Effects of telerehabilitation in occupational therapy practice: A systematic review

Abstract

Objective/background:
This study aimed to review the current evidence on the application of telerehabilitation in occupational therapy practice and its clinical outcomes over the last 10 years.

Methods:
A systematic review was performed on studies published in English in the decade 2008 to 2017, retrieved from seven electronic databases (MEDLINE, Cochrane Library, CINAHL, Web of Science, SAGE, Science Direct and EMBASE). Only articles evaluating the use of telerehabilitation to provide occupational therapy services from a distance were included, with no restrictions on pathology, impairment, age, or the nature of occupational therapy intervention.

Results:
Fifteen articles (three randomised controlled trials, eight quasi-experimental studies, one trial with single-group post-intervention and three case studies) were reviewed. Despite various study designs and outcome measures, most studies indicated positive therapeutic effects of using telerehabilitation in occupational therapy practice. There is insufficient evidence, however, to confirm that telerehabilitation is more effective than the face-to-face model. Little evidence was shown on the long-term effect and cost efficacy. Only two studies used smartphones in their applications.

Conclusion:
Telerehabilitation offers an alternative service delivery model for occupational therapy, not only bridging distance but also offering user-friendly treatment for patients at home. Further research, particularly on the use of the most cutting-edge mobile technology, is needed to determine effectiveness in occupational therapy practice treating various diseases, conditions and impairments and the characteristics of patients, interventions and therapists that lead to the best fit with this alternative and emerging form of service delivery.

Full text

Review
Effects of telerehabilitation in
occupational therapy practice:
A systematic review
Goris Hung KN
1
and Kenneth NK Fong
2
Abstract
Objective/background: This study aimed to review the current evidence on the application of telerehabilitation in
occupational therapy practice and its clinical outcomes over the last 10 years.
Methods: A systematic review was performed on studies published in English in the decade 2008 to 2017, retrieved
from seven electronic databases (MEDLINE, Cochrane Library, CINAHL, Web of Science, SAGE, Science Direct
and EMBASE). Only articles evaluating the use of telerehabilitation to provide occupational therapy services from a
distance were included, with no restrictions on pathology, impairment, age, or the nature of occupational therapy
intervention.
Results: Fifteen articles (three randomised controlled trials, eight quasi-experimental studies, one trial with single-
group post-intervention and three case studies) were reviewed. Despite various study designs and outcome measures,
most studies indicated positive therapeutic effects of using telerehabilitation in occupational therapy practice. There is
insufficient evidence, however, to confirm that telerehabilitation is more effective than the face-to-face
model. Little evidence was shown on the long-term effect and cost efficacy. Only two studies used smartphones in
their applications.
Conclusion: Telerehabilitation offers an alternative service delivery model for occupational therapy, not only bridging
distance but also offering user-friendly treatment for patients at home. Further research, particularly on the use of the
most cutting-edge mobile technology, is needed to determine effectiveness in occupational therapy practice treating
various diseases, conditions and impairments and the characteristics of patients, interventions and therapists that lead to
the best fit with this alternative and emerging form of service delivery.
Keywords
Telerehabilitation, occupational therapy, systematic review
Received 26 September 2018; accepted 16 April 2019
Introduction
Around 55.4% of occupational therapists deliver serv-
ices directly through face-to-face treatment in a medical
setting (American Occupational Therapy Association,
2010). However, face-to-face occupational therapy
(OT) services face challenges. Increasing demand for
long-term rehabilitation and a dwindling supply of
OT services in rural areas limit clients’ access
(Centers for Disease Control and Prevention, 2015;
Criss, 2013; Dorsey et al., 2007; Gardner, Bundy, &
Dew, 2016). Long traveling times add to the heavy
workloads of occupational therapists (Nix & Comans,
2017). Long travel time and distance, complicated
service structure and the cost of intensive clinic-based
interventions hinder clients’ access (Chen et al., 2013;
Gardner et al., 2016; Shimabukuro, Grosse, & Rice,
2008). An alternative service delivery model for OT is
needed to overcome these barriers while also improving
accessibility and promoting well-being and recovery.
1
Tung Wah Group of Hospitals, Mong Kok, Kowloon, Hong Kong
2
Department of Rehabilitation Sciences, Hong Kong Polytechnic
University, Kowloon, Hong Kong
Corresponding author:
Goris Hung KN, 11 Yuk Choi Road, Hung How, Hong Kong.
Email: gorishung@gmail.com
Hong Kong Journal of Occupational Therapy
0(0) 1–19
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DOI: 10.1177/1569186119849119
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Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-
NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and
distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.
sagepub.com/en-us/nam/open-access-at-sage).

