out to measure patient outcomes (n = 2) [47, 52]. The remaining study measured evaluators’ accuracy, including agreement on the presence of pressure ulcers, staging of pressure ulcers, wound characteristics, and wound size (n = 1) [45]. Details about outcomes measured may be found in Appendix Table 4. Observed Outcomes The quantitative outcome measures reported across eight studies [45, 46, 49, 50, 53–56] primarily demonstrated positive intervention impacts. Of the 57 outcome measures reported with statistical significance, 40 demonstrated positive impact, 15 demonstrated no impact, and 2 demonstrated negative impact. The latter demonstrated an increase in neurogenic bowel severity [55] and low satisfaction with videoconferencing equipment [56]. The remaining four studies [47, 48, 51, 52] reported outcomes in a qualitative form. Overall, these results were positive. The two studies [47, 52] that focused on teletherapy for social and mental support reported that teletherapy increased positive behaviors and attitudes and also supported more comprehensive care. Another study [48] identified facilitators and barriers to implementing telemedicine and found that a major facilitator was increased use of and familiarity with the technology. In contrast, a major barrier was lack of human resources. The final study [51] examined a wheelchair navigation program and reported positive observations of the participant’s navigation using the app and the accelerometer values were consistent with the route based on the study algorithm. Details about observed outcomes may be found in Appendix Table 4.

Discussion This review corroborates earlier literature suggesting the feasibility of incorporating telerehabilitation into multiple aspects—exercise plans, continuation of care, mental support,

and increased physical function—of SCI management. The studies included in this review took a range of approaches to supporting SCI patients in the home and community through telerehabilitation interventions. Despite this demonstration of feasibility, this review also highlights that incorporating telerehabilitation into SCI care plans has not yet become a common practice. Only 12 studies met our inclusion criteria. This contrasts significantly with telehealth interventions for other conditions; for example, a 2012 review found 1324 Medline publications between 1990 and 2011 about telemedicine and asthma, COPD, diabetes, heart failure, or hypertension [57]. The interventions reported in this review predominantly rely on traditional telemedicine platforms, including telemonitoring, videoconferencing, and phone calls. This is consistent with the general trend of telemedicine for other conditions—traditional telemedicine modalities are still more prevalent than mHealth interventions [58–61]. mHealth interventions for SCI remain rare, with only 2 of the 12 studies focusing on mHealth. These interventions were focused on independent living—wheelchair navigation and use of an iPhone or computer if paralyzed—rather than coordination of care. In addition to being less prevalent than telemedicine modalities, mHealth interventions are also less common for SCI than for other conditions. For example, a 2012 review focused on diabetes found 10 studies with mobile phone-related interventions [60], a 2016 review found 393 mobile apps for weight management [62], and a 2013 review found 42 mHealth platforms for chronic diseases and elders [63]. Medical applications are expected to grow by 23 % from 2012 to 2017 [30]. The rapid growth of the mHealth market is beneficial for managing a chronic disease associated with high medical costs [64]. mHealth reduces costs by reducing the need for as many in-person medical visits, which affects both medical and transportation costs [64]. Since rehabilitation for SCI is an ongoing and expensive process, the use of mHealth may help reduce the financial burden on individual patients and on the healthcare system. More studies are needed to be able to draw any meaningful conclusions about the role of mHealth within SCI rehabilitation. None of the studies discussed HIPAA compliance or data encryption, which are regarded as important topics in the expanding fields of telemedicine and mHealth [65, 66]. Security is a particularly important issue in mHealth since there are no comprehensive standards for HIPAA compliance nor other security regulations [65–67]. Despite the lack of formal discussion of HIPAA or data encryption, the issue of privacy was mentioned briefly in 3 of the 12 studies [52, 55, 56]. In these studies, the authors reported on privacy concerns that were

