School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)
Focused Question: technology delivered intervention
Does telehealth improve quality of life through adherence to interventions for individuals
diagnosed with neurodegenerative diseases?
Prepared By:
Talia Bartolotta, OTS
OT16.talia.bartolotta@nv.touro.edu
Department of Occupational Therapy

Michelle Wilson, OTS

OT16.michelle.wilson@nv.touro.edu
Department of Occupational Therapy

Touro University Nevada

874 American Pacific Drive
Henderson, NV 89074

Touro University Nevada

874 American Pacific Drive
Henderson, NV 89074

Both students under the supervision of Dr. Donna Costa, DHS, OTR/L, FAOTA
Associate Profession, School of Occupational Therapy
Donna.costa@tun.touro.edu
Date Review Completed:
October 8, 2015
Clinical Scenario:
Neurodegeneration is an umbrella term encompassing a wide variety of diseases in
which progressive loss of neuron structures occur which decreases an individuals
independence, further impacting quality of life (QOL). As symptoms advance throughout the
disease progression, the number of needed medications and medical team increases even more
so. Eventually, individuals struggling with neurodegenerative diseases may become
homebound, making it increasingly challenging to leave home and access services needed.
Health care visits become more frequent, increasing health care costs. Telehealth has been
shown to be a low-cost alternative as compared to routine care for those that are homebound or
living in rural areas requiring long travel time to access care needed (Dorsey et al., 2013).
Telehealth is a low-cost alternative due to the fact that computer and information technologies
have become increasingly accessible over the past decade (AOTA, 2013).

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

In addition to being cost-effective, telehealth provides access to health care for those
living in remote or underserved areas as well as those who are unable to access services due to
decreased function secondary to disease or disability (AOTA, 2013). By providing services in
the natural environment, QOL is expected to increase as a result of decreased mortality rate
and increased independence (Jelcic et al., 2014). Past research studies have utilized telehealth
to monitor symptoms, educate on disease progression, implement appropriate interventions,
monitor medication management, as well as provide additional services needed. Telehealth is
individualized to each patient being seen, comparable to routine care. Research studies
utilizing telehealth have been done using a variety of medical professionals including an
occupational therapist (OT), physical therapist, nurse, psychologist, doctor, etc. As stated
previously, as disease progresses, the medical team grows immensely. By providing services
via telehealth, individuals may access needed practitioners in the comfort of their own home.
Looking more specifically at the OT practice, telehealth may be utilized to deliver
encompassing services for evaluation, intervention, consultation, education, and supervision of
students or other personnel (AOTA, 2013). Additionally, OT practitioners have the skills and
education needed to treat individuals diagnosed with a wide variety of neurodegenerative
impairments. A telehealth model of service delivery may be used for providing interventions
that are preventative, habilitative, or rehabilitative in nature (AOTA, 2013).
Additionally, as technology becomes more widely utilized and accepted, healthcare
professionals need to be open and willing to provide services in this avenue. This will in turn
remove barriers in regards to accessing healthcare, including social stigma, travel,
socioeconomic and cultural barriers. Use of telehealth as a service delivery model within the
OT profession will increase access to care and ameliorate shortages of care in underserved
populations (AOTA, 2013).
Summary of Key Findings:
Summary of Levels I, II and III:
Level I:
Study results found that intervention through telerehabilitation for individuals with
Alzheimers Disease (AD) significantly improves QOL (Jelcic et al., 2014)
Results showed greater adherence to treatment sessions in telemedicine versus standard,
routine care (Dorsey et al., 2013)
Evidence found telemedicine to be feasible and effective due to decreased travel time
(Dorsey et al., 2013)
Telehealth through web-based physiotherapy is effective for improving physical
functioning for those diagnosed with multiple sclerosis (MS) (Paul et al., 2014)
Web-based physiotherapy decreases feelings of anxiety in those diagnosed with MS (Paul
et al., 2014)
Memory aids implemented through telehealth has been shown to increase adherence to
medication for those diagnosed with MS (Settle et al., 2015)
Teleconference fatigue management program for individuals with MS is effective in
significantly reducing fatigue (Finlayson, Preissner, Cho, & Plow, 2011)