Telerehabilitation (TR) was first used in 1998.
It refers to the use of information and communication
technologies to provide rehabilitation services at a dis-
tance. The technologies used include internet-based
media or programs, computers, videoconferencing, tel-
ephones, smartphones, applications, data transmission
through video and photos or email sent by the health-
care provider and/or the client (Brennan et al., 2010;
Kairy, Lehoux, Vincent, & Visintin, 2009; McCue,
Fairman, & Pramuka, 2010). TR can be broadly divid-
ed into ‘synchronous’ – the provider and patients are
connected at the same time, but located at different
places, or ‘asynchronous’ – the provider and patients
are not connected at the same time but using ‘store-
and-forward’ data transmission, which may include
video clips, digital photos, virtual technologies and
other forms of electronic communication (Cason,
Hartmann, Jacobs, & Richmond, 2013). TR is not a
new phenomenon since internet communication was
developed in the late 1990s; however, technological
advances have expanded options including the use of
mobile technologies since the introduction of smart-
phones in the commercial market in the mid-late
2000s. TRs emphasis not only on the use of the internet
and telephones, but also other mobile technology, is
now possible through the development of wearable
sensing technology and its application in clinical
practice for some common disorders related to motor
rehabilitation, mental health, general health and phys-
iological well-being. This means that monitoring and
treatment outcomes can be addressed in the community
and out of purely clinical settings. It is becoming
increasingly evident that TR can improve access to
rehabilitation services, prevent unnecessary delays in
the receipt of care (Cason, 2014) and reduce the
impact of shortages of rehabilitation professionals in
underserved areas (Cason, 2012). Reviews have
also found that TR has similar clinical outcomes to
in-person interventions (Kairy et al., 2009).
In 2014, the World Federation of Occupational
Therapists acknowledged TR as an appropriate service
delivery model for OT services. ‘Occupational therapy
practitioners use telehealth as a service delivery model
to help clients develop skills; incorporate assistive tech-
nology and adaptive techniques; modify work, home,
or school environments; and create health-promoting
habits and routines’ (Cason et al., 2013, p. S69). TR
also include tele-evaluation in OT such as the use of
low-cost traditional telephone system for conducting
phone interview as an alternative for cognitive assess-
ment, wheelchair and assistive device prescription and
home modification, etc. (Cason et al., 2013). Patients
and caregivers are satisfied and have positive attitudes
toward the use of TR in OT services (Cason, 2009;
Gardner et al., 2016). Previous reviews of the
effectiveness of TR in relation to various pathologies
and impairments, healthcare utilisation and cost of reha-
bilitation use have found that TR has similar clinical
outcomes to face-to-face rehabilitation services
(Amatya, Galea, Kesselring, & Khan, 2015; Block
et al., 2016; Dorstyn, Mathias, & Denson, 2013; Huang
et al., 2015; Johansson & Wild, 2011; Kairy et al., 2009;
Khan, Amatya, Kesselring, & Galea, 2015; Rogante,
Grigioni, Cordella, & Giacomozzi, 2010; Santos et al.,
2014). However, to date, no review has been conducted
on the effects of TR in OT practice. The aim of this study
was to review the current evidence on the application of
TR and its clinical outcomes in OT practice.
Methods
Search strategy
Considering the advances in mobile technology over
the last 10 years, it was decided to limit the systematic
literature search to articles published between January
2008 and October 2017. Studies were identified using
seven electronic databases, namely MEDLINE,
Cochrane Library, CINAHL, Web of Science, SAGE,
Science Direct and EMBASE. The following keywords
were used: ‘Telerehabilitation’, ‘Tele-rehabilitation’,
‘Telemedicine’, ‘Telehealth’, ‘eHealth’, or ‘mobile
health or mHealth’, and ‘Occupational Therapy’.
Additional methods included manual searches of all
the reference lists of articles identified as relevant.
Selection criteria
Only studies published in English whose full text was
available were selected. All clinical trials evaluating the
use of TR to provide OT services from a distance were
considered, with no restrictions on pathology, impair-
ment, age or the nature of OT intervention.
Overviews of the application of TR in OT, systematic
reviews, meta-analyses, duplicates and studies unavail-
able in full were excluded. Also excluded were studies
examining the development of technology systems, the
reliability and validity of assessment, application in con-
tinuing professional development and treatment carried
out by multidisciplinary teams focusing on the implica-
tions of TR in rehabilitation services.
Methodological quality assessment
The Physiotherapy Evidence Database (PEDro) scale
was used to measure quality (Maher, Sherrington,
Herbert, Moseley, & Elkins, 2003). All randomised
controlled trial (RCT) studies were further rated
using the PEDro Scale. PEDro score at 6–10 was con-
sidered as a high methodological quality of RCT, but it
was not part of the selection criteria for this study.
2Hong Kong Journal of Occupational Therapy 0(0)

Results
Study selection
Four hundred one articles were identified from
seven databases: MEDLINE (n¼84), SAGE
(n¼31), CINAHL (n¼14), Science Direct (n¼88),
Cochrane Library (n¼22), Web of Science (n¼14)
and EMBASE (n¼148). Only 15 fulfilled all the
selection criteria. The other studies were rejected
after a review of their titles and abstracts. The
main reasons for exclusion were duplication, treat-
ment carried out by multidisciplinary teams focused
on the implications of TR in rehabilitation services
and absence of TR use for intervention or promotion
of well-being (Figure 1).
Studies’ characteristics
The designs of the 15 selected studies varied, according
to the level of evidence by Moore, McQuay, and Gray
(1995) with Level 1 indicating the strongest evidence and
Level V the weakest evidence, there were eight quasi-
experimental studies which were considered as Level
III studies (Bergquist, Gehl, Lepore, Holzworth, &
Beaulieu, 2008; Breeden, 2016; Criss, 2013; Gibbs &
Toth-Cohen, 2011; Golomb et al., 2010; Lawson,
Tang, & Feng, 2017; Ng, Polatajko, Marziali, Hunt, &
Dawson, 2013; Nix & Comans, 2017), three single-case
studies which were Class IV (Boehm, Muehlberg, &
Stube, 2015; Hermann et al., 2010; Reifenberg et al.,
2017), one trial with single-group post-intervention
which belonged to Class III (Yuen & Pope, 2009) and
Objective
To review the current evidence on the application of TR and clinical
outcomes in OT practice
Study Selection
•All clinical trials (Class I–IV studies) were indicated;
•Full text published in English 1/2008–10/2017;
•Use of telerehabilitation to provide clinical OT services from a
distance;
•Any pathology and impairment;
•Study population of all ages;
•All types of occupational therapy intervention
Included: 15 articles
Excluded: 386
Class II & III:
8 quasi-experimental study
1 trial with single-group
post-intervention
Class IV:
3 single-case studies
Class I:
3 RCTs
Keywords
“Telerehabilitation” OR “Tele-rehabilitation” OR “Telemedicine” OR “Telehealth” AND “Occupational
Therapy”
Data Sources:
Medline = 84, SAGE = 31, CINAHL = 14, Science Direct = 88, Cochrane Library = 22, Web of Science = 14,
EMBASE = 148
Outcome: 401 abstracts
Figure 1. Flowchart of the literature review and recruitment process.
TR: telerehabilitation.
Hung and Fong 3