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mentioned by participants. These specific concerns included a lack of privacy on the phone while at home for mental care [52], a desire to use the DMD without the assistance of a caregiver for privacy and confidentiality [55], and a violation of privacy when using videoconferencing [56]. Given participant feedback and the clinical and legal issues posed by minimal regulation [66, 67], future research must systematically address the privacy and security features of telerehabilitation and mHealth interventions for SCI. Our systematic review found that participation in SCIrelated mHealth and telemedicine studies is representative across characteristics such as gender, age, and type of injury (i.e., complete or incomplete). However, it is not representative in terms of geographic distribution of SCI cases. A review of global prevalence and incidence of traumatic SCI cites a high male-to-female ratio [68], which is consistent with the higher male representation in the majority of the studies included in this review. The average age of injury is 42 years [69], which is also consistent with the central tendency of participant ages represented in the included studies. Furthermore, incomplete injuries are more common, comprising 66.3 % of all spinal cord injuries [69]. The participants of included studies were also predominantly persons with incomplete spinal cord injuries. Based on gender and age, the studies were fairly representative of the SCI population. In contrast, even though the searches were not filtered by language, all studies were published in English, and most of the studies were based in the USA or Canada. Other geographic regions with similar incidence rates such as Estonia, Iran, and Portugal were absent from the literature [68]. However, given the absence of an accurate global prevalence estimate, establishing geographic representation is difficult [2]. This shortcoming is indicative of the need for global SCI reporting standards and guidelines [70–72]. The lack of reporting standards for SCI also leads to challenges in creating a synthesized understanding of current work and future needs [70–72]. For example, two studies used the American Spinal Injury Association Classification level while the other studies reported either the specific nerve injury level or range of nerve injury levels. Yet another study reported high or low injury level instead of listing the specific nerves. Similarly, there was inconsistency in whether studies reported complete or incomplete SCI. This inconsistency is a barrier to summarizing results and identifying gaps across studies. Recognizing this limitation within the SCI field, an international research team has begun to develop reporting standards for SCI studies [73]. One reporting standard that the team suggested is common data elements and minimum information standards [73]. This development

should lead to improvements in creating actionable results from systematic reviews. This review also found that the reported outcome measures were largely positive, similar to the SCI systematic review [42] and meta-analysis [43] mentioned earlier. Together, these previous reviews and ours suggest that telerehabilitation may be beneficial for SCI patients suffering from depression, which is important since SCI leads to much higher rates of depression, anxiety, post-traumatic stress, and suicide [2, 6, 7]. Both studies identified a knowledge gap and a need for further research on SCI and telehealth. Our results support this conclusion. Limitations A major limitation of this review is that inclusion criteria had to be kept broad to capture a sizable corpus of articles. The studies addressed different aspects of SCI including oral health, wheelchair accessibility, shoulder strength, and weight loss. Consequently, the heterogeneity of the included articles made comparison difficult, particularly for outcome measures.

Conclusions This review highlights the opportunity to expand our understanding of the impact of telerehabilitation and mHealth on SCI. The large majority of the included studies demonstrated positive outcomes. Thus, there is demonstrated potential for telerehabilitation and mHealth interventions to improve lives of individuals with SCI in home and community settings. Given both the paucity and heterogeneity of the studies, it is difficult to generate conclusive recommendations about the most promising directions for future research. Consequently, we encourage a diversity of research in this space. Acknowledgments This research is supported by the Agency for Healthcare Research and Quality (AHRQ) under award number 1 R21 HS023849-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ.

Compliance with Ethical Standards Conflict of Interest Claire A. Wellbeloved-Stone and Rupa S. Valdez report a grant from Agency for Healthcare Research and Quality, during the conduct of the study. Justin L. Weppner declares that he has no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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Appendix

Table 1

Search terms

Database

Search performed

Association for Computing Machinery (ACM)