three RCT studies that were Level II (Ferre et al., 2017;
Hegel et al., 2011; Linder et al., 2015). As noted above,
the RCT studies were further rated using the PEDro
scale. The study by Ferre et al. (2017) scored 7 and
that by Linder et al. (2015) rated 6 which were consid-
ered to be high quality and one (Hegel et al., 2011) was
considered to be fair (Table 1).
Participants’ characteristics
A total of 198 participants were included in this review.
Sample size ranged from 1 to 99 participants. One
study discussed occupational therapists’ cost effective-
ness, and therefore no participants were counted (Nix
& Comans, 2017).
The age of participants ranged from two years and
six months to over 70. Five studies were conducted
with participants aged under 18 (Bergquist et al.,
2008; Criss, 2013; Ferre et al., 2017; Gibbs & Toth-
Cohen, 2011; Golomb et al., 2010; Reifenberg et al.,
2017; Yuen & Pope, 2009), three with elderly aged
over 65 (Boehm et al., 2015; Breeden, 2016; Nix &
Comans, 2017) and seven studies involved adults
aged 18 (Bergquist et al., 2008; Hegel et al., 2011;
Hermann et al., 2010; Lawson et al., 2017; Linder
et al., 2015; Ng et al., 2013; Yuen & Pope, 2009).
The pathologies of the participants varied. They
included hemiplegic cerebral palsy (Ferre et al., 2017;
Golomb et al., 2010; Reifenberg et al., 2017), stroke
(Boehm et al., 2015; Hermann et al., 2010; Lawson
et al., 2017; Linder et al., 2015), acquired brain injury
(Bergquist et al., 2008), traumatic brain injury (Ng et al.,
2013), breast cancer survivors undergoing chemotherapy
(Hegel et al., 2011), tetraplegia (Yuen & Pope, 2009),
community-dwelling older adults (Breeden, 2016),
orthopaedic issues (Nix & Comans, 2017), autism
spectrum disorders (Gibbs & Toth-Cohen, 2011) and
visual-motor and/or fine motor deficits (Criss, 2013).
All the participants received TR at home, with one
exception, who received TR in a community centre
(Ng et al., 2013).
Eight studies required the involvement of a signifi-
cant other (parent or caregiver) in the provision of TR.
Their roles included participation in assessment,
assisting in treatment implementation and support
and monitoring. A summary of participant character-
istics is given in Table 2.
Characteristics of telerehabilitation
The technologies used in the studies are shown in
Table 3. A range of hardware and software was used
for videoconferencing, training, monitoring and assess-
ment and/or recording.
Fourteen studies required initial preparation prior
to implementation of intervention. Seven required the
supply of necessary tools, equipment or handouts in
advance and/or training on how to set up the equip-
ment through tele-media (Boehm et al., 2015; Criss,
2013; Ferre et al., 2017; Hegel et al., 2011; Ng et al.,
2013; Nix & Comans, 2017; Reifenberg et al., 2017).
Eight studies required in-person sessions conducted
either in clinics or in participants’ homes for set up
and training on the use of equipment (Bergquist
et al., 2008; Breeden, 2016; Ferre et al., 2017; Gibbs
& Toth-Cohen, 2011; Golomb et al., 2010; Hermann
et al., 2010; Lawson et al., 2017; Linder et al., 2015).
One study (Nix & Comans, 2017) mentioned upgrading
staff phones to smartphones with data plans.
The applications of TR in OT practice were diverse.
They were applied in intervention or training
(Bergquist et al., 2008; Boehm et al., 2015; Criss,
2013; Ferre et al., 2017; Ng et al., 2013; Yuen &
Table 1. PEDro scale scores for each study.
PEDro scale items Ferre et al. (2017) Linder et al. (2015) Hegel et al. (2011)
Eligibility Yes Yes Yes
1. Random allocation 1 1 1
2. Concealed allocation 1 0 0
3. Baseline comparability 1 1 1
4. Blind subjects 0 0 0
5. Blind therapists 0 0 0
6. Blind assessors 1 1 0
7. Adequate follow-up 0 0 0
8. Intention-to-treat analysis 1 1 0
9. Between-group comparisons 1 1 1
10. Point estimated variability 1 1 1
Score 7/10 6/10 4/10
Quality High High Fair
PEDro Scale: Physiotherapy Evidence Database Scale; RCT: randomised controlled trial.
4Hong Kong Journal of Occupational Therapy 0(0)

Table 2. Characteristics of the participants recruited to each study.
Author (Year)
(Country)
Application
(Model of Care) Population
Total no. of
participants
(n)
No. of
Experimental
gps (n)
No. of
Control
gps (n)
Aged (y.o.)
Mean SD
Settings to
Received TR
Significant others
Required and role
Criss (2013)
(USA)
FM and VP Tx
(tele-
intervention)
Students with VM
and/or FM defi-
cits that impact
handwriting skills
8 8 0 6–11 y.o.
(grades 1–6)
Home Yes (parent)
directing if needed-
follow
up on suggestions
and Tx
Gibbs and
Toth-Cohen
(2011)
(USA)
Sensory diet
(tele-
consultation)
Children with ASD 4 4 0 5–12 y.o. Home Yes (parent)
•implementation of
home program
•demonstrated tech-
nique to OT
Reifenberg et al.
(2017)
(USA)
Hand function Tx
(tele-consulta-
tion,
tele-monitoring)
Children with spas-
tic haemipa-
retic CP
1 1 0 5 y.o. Home Yes (parent)
•coaching
•conducting
home program
Ferre et al.
(2017)
(USA)
Hand function Tx
(tele-monitoring)
Children with uni-
lateral spastic CP
(mild to moder-
ate impairment)
24 12 12 2 y.o. 6 mo–
10 y.o. 1 mo
Tgp: m ¼5.2
þ2.7
Cgp: m ¼5.8
þ2.3
Home Yes (caregivers)
•conducting ax
•directing Tx
Nix and Comans
(2017)
(Australia)
Home modification
(tele-
intervention)
Patients awaiting
discharge home
from inpatient
medical and
orthopaedic
ward
NA NA NA Elderly aged
over 70
Three community
and
rural hospitals
Yes (patient’s
family member)
•present during OT
home visit
Breeden (2016)
(USA)
Home safety edu-
cation
(tele-education)
Community-dwell-
ing older adults
6 00>65 y.o. Home No
Linder et al. (2015)
(USA)
Home-based
Robot-assist with
Home Exercise
Program
(tele-monitoring)
Subacute stroke 99 51 48 Tgp: m ¼59.4 
13.6
Cgp: m ¼55. 5
12.6
Home Yes (caregiver)
•included in prepara-
tion phrase
•needs and role in Tx
phrase not specified
Boehm et al.(2015)
(USA)
Energy
Conservation
with Fatigue
Management
(tele-education)
Mild to moderate
stroke with post-
stroke fatigue
1 1 0 70 y.o. Home No
(continued)
Hung and Fong 5

Table 2. Continued
Author (Year)
(Country)
Application
(Model of Care) Population
Total no. of
participants
(n)
No. of
Experimental
gps (n)
No. of
Control
gps (n)
Aged (y.o.)
Mean SD
Settings to
Received TR
Significant others
Required and role
Hegel et al. (2011)
(USA)
Disability
Prevention
Program
(tele-education)
Breast cancer
survivors
undergoing
chemotherapy
31 15 16 m ¼52.6 
9.4 y.o.
Home No
Hermann et al. (2010)
(USA)
Application of FES
to engage in pur-
poseful activity
Tx (tele-
intervention)
Stroke 1 1 0 62 y.o. Home No
Ng et al. (2013)
(Canada)
CO-OP Tx
(tele-
intervention)
Adult with TBI 3 3 0 34 y.o.,
47 y.o., 55 y.o.
2/3 at Home
1/3 community
center
Yes (caregiver)
•participating in ax
through phone
Lawson et al. (2017)
(USA)
Upper Limbs Home
Program
(tele-monitoring)
Chronic
Stroke Survivors
6 60m¼53 y.o. Home Yes (caregiver)
•providing support
and offering
encouragement
Golomb et al. (2010)
(USA)
Virtual Reality
Video Game-
based Home
Program
(tele-monitoring)
Severe hemiple-
gic CP
3 30m¼14 y.o. Home No
Yuen and Pope (2009)
(USA)
Oral Care Tx
(tele-
intervention)
Adult with
tetraplegia
2 2 0 42 y.o., 46 y.o. Home No
Bergquist et al. (2008)
(USA)
Cognitive Tx
(tele-
intervention)
Individuals with
ABI with
memory
impairment
10 10 0 m ¼45.5 þ
11.4 y.o
Home No
n: number; y: years; gp: group; y.o.: years old; VM: visual motor; FM: fine motor; ASD: autism spectrum disorders; CP: cerebral palsy; ax: assessment; tx: training; mo: months; Tgp: telerehabilitation group;
Cgp: control group; m: mean; NA: not applicable; TBI: traumatic brain injury; CO-OP: Cognitive Orientation to daily Occupational Performance; ABI: acquired brain injury.
6Hong Kong Journal of Occupational Therapy 0(0)

Table 3. Summary of studies investigating the use of telerehabilitation in OT practice.
Author
(Year) Study design
Description of pro-
gram technology used Type of TR Treatment activities
Treatment regime
(Duration per session/
frequency/length of
intervention)
Outcome measures (Modality
in conduct assessment)
Criss (2013) One gp pretest–
posttest quasi-
experimental
Internet-based PC
and web camera
Internet-based ax
tool: The
Print Tool
TM
Synchronous Set up:
Extensive tool kit sent to
client’s home in advance
TR:
A variety of interactive
activities selection, explana-
tion, demonstration and
practice with occupational
therapist via web camera
Consultation provided to
parent at the end of each
session
Parent assisted in guiding and
directing if needed, follow-up
on suggestions and tx
30 min
weekly
6 wks
Satisfaction questionnaire
administered to parents
and students
handwriting performance
ax by The Print Tool
TM
(Pretest–posttest tele-ax
done at home)
Gibbs and Toth-
Cohen (2011)
One gp pretest–
posttest quasi-
experimental
Website for inter-
net conferencing
using webcam
Sessions were
archived
via website
Synchronous and
asynchronous
Set up:
First clinical OT tx conducted
in terms of ax, parent edu-
cation and transfer skills
TR:
Reviews home program,
observed parent–child inter-
action, techniques demon-
stration, rational explanation
via website on sensory diet
implementation
First attend clinical OT
Tx:
30 min
weekly
4 wks
Followed by TR:
30 min
weekly
6 wks
SPM Home form
Parents’ report/interview
OT report through prog-
ress notes
(Pretest–posttest ax
done clinic)
Reifenberg
et al. (2017)
Pre- and post-
single-case study
Web-based video
game: Timocco
with videoconfer-
encing
Telepresence robot
(Kubi) with back-
end control,
webcam, iPad and
Bluetooth
Data retrieved
Synchronous and
asynchronous
Set up:
Necessary equipment for
GbN and TT shipped to par-
ticipant
TR:
Treatment at home with
Timocco, program moni-
tored weekly by researchers
Consultation for participants
and parents through TR
Use of Timocco:-
1 h-daily-
8 wksConsultation:-
30 min
weekly
8 wks
Progress moni-
toring
weekly
AHA
BOT-2
QUEST
PMAL
PEDI-CAT
PSS-14
GbN performance met-
rics
Informal questionnaires
parent and child
(continued)
Hung and Fong 7

Table 3. Continued
Author
(Year) Study design
Description of pro-
gram technology used Type of TR Treatment activities
Treatment regime
(Duration per session/
frequency/length of
intervention)
Outcome measures (Modality
in conduct assessment)
from the
Timocco platform
interviews
Session notes
(Pretest–posttest ax done
in clinic; Time for ax: 
Pretest: 2 wks before tx
Posttest: 2 wks after tx)
Ferre et al. (2017) RCT: Pretest–post-
test control gp
monitoring via
webcam-based
software: Adobe
Connect
Synchronous and
asynchronous
Set up:
Supply and
training on BBT
and AHA pro-
vided to care-
givers in
advance
Training on
caregiver-
administrated
ax and tx pro-
vided in
advance
Tgp:
Performed H-
HABIT tx
supervised and
monitored via
checking log
submission
online by occu-
pational thera-
pist
Cgp
performed
intensive tx on
lower-limb
through
Adobe Connect
Training on caregiver-
administrated ax and tx:
1h
total 2 sessions
TR Tx:
2hr
5 days/week
9 wks
BBT
AHA
COPM
(Ax done at home
by caregiver; Time
for ax:
PretestPosttest
FU: 6 months
after posttest)
Nix and
Comans (2017)
Pretest–posttest
quasi-
experimental
Smartphone
Video phone calling
apps: Skype on
PC/tablet
Synchronous and
asynchronous
Set up:
The instruction booklet
designed to educate
patients, families,
carers, and new staff
on the correct method of
measuring a property
One-time home
visit
Comparison
between two six-
month periods
(2–8/2013 and2–
8/2014)
No. of OT interventions
on acute inpatient wards
Time taken to complete
the home visit from time
of referral
No. of home visits
(continued)
8Hong Kong Journal of Occupational Therapy 0(0)

Table 3. Continued
Author
(Year) Study design
Description of pro-
gram technology used Type of TR Treatment activities
Treatment regime
(Duration per session/
frequency/length of
intervention)
Outcome measures (Modality
in conduct assessment)
in development phase
Upgrade staff phones to smart-
phones with data plan, purchase
of tablets in advance
TR:
Pre-discharge home visit con-
ducted through ‘Home Quick’
included Virtual Home Visit/ax
with family present and OT
present remotely
conducted (Pretest–post-
test ax done in situ)
Breeden (2016) One gp pretest–
posttest quasi-
experimental
Videoconferencing
via web-based
VSee software
program with
PC/iPad
Digital camera or
cell phone used for
taking photographs
sent through email
or text message
Sessions were
audio/video
recorded using
Vsee and tran-
scribed using
Microsoft WordV
R
Synchronous and
Asynchronous
Set up:
Participant-generated digital
photographs were sent to OT
prior to each session through
email/text message
TR:
Narrative learning about home
safety through video confer-
ence
A new photo assignment was
given based on the discussion
for next session
weekly
3 wks
SAFER-HOME v3
(Pretest–posttest ax con-
ducted through
home visit)
Linder et al. (2015) RCT:Pretest–post-
test control gp
Remote progress
monitor via phone
call, cellular con-
nection to the
Mentor Home
TM
website
Synchronous and
asynchronous
Set up:
Home visit for
education con-
ducted before
the home pro-
gram
Tgp:
Hand Mentor
Pro robot-
assisted device
coupled with
HEP
Tgp:
3 h (2 h in robot-assisted
device, 1 h HEP
5 days/week
8 wks
Cgp:
3honHEP
5 days/week
8 wks
SIS (QoL)
CES–D (Pretest–
posttest ax done
through
home visit)
(continued)
Hung and Fong 9