1. (mhealth OR mobile health OR m-health OR m health OR telehealth OR telemedicine OR cell phone OR smartphone OR iphone OR android phone OR texting OR text messaging +spinal +cord +injury); 2. (+central +cord +syndrome mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 3. (+paraparesis mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 4. (+ quadriplegia mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 5. (+posterior +cord +syndrome mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 6. (+anterior +cord +syndrome mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 7. (+conus +medullaris +syndrome mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 8. (+cauda +equina +syndrome mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 9. (+tetraparesis mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 10. (+tetraplegia mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 11. (+paraplegia mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging); 12. (+brown-sequard +syndrome mhealth mobile health m-health m health telehealth telemedicine cell phone smartphone iphone android phone texting text messaging) S1 ((“mobile health or mhealth or m-health” OR (MH “Telehealth”))) OR (cell phones or smartphones or smart phones or cellular phones) OR (texting or text messaging) S2 ((MH “Spinal Cord Injuries”) OR (MH “Central Cord Syndrome”) OR (MH “Brown-Sequard Syndrome”) OR “spinal cord injury” OR (MH “Paraplegia”) OR “tetraplegia” OR (MH “Quadriplegia”) OR (MH “Cauda Equina”) OR (MH “Polyradiculopathy”) OR “conus medullaris syndrome”) S3 (((MH “Spinal Cord Injuries”) OR (MH “Central Cord Syndrome”) OR (MH “Paraplegia”) OR “tetraplegia” OR (MH “Quadriplegia”) OR (MH “Polyradiculopathy”) OR “conus medullaris syndrome”)) AND (S1 AND S2) S1 ((“mobile health or mhealth or m-health” OR (MH “Telehealth”))) OR (cell phones or smartphones or smart phones or cellular phones) OR (texting or text messaging) S2 ((MH “Spinal Cord Injuries”) OR (MH “Central Cord Syndrome”) OR (MH “Brown-Sequard Syndrome”) OR “spinal cord injury” OR (MH “Paraplegia”) OR “tetraplegia” OR (MH “Quadriplegia”) OR (MH “Cauda Equina”) OR (MH “Polyradiculopathy”) OR “conus medullaris syndrome”) S3 (((MH “Spinal Cord Injuries”) OR (MH “Central Cord Syndrome”) OR (MH “Brown-Sequard Syndrome”) OR “spinal cord injury” OR (MH “Paraplegia”) OR “tetraplegia” OR (MH “Quadriplegia”) OR (MH “Cauda Equina”) OR (MH “Polyradiculopathy”) OR “conus medullaris syndrome”)) AND (S1 AND S2) (((Cell phone OR Cell phones OR Cellular phone OR Mobile phone OR Mobile phones OR Smart phone OR Smart phones OR Smartphone OR Smartphones OR Tablet OR iPod OR iPad OR Android OR Text Messaging OR Texting) WN ALL) AND ((spinal cord injury OR Central cord syndrome OR Brown-Sequard Syndrome OR Paraplegia OR Paraparesis OR Tetraplegia OR Tetraparesis OR Cauda Equina Syndrome OR Conus Equina Syndrome OR Conus Medullaris Syndrome OR Anterior Cord Syndrome OR Posterior Cord Syndrome) WN ALL)) ((mhealth OR mobile health OR m-health OR m health OR telehealth OR telemedicine) AND (spinal cord injury OR spinal cord injuries OR paraplegia OR tetraplegia)) ((texting OR text messaging) AND (spinal cord injury OR spinal cord injuries OR paraplegia OR tetraplegia)) ((cell phone OR smartphone OR iphone OR android phone) AND (spinal cord injury OR spinal cord injuries OR paraplegia OR tetraplegia)) (“telemedicine” [MeSH Terms] OR “telemedicine” [All Fields] OR “mhealth” [All Fields] OR “Cell Phones” [MeSH Terms] OR “Computers, Handheld” [MeSH Terms] OR “Cell phone” [All Fields] OR “Cell phones” [All Fields] OR “Cellular phone” [All Fields] OR “Mobile phone” [All Fields] OR “Mobile phones” [All Fields] OR “Smart phone” [All Fields] OR “Smart phones” [All Fields] OR (“smartphone”[MeSH Terms] OR “smartphones”[All Fields]) OR “mp3-player”[MeSH Terms] OR “mp-3 player”[All Fields] OR “ipod” All Fields” OR “iPad”[All Fields] OR “tablet computer”[All Fields] OR “Android phone”[All Fields] OR “text messaging”[All Fields]) AND (“Central cord syndrome”[All Fields] OR “Brown-Sequard Syndrome”[All Fields] OR “Traumatic spinal cord injury”[All Fields] OR “paraplegia”[MeSH Terms] OR “paraplegia”[All Fields] OR “tetraplegia”[All Fields] OR “tetraparesis”[All Fields] OR “Cauda Equina Syndrome”[All Fields] OR “Conus Medullaris Syndrome”[All Fields] OR “Anterior Cord Syndrome”[All Fields] OR “Posterior Cord Syndrome”[All Fields] OR (Incomplete[All Fields] AND “spinal cord injuries”[MeSH Terms]) OR “spinal cord injuries”[All Fields] OR (“spinal”[All Fields] AND “cord”[All Fields] AND “injury”[All Fields]) OR “spinal cord injury”[All Fields]) TS = ((“mobile health” OR “mhealth” OR “m-health” OR “telehealth” OR “cell phones” OR “smartphones” OR “smart phones” OR “cellular phones” OR “texting” OR “text messaging”) AND (“Spinal Cord Injuries” OR “Central Cord Syndrome” OR “Brown-Sequard Syndrome” OR “spinal cord injury” OR Paraplegia OR tetraplegia OR Quadriplegia OR “Caude Equina” OR Polyradiculopathy OR “conus medullaris syndrome”))

Computers and Applied Sciences Complete (CASC)

Cumulative Index to Nursing and Allied Health Literature (CINAHL)

Engineering Village

Institute of Electrical and Electronics Engineers (IEEE)

National Center for Biotechnology Information-PubMed (PubMed)

Web of Science

ACM Association for Computing Machinery, CASC Computers and Applied Sciences Complete, CINAHL Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, Engineering Village, Institute of Electrical and Electronics Engineers, PubMed National Center for Biotechnology Information-PubMed, and Web of Science

Accessing peers’ and healthcare experts’ wisdom: a telephone peer support program for women with SCI living in rural and remote areas Exploring routine use of telemedicine through a case study in rehabilitation

Assessment of the tongue-drive system using a computer, a smartphone, and a powered-wheelchair by people with tetraplegia In-home tele-rehabilitation improves tetraplegic hand function

Jalovcic 2009

Kim 2016

Telehealth weight management intervention for adults with physical disabilities: a randomized controlled trial

Rimmer 2013

Mozer 2008

Wegoto: a smartphone-based approach to assess and improve accessibility for wheelchair users Psychotherapeutic intervention by telephone

Mourcou 2013

Kowalczewski 2011

Kairy 2014

A pilot study of a telehealth intervention for persons with spinal cord dysfunction

Houlihan 2013

100 % (n = 1)

100 % (n = 2)

24.2 % (n = 22)

2

102

54 % (n = 7)

82 %

Mean = 46. ± 12.7

One participant in 50s and one participant in 60s

47

Mean = 35.92 ± 11.96

Median = 37 (range 27–56)

Mean = 37.2 (range 21–60)

Mean = 48.4 (range 43–58)

0 % (n = 0)

100 % (n = 5)

Mean = 48.2 ± 13.3

Mean = 58 ± 13

Age

61.3 % (n = 87)

95 % (n = 40)

1

13

21 (in phase 3)

5

7

142

Validation of home telehealth for 42 pressure ulcer assessment: a study in patients with spinal cord injury

Hill 2009

Sample size Gender (% (N) male)

Title

Publication and sample information

Study (author, year)

Table 2

Spinal cord injury, multiple sclerosis, spina bifida, cerebral palsy, stroke, or

SCI

SCI

SCI

SCI = 60 % (n = 3); TBI = 40 % (n = 2) SCI

SCI

SCI = 74.6 % (n = 106); MS = 25.3 % (n = 36)