Table 3. Continued
Author
(Year) Study design
Description of pro-
gram technology used Type of TR Treatment activities
Treatment regime
(Duration per session/
frequency/length of
intervention)
Outcome measures (Modality
in conduct assessment)
Progress moni-
tored from
websites and
weekly phone
call to FU
progress
Cgp:
HEP
Weekly phone
call to
FU progress
Boehm et al. (2015) Pretest–posttest
single-case study
Teleconference
through home/
office phone
Synchronous Set up:
The Managing Fatigue course
handouts sent before tx
began
TR:
Course conducted through
phone call made with OT
Client required to complete
homework after each
phone call
1h
Weekly
5 wks
FIS
COPM
Question on perception
of teleconferencing deliv-
ery (Pretest–posttest ax
done via tele-phone)
Hegel et al. (2011) RCT:pretest–post-
test control gp
Telephone Synchronous Set up:
Program manual mailed to
participants in Tgp in advance
Tgp:
Problem solving and OT
intervention program
through phone
Cgp
Attended usual care without
problem solving and OT
intervention program
Tgp:
weekly
6 wks
Satisfaction survey
SF-36
FACT-36
HADS
Healthy activities atten-
dance record
(Ax done via mail; Time
for ax: pretest post-
test: 6 wks FU: 6 wks
after posttest)
Hermann
et al. (2010)
Pretest–posttest
single case study
Logitech Buddy
Cams, Skype
through PC
Synchronous Set up:
1 h education and FES fitting
done in laboratory in
advance
TR:
Tx supervised by OT on line
1st wk:
10 min, with 5 min
increased each day
for first five days
2nd–4th wk:
30 min
FM scale
ARA
COPM
(Pretest–posttest ax done
in lab
Time for ax: pretest: 1
(continued)
10 Hong Kong Journal of Occupational Therapy 0(0)

Table 3. Continued
Author
(Year) Study design
Description of pro-
gram technology used Type of TR Treatment activities
Treatment regime
(Duration per session/
frequency/length of
intervention)
Outcome measures (Modality
in conduct assessment)
2 times/week
4 wks
wk before tx posttest:
1 wk after tx)
Ng et al. (2013) One gp pretest–
posttest quasi-
experimental
Videoconferencing
using Skype in PC
with Logitech
TM
webcams and noise-
cancelling headsets
Session record using
Pamela for Skype
TM
Professional version
Telephone
Synchronous Set up:
Webcam, headphones and
materials provided in
advance
One training session on
software and hardware set-
up use through telephone
and videoconference prior
to ax
TR:
Tx provided through video-
conference and telephone
1h
Twice a week
10 wks
COPM
DEX
MPAI-4-P
QoL
Feedback interview
(Ax done via videocon-
ferencing with partici-
pants and telephone with
significant others;
Time for ax: pretest 
posttest 
FU: 3 months)
Lawson
et al. (2017)
One gp pretest–
posttest quasi-
experimental
Mobile app:
ARMStrokes
through
smartphone
Asynchronous Set up:
App and exercise program
installed and selected by OT
in advance
TR:
Use of the app was moni-
tored from website.
Therapists contacted partici-
pants who demonstrated
limited use of the app
At wk 3, participants were
seen for adjustments
6-wk protocol ARAT
CAHAI
AM-PAC
MAS
MMT
General fatigue scale
(Pretest–posttest ax
done in clinic)
Golomb
et al. (2010)
One gp pretest–
posttest quasi-
experimental
Internet-based
video game system
that included a
5DT 5 Ultra Glove
and PlayStation3
and networked to
hospital/research
centre through
DSL modem/
router
Asynchronous Set up:
One time several hour
introductory sessions about
the games conducted two
months in advance
System installed at home by
research team in advance
TR:
Performance monitored
remotely through website
30 min
5 days/week
3 months
Sammons Preston Jamar
dynamometer
Pinchometer
BOT
Jebsen Hand Function
Test
Remote assessment based
on sensor glove reading
on finger ROM
DXA
(continued)
Hung and Fong 11