SCI

Condition

Tetraplegia

N/R

Complete paraplegia = 31 % (n = 13); incomplete paraplegia = 24 % (n = 10); missing paraplegia information = 7 % (n = 3); tetraplegia = 38 % (n = 16) Paraplegia, incomplete = 30.0 % (n = 30); paraplegia, complete = 24.0 % (n = 24); tetraplegia, incomplete = 28.0 % (n = 28); tetraplegia, complete = 18.0 % (n = 18) Tetraplegia = 14.3 % (n = 1); paraplegia = 85.7 % (n = 6)

Type of SCI

N/R

N/R

One participant with incomplete tetraplegia and one participant without specified SCI type N/R

Complete tetraplegia 31 % (n = 4); incomplete tetraplegia 69 % (n = 9) D6–D7 = 100 % (n = 1) Paraplegia

C5 = 38 % (n=5); C6 = 31 % (n = 4); C7 = 31 % (n = 4)

N/R

N/R

N/R

High tetraplegia incomplete = 7 % (n = 3); low tetraplegia complete = 10 % (n = 4); low tetraplegia incomplete = 21 % (n = 9) c1–c8 = 49.5 % (n = 51); t1–t12 = 44.7 % (n = 46); l1–l2 = 5.8 % (n = 6)

SCI level

BMI over 25 required

Depressed mood and substance abuse

N/R

N/R

N/R

N/R

History of pressure ulcers = 46.5 % (n = 66); currently has pressure ulcer(s) = 7.0 % (n = 10); past diagnosis of depression = 38.7 % (n = 55) N/R

Pressure ulcers

Comorbidities reported

12.7 % (n = 13)

N/A (case study)

0 % (n = 0)

0 % (n = 0)

47.6 % (n = 10)

0 % (n = 0)

0 % (n = 0)

6.3 % (n = 9)

N/R

Attrition rate

Curr Phys Med Rehabil Rep

Effect of a home telecare 8 program on oral health among adults with tetraplegia: a pilot study

Yuen 2013

N/R not reported

Woo 2016

Effectiveness of home exercise 16 on pain, function, and strength of manual wheelchair users with spinal cord injury: a high-dose shoulder program with telerehabilitation 33 Increasing specialty care access through use of an innovative home telehealth-based spinal cord injury disease management protocol (SCI DMP)

Van Straaten 2014

Mean = 49 ± 11

Mean = 57 (range 36–84)

100 % (n = 33)

87.5 % (n = 7)

Mean = 41 (range 25–64)

Age

81 % (n = 13)

Sample size Gender (% (N) male)

Title

Study (author, year)

Table 2 (continued)

SCI

SCI

lupus; participants with SCI = 47.1 % (n = 48) SCI

Condition

N/R

N/R

Type of SCI

C5 =62.5% (n=5); Tetraplegia C4 = 25 % (n = 2); C6 = 12.5 % (n = 1) and American Spinal Injuries Association Impairment Scale A = 62.5 % (n = 5) and D =37.5 % (n = 3)

C6–7 = 6.3 % (n = 1); T2–7 = 31.3 % (n = 5); T8 and below = 56.3 % (n = 9); post-polio = 6.3 % (n = 1) N/R

SCI level

Pain n = 8; UTI n = 1; neurogenic bladder n = 4; neurogenic bowel n = 1; diabetes n = 1; hypertension n = 1 Tooth decay

Shoulder pain required

Comorbidities reported

12.5 % (n = 1)

N/R

25 % (n = 4)

Attrition rate

Curr Phys Med Rehabil Rep

N/R

Lab

Kim 2016

Participatory development tools

Atlanta, Georgia Observations and Chicago, Illinois

Specialized centers and regional centers

Kairy 2014

Interviews; focus groups

N (evaluators are randomized)

N

N

N

Case–control

Case study

Community-based participatory research

Single blind RCT

Cohort study

Randomization Type of study of participants

Y PUSH version 3.0; Patient Health Questionnaire; Cornell Services Index; Craig Hospital Inventory of Environmental Factors-Short Form version 3.0; CareCall log

N/R

Standardized data collection tools

N/R

Rural communities in Ontario

Home, over the phone

Jalovcic 2009

Interviews; questionnaires

Clinical assessment

Data collection methods

Quebec, Canada Interviews; observations of videos

Massachusetts and Connecticut

Simulated home Palo Alto, environment California

Hill 2009

Houlihan 2013 General community

Study setting Geographic location

Study methods

Study (author, year)

Table 3 Description of intervention technology platform

Three trained evaluators who were all physical therapists assessed patients’ skin or pressure wounds over the phone, through videoconference and in person 6 months Participants received automated calls from CareCall once weekly and could call in at any time. The CareCall system uses interactive voice response to generate call scripts and control the conversation at an individualized level. The CareCall system was developed for the study 20 months Participants planned 2 types of telephone support teleconferences, (1) calls with expert speakers and (2) peer support calls. All teleconferences were facilitated by an experienced facilitator. Expert guests included physicians (physiatrists, gynecologists, pain specialists), exercise physiologists, dieticians, and physiotherapists N/R Health professionals and specialist clinicians communicated with patients using conference room videoconferencing equipment and similar mobile units (Tanberg conferencing equipment, which is commercially available), accessed by patients in specialized centers and regional centers The Tongue Drive System (TDS) Five or six uses a small magnetic tracer on consecutive sessions the tongue that collects signals with session and sends them to a computer or intervals iPhone. The computer or ranging iPhone translates the commands 2-10 days, received in real-time. It was after 4-week used to control electric powered recovery wheelchairs (drive, weight from shifting) and access smartphone piercing applications and phone dialing. The application used was a dedicated app for the study

N/R

Length of study

None

None

None

None

Videoconferencing equipment (Aviva 1010XR and American Telecare)

N/R

N/R

N/R

None eTDS headset, TDS-PWC-smartphone interface, magnetic sensor board, magnetic tongue stud, USB transceiver, control unit of the eTDS headset. The TDS system is not yet commercially available

Discussion of HIPAA or data encryption

Secondary technology used in intervention

Curr Phys Med Rehabil Rep

Home, over the phone

Home

Mayo Clinic and Minnesota home

Home

Mozer 2008

Rimmer 2013

Van Straaten 2014

Woo 2016

Cleveland, Ohio; Tampa, Florida; Milwaukee, Wisconsin; and East Orange, New Jersey

MMSE

N/R

Surveys; clinical Wheelchair User’s assessment Shoulder Pain Index (WUSPI); Shoulder Rating Questionnaire (SRQ); Disabilities of the Arm, Shoulder, and Hand (DASH) Clinical Overall DUSOI score, assessment; Short-form 8 interviews

Atlanta, Georgia Health and Chicago, appraisals Illinois

N/R

Observations

Crolles, France

Streets of Crolles, France

Mourcou 2013

Palo Alto, California

N/R

Clinical assessment

Host laboratory Alberta, Canada and (hospital lab) Melbourne, and home Australia

Kowalczewski 2011

N/R

Standardized data collection tools

Data collection methods

Study setting Geographic location

Study (author, year)

Table 3 (continued)

RCT

Pre-post trial

Pilot

N

N

Case study

Case study

Double blind crossover RCT

Y

N

N

Y

Randomization Type of study of participants

Description of intervention technology platform

6 months

Discussion of HIPAA or data encryption

None

None

None

N/R

N/R

Web cam

None

None

N/R

None ReJoyce workstation, fingerless glove, earpiece with accelerometer, web cam. The ReJoyce system is commercially available

Secondary technology used in intervention

Data messaging devices (DMD) N/A were used to give patients customized disease management protocol questions. Nurses monitored responses daily. The DMD used was HealthBuddy, a commercially available device