Table 3. Continued
Author
(Year) Study design
Description of pro-
gram technology used Type of TR Treatment activities
Treatment regime
(Duration per session/
frequency/length of
intervention)
Outcome measures (Modality
in conduct assessment)
pQCT
fMRI of hand grip task
(Pretest–posttest ax done
included remotely
and clinic)
Yuen and
Pope (2009)
Trial with post-
intervention ax
Videoconferencing
via AcrobatV
R
Connect
TM
Professional with
high-speed internet
Synchronous Repeated training, supervised
practice of oral hygiene and
immediate corrective feed-
back and positive reinforce-
ment in use of adaptive oral
hygiene devices for the par-
ticipants via
videoconferencing
20–30 min
weekly
4 wks
OHTQ
In-depth interview
(Posttest ax done via
videoconferencing)
Bergquist
et al. (2008)
One gp pretest–
posttest quasi-
experimental
Internet-based
cognitive training
through instant
messaging system
Synchronous Set up:
One face-to-face training ses-
sion on how to use the instant
messaging system in advance
TR:
Online cognitive therapy with
OT
Calendar used to assist in
remembering to attend
therapy sessions
weekly
10 wks
RBANS
WRAT-3 (Reading sub-
test)
Attendance record
(Pretest-posttest ax done
in clinic)
n: number; gp: group; tx: training or intervention; min: minutes; ax: assessment; h(s): hour(s); wk(s): week(s); TR: telerehabilitation (program); prog: program; OT: occupational therapy; PC: personal
computer; SPM: sensory processing measure; AHA: Assisting Hand Assessment; BOT-2: Bruininks–Oseretsky Test of Motor Proficiency, Second Edition; QUEST: Quality of Upper Extremity Skills Test;
PMAL: Pediatric Motor Activity Log; PEDI-CAT: Pediatric Evaluation and Disability Inventory–Computer Adapted Test; PSS-14: Perceived Stress Scale; GbN: game-based neurorehabilitation; TT: telehealth
technologies; BBT: Box and Blocks Test; COPM: Canadian Occupational Performance Measure; FU: follow-up; H-HABIT: home-based Hand-arm bimanual intensive therapy; Tgp: telerehabilitation group;
Cgp: control group; fx: functional; SAFER-HOME: Safety Assessment for Function and the Environment for Rehabilitation – Health Outcome Measurement and Evaluation; SIS: Stroke Recovery domains of
the Stroke Impact Scale; CES–D: Center for Epidemiologic Studies Depression Scale; FIS: Fatigue Impact Scale; MoCA: Montreal Cognitive Assessment; v: version; SF-36: Medical Outcomes Short Form-36;
FACT-B: Functional Assessment of Cancer Therapy–Breast Cancer Version; HADS: Hospital Anxiety and Depression Scale; FM scale: Fugl-Meyer Scale; ARA: Action Research Arm Test; FES: Functional
Electrical Stimulation; DEX: The Dysexecutive Questionnaire; MPAI-4-P: The Mayo-Portland Adaptability Inventory–4 Participation Index; QoL: The Flanagan’s Quality of Life Scale; app: application; CAHAI:
Chedoke Arm and Hand Activity Inventory; AM-PAC: Boston University’s Activity Measure–Post Acute Care Short Form; MAS: Modified Ashworth Scale; MMT: manual muscle tests; DXA: dual-energy X-
ray absorptiometry; pQCT: peripheral quantitative computed tomography; fMRI: functional magnetic resonance imaging; ROM: range of motion; OHTQ: Oral Home Telecare Questionnaire; RBANS:
Repeatable Battery for the Assessment of Neuropsychological Status; WRAT-3: Wide Range Achievement Test, 3rd ed.; DSL: digital subscriber line.
12 Hong Kong Journal of Occupational Therapy 0(0)

Table 4. Summary of results of the included studies.
Author
(Year)
Results
Participants Other effects Perception and acceptance on TR
Linder
et al.
(2015)
•Improved QoL noted
•Statistically significant changes
(except memory and mood domain)
in the SIS and CES–D in both
gps (p<0.001)
•NA •Many of the participants in this
study looked forward to the TR
not only for exercise programs
but also that they reported that
they viewed it as a social outlet
Ferre
et al.
(2017)
•Significantly better improvement in
fx goals in COPM in Tgp (mi ¼þ3.9)
than in Cgp (mi ¼þ2)
•Gps showed equal improvement in
COPM-Satisfaction (mi Tgp ¼3.5
vs. Cgp ¼2.6)
•Greater improvement in dexterity
on BBT in Tgp (mi ¼þ5.5) than
Cgp (mi ¼þ1.3)
•No improvement in bimanual per-
formance on AHA in both gps
•High reliability reported in
caregiver-administrated stand-
ardised assessment at baseline
•NA
Hegel
et al.
(2011)
•Better QoL and emotional state in
Tgp than Cgp
•Tgp scored better in SF-36, FACT-36,
HADS than Cgp
•Tgp scored better on the Role
Emotional subscale of the SF-36 than
the Cgp in FU
•No differences between groups in
the frequency of engaging in
healthy activities
•Completion rates for home-
work tasks were high:
•97% of planned treatment
sessions were completed
in Tgp
•92% of participants in Tgp
reported that they were highly
satisfied with the intervention
Criss (2013) •Improvements in handwriting per-
formance shown
•score improve more than 6%
on average
•most significant improvements
appeared to be in the areas of
memory and letter placement
•positive effects appeared in decreas-
ing number of reversed letters
•NA •High satisfaction with OT inter-
vention via TR reported by
parents and students:
•100% satisfied with quality
of program
•86% observed improvement in
school performance
•71% disagreed with the statement
on preferring OT tx in clinic
over virtual
•86% of parents happy with
online format
Gibbs and
Toth-
Cohen
(2011)
•SPM score: 3/4 children remained
stable or improved
•Positive effect reported by parents
and OT report
•child’s interaction with peers and
siblings (2/4 children)
•FM (3/4 children)
•self-helped skills 2/4 children)
•reduced self-stimulatory behaviours
(2/4 children)
•Improved carryover of home
program reported for children
with ASD by providing
opportunities for parents to
ask questions, review sensory
techniques and understand
the therapist’s clini-
cal reasoning
•Improvement noted in most
participants via OT prog-
ress included
•Parent-therapist collaboration
•parental feelings
of competence
•family interaction
•reduced parental stress
•NA
(continued)
Hung and Fong 13

Table 4. Continued
Author
(Year)
Results
Participants Other effects Perception and acceptance on TR
Reifenberg
et al.
(2017)
•Positive effects on hand func-
tion noted
•Improved scores in AHA, BOT-2,
PMAL, PEDI-CAT
•Improved grasp score indicated
in QUEST
•Dissociation movement remained
the same in QUEST
•High motivation for participants
•Reduction of mother’s stress
indicated in PSS-14
•NA
Nix and
Comans
(2017)
•NA •Total interventions increased
with the same level of staffing
in place
•50% increase in home visits
conducted (145 vs. 223)
•Significantly increase in the
number of patients seen ear-
lier following referral
(X2 ¼69.3; p<0.001)
•Increased the number of
other inpatient interventions
(þ31% on average, range þ16
to þ115%)
•NA
Breeden
(2016)
•Fewer home safety issues in 5/6
participants after tx (–3.6 on average,
ranging from –1 to –8)
•One participant’s score
remained unchanged
•NA •NA
Boehm
et al.
(2015)
•Reduced fatigue impact was noted
on the FIS (score from 47/160 to
13/160)
•Modest improvement in occupation-
al performance (average score
improved by 0.4 points) and satis-
faction (average score improved by
0.8 points) were evidenced by
the COPM
•NA •Participant expressed that service
via TR was adequate, but face-to-
face delivery and group partici-
pation with peers were his pre-
ferred modes of service delivery
Hermann
et al.
(2010)
•Significant improvement in COPM
(4–6 point gain)
•Improved upper-limb and
hand functions
•score gain on FM scale (25/66 to
27/66)
•grasp improved in ARA (10/40 to
18/40)
•NA •NA
Ng
et al.
(2013)
•Significant improvement in COPM
(5/10 improved trained goals). All
participants indicated self-reported
improvement in both trained and
untrained goals
•Significant carry-on effect of
decreased impact of executive dys-
function on daily life
•The CO-OP approach admin-
istered in TR format was
found to be feasible
•All participants expressed satis-
faction with the internet deliv-
ery method
•1/3 caregivers and 1/3 partici-
pants expressed a preference for
face-to-face intervention
(continued)
14 Hong Kong Journal of Occupational Therapy 0(0)