Telesupervisors were trained by physical therapists. Telesupervisors communicated with participants through Skype and used virtual network to remote control the participant’s computer. Participants engaged in standard exercise therapy and in ReJoyce exercise therapy, in which the participant played custom computer games for therapy N/R The participant used the Wegoto smartphone application (commercially available on the App Store), which records the GPS position of the user, the frontal and sagittal inclinations of the wheelchair, the direction of travel, acceleration and deceleration, and instantaneous speed. The app creates an accessibility index for the route to a place of interest N/R The participants connected with a mental health professional for therapy over the phone 9 months Participants engaged in telephone-based coaching with trained telephone coaches, who had undergraduate degrees in exercise science, nutrition, health education, or a related field. Participants also attended in-person exercise group support sessions A physical therapist monitored 12-week home exercise 3 times weekly intervention, via videoconference, using total Skype 24 weeks with follow-up

16 weeks

Length of study

Curr Phys Med Rehabil Rep

Clinical assessment; interviews

Birmingham, Assessment Alabama conducted at University of Alabama at Birmingham, remainder of study at home

Yuen 2013

N/R not reported

Data collection methods

Study setting Geographic location

Study (author, year)

Table 3 (continued)

N

Loe-Silness Gingival Index (LSGI); Oral Home Telecare Questionnaire (OHTQ)

Length of study

One group pre- and 12 months post-test

Randomization Type of study of participants

Standardized data collection tools

Participants engaged in approximately 5 videoconferencing sessions using Scopia over 12 weeks with an occupational therapist to educate the patient on oral hygiene and give feedback

Description of intervention technology platform

Discussion of HIPAA or data encryption None

Secondary technology used in intervention

Powered toothbrush, adapted flosser and/or oral irrigator

Curr Phys Med Rehabil Rep

Curr Phys Med Rehabil Rep Table 4

Outcomes reported

Study (author, year)

List of outcomes measured

Hill 2009

Agreement on the presence of pressure ulcers, staging of pressure 1. Agreement on the presence of pressure ulcers: positive for both ulcers, wound characteristics, and wound size telephone and videoconferencing approaches 2. Staging of pressure ulcers: overall staging was inconclusive, with evaluators agreeing more strongly on some stages than others. There was a closer correspondence between the videoconferencing and in-person condition than between the telephone and in-person condition on the staging of the pressure ulcer 3. Evaluation of wound characteristics: positive for both videoconference and phone evaluators but stronger correlation for videoconference evaluators 4. Wound size measurements were evaluated: positive for both videoconference and phone evaluators but stronger correlation for videoconference evaluators. Strongest in person

Houlihan 2013 Change in pressure ulcers, depression severity, healthcare utilization, and care call usage

Jalovcic 2009

Kairy 2014

Kim 2016

N/A—none specified at outset of study

Outcomes observed

1. Pressure ulcers: positive 2. Depression: positive 3. Healthcare utilization: inconclusive for utilization. Positive for perception of healthcare availability 4. Care call usage: positive (participants were mostly adherent) Seventeen themes emerged from the phenomenological approach, grouped into four universal structures: 1. Space: telephone peer support group program, emotional support, learning, participation in decision making, facilitator, telephone. and participatory development tools 2. Relation to others: isolation and loneliness, physical aspects of spinal cord injury, self-confidence, traditional role of women, being different 3. Relation to self: support, care, compassion, and belonging, exchange of information and knowledge, comparison and validation, improving relations with others 4. Causality: change, attitudes and knowledge, behaviors