Table 4. Continued
Author
(Year)
Results
Participants Other effects Perception and acceptance on TR
•a greater number of trained and
untrained goals showed improve-
ment at FU in COPM (Performance:
FU: 9/12 vs. Posttest: 7/18;
Satisfaction: FU: 11/12 vs. Posttest:
7/18)
•participants reported that they con-
tinued to apply CO-OP approach
after active tx was completed
•Trends toward fewer symptoms of
executive dysfunction and greater
community integration were dem-
onstrated in DEX, MPAI-4-P and
QoL (0.05 <p<0.10)
Lawson
et al.
(2017)
•Improvements reported in accuracy
of movement, range of motion, abil-
ity to perform daily activities and
reduced fatigue
•Participants were motivation in
home program
•NA •NA
Golomb
et al.
(2010)
•Meaningful gain in function and fore-
arm bone health of the hemiplegic
hand found in all participants
•Improvement in grip testing and the
Jebsen test, including a clinically
meaningful improved ability to lift
light and heavy objects
•Gain in forearm bone health as
measured by DXA and pQCT
•fMRI changes were signifi-
cant (p<.001)
•NA •NA
Yuen and
Pope
(2009)
•Participants reported increased
motivation to perform oral care and
enhanced performance
•NA •Participants’ perception of using
videoconferencing was very pos-
itive (m ¼4.5 in OHTQ)
Bergquist
et al.
(2008)
•Participants were able to reliably and
independently use an IM system to
access cognitive rehabilitation
•The trend for more cognitively
impaired participants to miss more
sessions was not significant (r¼–
0.334, p¼0.345)
•Internet-based cognitive reha-
bilitation is likely to be feasi-
ble, even among individuals
with severe memory impair-
ments, following acquired
brain injury
•NA
NA: not mentioned; gp(s): group(s); tx: training or intervention; ax: assessment; TR: telerehabilitation (program); OT: occupational therapy; SPM:
sensory processing measure; AHA: Assisting Hand Assessment; BOT-2: Bruininks–Oseretsky Test of Motor Proficiency, 2nd ed.; QUEST: Quality of
Upper Extremity Skills Test; PMAL: Pediatric Motor Activity Log; PEDI-CAT: Pediatric Evaluation and Disability Inventory–Computer Adapted Test;
PSS-14: Perceived Stress Scale; BBT: Box and Blocks Test; COPM: Canadian Occupational Performance Measure; FU: follow-up; mi: mean improve-
ment; fx: function; Tgp: telerehabilitation group; Cgp: control group; SIS: Stroke Recovery domains of the Stroke Impact Scale; CES–D: Center for
Epidemiologic Studies Depression Scale; FIS: Fatigue Impact Scale; SF-36: Medical Outcomes Short Form-36; FACT-B: Functional Assessment of Cancer
Therapy–Breast Cancer Version; HADS: Hospital Anxiety and Depression Scale; FM scale: Fugl-Meyer Scale; ARA: Action Research Arm Test; DEX:
The Dysexecutive Questionnaire; MPAI-4-P: The Mayo-Portland Adaptability Inventory–4 Participation Index; QoL: The Flanagan’s Quality of Life Scale;
DXA: dual-energy x-ray absorptiometry; pQCT: peripheral quantitative computed tomography; fMRI: functional magnetic resonance imaging; CO-OP:
Cognitive Orientation to Daily Occupational Performance.
Hung and Fong 15

Pope, 2009), consultation (Nix & Comans, 2017), edu-
cation (Breeden, 2016; Gibbs & Toth-Cohen, 2011),
prevention programme (Hegel et al., 2011) and use of
assistive technology (Golomb et al., 2010; Hermann
et al., 2010; Lawson et al., 2017; Linder et al., 2015;
Reifenberg et al., 2017).
Intervention regime and length of study
Frequency, duration and length of intervention varied
among the 15 studies. Eight performed TR on a weekly
basis, two studies did so twice a week, three involved
participation five times a week and one study was per-
formed on a daily basis. In terms of the duration of
each session, five studies involved sessions of 30 min,
three studies were 1 h, one study was 2 h and one study
was 3 h. Four studies did not specify duration
(Bergquiset et al., 2008; Breeden, 2016; Hegel et al.,
2011; Lawson et al., 2017). The length of intervention
ranged from three weeks to three months. One study
performed a one-time home visit for home modification
(Nix & Comans, 2017).
Only three studies followed-up with their partici-
pants, after six months, at six weeks and three
months after active intervention was completed (Ferre
et al., 2017; Hegel et al., 2011; Ng et al., 2013).
Types of outcome measures
The outcome measures used included both standar-
dised and non-standardised assessments of cognitive
function, motor function, functional performance and
quality of life (QoL). Satisfaction level, attendance
records, therapists’ progress notes, bone dexterity and
brain imaging results were also considered as outcome
measures. One study (Nix & Comans, 2017) used the
total number of interventions conducted as an out-
come measure.
The outcome measures were assessed by investiga-
tors, occupational therapists, caregivers and partici-
pants. One study (Ferre et al., 2017) trained
caregivers to conduct standardised assessments at
home. In terms of modalities in conducting the assess-
ment, six studies were assessed in clinics, four used tele-
evaluation, two studies required OT performed during
home visits and one was delivered by mail. Two studies
(Golomb et al., 2010; Reifenberg et al., 2017) involved
both remote and clinical assessment.
Effects of telerehabilitation in OT practice
Among the RCT studies, significant improvement
in the TR group relative to the control group was
found in functional performance among children with
unilateral cerebral palsy, and in QoL and emotional
status among breast cancer survivors undergoing
chemotherapy. Greater improvement among TR
groups than control groups was shown in dexterity
for children with cerebral palsy and carry-out effects
on emotional state for breast cancer survivors. Linder
et al. (2015) found that both TR and control groups
showed significant improvement in QoL among stroke
survivors. One study found equal improvement in sat-
isfaction with occupational performance in both
groups (Ferre et al., 2017). There was no difference in
the effects on bimanual performance and engaging in
healthy activities (Ferre et al., 2017; Hegel et al., 2011).
For Level III–IV studies, all the studies demonstrat-
ed that applying TR to deliver OT services was feasible
for various pathologies and age groups. Three studies
(Hermann et al., 2010; Ng et al., 2013) showed signif-
icant improvement in functional performance. Five
indicated positive effects in the improvement of partic-
ipants’ occupational performance (Boehm et al., 2015;
Criss, 2013; Gibbs & Toth-Cohen, 2011; Lawson et al.,
2017; Yuen & Pope, 2009), increased carryover of
home programs (Gibbs & Toth-Cohen, 2011; Hegel
et al., 2011), increased motivation (Lawson et al.,
2017; Reifenberg et al., 2017; Yuen & Pope, 2009),
enhanced home safety (Breeden, 2016), enhanced
hand function (Golomb et al., 2010; Hermann et al.,
2010; Lawson et al., 2017; Reifenberg et al., 2017),
improved cognitive function (Bergquist et al., 2008)
and reduced parental stress (Gibbs & Toth-Cohen,
2011; Reifenberg et al., 2017). Ng et al. (2013)
showed a significant carry-on effect of reduced impact
of executive dysfunction on daily life among partici-
pants with traumatic brain injury.
Six studies measured the satisfaction of participants,
parents and/or caregivers (Boehm et al., 2015; Criss,
2013; Hegel et al., 2011; Linder et al., 2015; Ng et al.,
2013; Yuen & Pope, 2009). All participants and care-
givers expressed satisfaction with the quality of their
program and had a positive perception of TR. Two
participants and one caregiver preferred face-to-face
intervention if given the choice (Boehm et al., 2015;
Ng et al., 2013). One study (Nix & Comans, 2017) indi-
cated a significant increase in total OT intervention,
including an increase in the number of patients seen
earlier following referral and an increase in the
number of inpatient intervention visits conducted.
Discussion
Study design
Little research has been conducted on the effectiveness
of telerehabilitation in OT practice. According to the
PEDro scale, only two of the RCTs (Ferre et al., 2017;
Linder et al., 2015) reviewed in this study had
good methodological quality. Twelve articles were
16 Hong Kong Journal of Occupational Therapy 0(0)