Participants discussed lack of research knowledge about the issues women with SCI face. The learning process of the participatory approach influenced the women’s behaviors and attitudes Whether telerehabilitation did or did not become part of routine 1. Whether telerehabilitation did or did not become part of routine use: telerehabilitation was incorporated into routine practice for use, factors that enabled or constrained telerehabilitation use, interprofessional care plans between the centers, was and if the factors related to the structure or the agent, as defined occasionally used or consultations, but had not been in the conceptual framework successfully applied to long-term follow up with patients 2. The factors that enabled or constrained telerehabilitation use: organizational and clinical leadership along with hands-on experience enabled use of telerehabilitation. Constraints included therapists’ beliefs and assumptions about patients and the compatibility of telerehabilitation with clinical practice. Passive participation, lack of human resources, and lack of previous collaborations between the centers were also constraints 3. If the factors related to the structure or the agent, as defined in the conceptual framework: at the agent level, the extent of participation in telerehabilitation influenced routine use, and passive use did not encourage future use. The main constraints occurred at the structural level, specifically the lack of human resources and the lack of previous collaboration between the centers Unidirectional tapping tasks multidirectional tapping tasks; 1. Unidirectional tapping tasks: positive wheelchair driving tasks; phone-dialing completion time; 2. Multidirectional tapping tasks: positive weight shifting completion time 3. Wheelchair driving tasks: positive 4. Completion time for phone dialing: positive between first and second session; Inconclusive after second session

Curr Phys Med Rehabil Rep Table 4 (continued) Study (author, year)

List of outcomes measured

Outcomes observed

5. Completion time for weight shifting: positive between first and second sessions; inconclusive after second session Kowalczewski Action Research Arm Test (ARAT) and ReJoyce automated hand ReJoyce ET 2011 function test 1. ARAT score: positive 2. RAHFT score: positive 3. Grasp force: positive 4. Pinch force: positive Conventional ET 1. ARAT score: positive 2. RAHFT score: positive 3. Grasp force: inconclusive 4. Pinch force: inconclusive Mourcou 2013 Cycles of pushes and energy

Mozer 2008

Rimmer 2013

Van Straaten 2014

Woo 2016

Yuen 2013

Cycles of pushes were regular and wide on first part and irregular and absent on second part. The validity of the algorithm and approach was confirmed. Obstacle denunciation is not integrated into the system N/A—none specified at outset of study Telephone therapy assisted two SCI subjects will their mental health needs. Psychotherapy conducted over the telephone offers advantages to patients including increased access to and increased comprehensiveness of care Body weight, BMI, Barriers to physical activity (B-PADS) score, 1. Body weight: positive aerobic exercise (min/week), strength exercise (min/week), total 2. BMI: positive exercise (min/week), fat score, fiber score, and fruit/vegetable 3. B-PADS score: positive 4. Aerobic exercise: inconclusive score 5. Strength exercise: inconclusive for POWERS group. Positive for POWERS plus group 6. Total exercise: inconclusive 7. Fat score: inconclusive 8. Fiber score: inconclusive for POWERS group. Positive for POWERS plus group 9. Fruit/vegetable score: inconclusive for POWERS group. Positive for POWERS plus group Pain and function measured with the Wheelchair User’s Should 1. WUSPI score: positive Pain Index (WUSPI), Disabilities of the Arm, Shoulder, and 2. SRQ score: positive Hand (DASH) Index, and Shoulder Rating Questionnaire 3. DASH index: positive (SRQ). Secondary outcomes of strength were measured with 4. Isometric strength for the serratus anterior: positive isometric strength tests and static fatigue tests 5. Isometric strength for scapular retractors: positive 6. Isometric strength for lower trapezius: inconclusive 7. Isometric strength for glenohumeral rotators: inconclusive 8. Isometric strength for abductors: inconclusive Individualized patient outcomes and progress toward treatment 1. DUSOI score: positive goals 2. Severity of UTIs: positive 3. Severity of neurogenic bladder: positive 4. Diabetes: positive 5. HTN: positive 6. SCI-related pain: positive 7. Severity of neurogenic bowel: negative 8. Patient perceived physical and mental quality of life: positive 1. LSGI scores: positive Gingival inflammation in LSGI scores (baseline, 6 months, 12 months), frequency of brushing, flossing and oral irrigator 2. Daily tooth brushing: positive 3. Dental flossing: positive use, tooth brushing time 4. Use of oral irrigator: positive 5. Videoconferencing connection satisfaction score on OHTQ: negative 6. Satisfaction scores on participants’ oral care: positive

Curr Phys Med Rehabil Rep

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