one-group pretest–posttest quasi-experimental studies,
single-group studies with-post intervention or case
studies, designs which are indicative of low evidence.
Effects of telerehabilitation in OT practice
Two of the RCT studies found that TR groups had
better effects than control groups and one study
showed comparable improvement in both groups.
However, there is insufficient evidence to confirm that
the effects of TR are more effective than the face-to-
face model due to the inadequate number of RCTs.
The use of TR in OT practice is feasible and has
positive effects in improving various functions among
different pathologies and age groups. However, the
majority of the changes in most of the standardised
assessments in Class II–IV studies did not exceed the
minimum level for clinically important difference. It is
difficult to generalise the results.
Only three studies (Ferre et al., 2017; Hegel et al.,
2011; Ng et al., 2013) conducted follow-up evaluations.
Only one (Nix & Comans, 2017) investigated all inter-
ventions with the same level of staffing in place after
the application of TR. But this study did not provide
enough evidence to make conclusive comments on
long-term effects or cost efficiency. This could serve
as a reference for future studies.
Participants and caregivers were satisfied and had
positive attitudes toward the use of TR in OT services.
The findings noted in this review are similar to those in
previous studies on clients’ perception and acceptance
of the application of TR in OT (Cason, 2009; Gardner
et al., 2016), rehabilitation services (Bragadottir, 2008;
Johansson & Wild, 2011; Kairy et al., 2009; Wakeford,
2002) and speech-language pathologists (Dunkley,
Pattie, Wilson, & McAllister, 2010). Very few partici-
pants and caregivers expressed a preference for face-to-
face intervention over TR. The client and caregiver
characteristics that lead to the best fit with TR service
delivery can be investigated further.
Feasibility
Bergquist et al. (2008) reported that clients with
acquired brain injury involving memory impairment
were able to participate in internet-based cognitive
rehabilitation independently. However, due to the
small sample size, caution should be taken against
overgeneralising.
The studies indicate that it is necessary to provide
initial preparation or training prior to OT intervention
through TR, and to upgrade staff equipment and tech-
nical support in order to provide a successful service.
Considering the popularity and affordability of smart-
phones, it is surprising that only two studies applying
smartphone and/or applications were found (Lawson
et al., 2017; Nix & Comans, 2017). The keyword
‘mobile technology’ brought up various articles that
examine the development of smartphone applications
for use in TR. But it may be necessary to await the
development of more advanced technology to examine
the effects of smartphone use in TR for OT practice.
One study used the Skype app (Nix & Comans, 2017),
but none used wearable devices for measurements or
quantitative (such as kinematic data) and qualitative
(such as video filming) feedback, or Bluetooth connec-
tion and data synchronising with smartphones.
There has been no discussion of the barriers to the
development of TR related to legal uncertainty and
malpractice insurance, cost effectiveness, data privacy
and security or the reimbursement of services/payment
related to TR.
Treatment regime
Because OT intervention is devised according to the
client-specific functional strengths, needs and impair-
ments, all the studies used different protocols, which
is why no exact comparison of the intensity and
length of the treatment regimes can be made. Further
reviews could extend focus to the use of TR for differ-
ent client-specific functional strengths, needs and
impairments in OT practice.
Outcome measures
Most of the outcome measures used were question-
naires on tele-evaluation. Caregivers were trained to
administer a standardised assessment in Ferre et al.
(2017). Although the reliability of caregiver-
administered assessments was examined at baseline,
the reliability of the posttest and six-month follow-up
were not assessed. Further research is needed to
determine which OT assessments are appropriate for
TR and the test–retest reliability of caregiver-
administered standardised assessment.
Limitations
Limitations in the studies’ design included small sample
size, inadequate control groups, and inadequate follow-
up and report outcomes in the short term. It is difficult
to confirm whether the effects of TR are comparable to
or more effective than in-person intervention. The
results serve as proof of principle that the application
of TR in OT practice is an alternative service deliv-
ery model.
Four of 15 articles were retrieved through manual
search (Ferre et al., 2017; Golomb et al., 2010; Lawson
et al., 2017; Yuen & Pope, 2009). An overall lack of
Hung and Fong 17

standardisation in the terminology used in OT and TR
is noted and it is hard to identify relevant studies.
Conclusion
This systematic review shows that using TR in OT
practice has positive therapeutic effects. TR offers an
alternative service delivery model. Further trials with
larger samples and more comprehensive follow-ups are
needed. It is particularly important that more research
is conducted on the use of cutting-edge mobile technol-
ogy to determine its effectiveness in TR for various
pathologies and impairments, its cost efficacy and the
characteristics of clients, interventions and therapists
leading to the best fit for this alternative form of service
delivery.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Goris Hung KN https://orcid.org/0000-0002-4439-5660
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