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Studies show that as fatigue decreases utilizing a teleconference fatigue management

program, physical and social components correlated to QOL increase (Finlayson,
Preissner, Cho, & Plow, 2011)
Improvements in energy levels achieved in teleconference fatigue management program
were seen evident six months following the intervention program (Finlayson, Preissner,
Cho, & Plow, 2011)
Studies show that individuals prefer video method teleconference over telephone-based
teleconference (Fincher, Ward, Dawkins, Magee, Willson, 2009)
Research found that education and counseling via telehealth regarding medication
management increases mood, emotions, physical functioning, sleep, and overall QOL in
those diagnosed with Parkinsons disease (PD) (Fincher, Ward, Dawkins, Magee, Willson,
2009)
Telehealth is found effective and easily used by individuals diagnosed with PD as well as
nursing staff (Fincher, Ward, Dawkins, Magee, Willson, 2009)
Telecare used with individuals diagnosed with MS displayed improvements in QOL as
evidence by self-reported decrease in MS related symptoms (Zissman, Lejbkowicz, Miller,
2010)

Level II:
Short term goals established via teleconference are more likely to be achieved than
intermediate or long term goals for those diagnosed with MS (Asano, Preissner, Duffy,
Meixell, & Finlayson, 2015)
Goals established through teleconference structured around IADLs and leisure activities
had the highest achievement rates (Asano, Preissner, Duffy, Meixell, & Finlayson, 2015)
Teleconference delivered intervention can be used to educate individuals with MS on the
importance of establishing achievable and measurable goals (Asano, Preissner, Duffy,
Meixell, & Finlayson, 2015)
Level III:
The use of in-home, remotely monitored, virtual reality videogame-based telerehabilitation
displayed improvements in finger flexion and extension, overall finger dexterity, and
thumb movement (Golomb et al., 2010)
Engagements in virtual reality videogame via telerehabilitation displayed improvements in
spatial firing for adolescents with hemiplegic cerebral palsy (CP) (Golomb et al., 2010)
Studies found that telephone-based cognitive behavioral therapy does not increase QOL for
those with depression associated with PD (Dobkins, 2011)
Summary of Level IV and V:
N/A
Contributions of Qualitative Studies:
N/A

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
Telehealth is an effective healthcare service delivery for individuals diagnosed with
neurodegenerative diseases
When utilizing telehealth for fatigue management purposes, OT practitioners should focus
intervention strategies on IADLs more so than ADLs due to increased achievement of selfidentified goals
Through the application of telehealth-based programs and interventions, individuals
diagnosed with MS or PD have displayed increases in episodic memory, decreased fatigue
and disease related symptoms, and increased QOL
Telehealth service delivery leads to increased perceived health and well-being, therefore
leading to more occupational engagement and increased QOL (Paul et al., 2014)
Implementing memory aids into a telehealth medication management programs lead to
increased independence in IADLs, specifically medication management
Program development:
Telehealth can be just as effective as routine, in-person care for individuals diagnosed with
neurodegenerative diseases
Telehealth is found to have greater attendance to therapy interventions as compared to
routine care for all health care disciplines
Treatment administered through videophone is more effective for telehealth than a regular
telephone
Societal Needs:
Telehealth allows those living in rural areas or who are homebound to receive medical
treatment despite difficulties associated with traveling to and from the clinic
Those unable to seek treatment in a clinic can still achieve improvement inside their home
in the natural setting
Individuals diagnosed with neurodegenerative diseases benefit from receiving therapy in
their homes
Telehealth can improve fatigue-related deficits, cognitive impairments, and reduce the
disease-related symptoms associated with neurodegenerative diseases
Healthcare delivery and policy:
Telehealth can significantly decrease healthcare costs and reduce the current health related
economic burden
Additional research needs to be done to determine how telehealth as a service delivery
method will be funded in the future
Treatment can be monitored more frequently and closely when telehealth is utilized
Successful treatment of telehealth leads to increased self-perceived QOL further
decreasing higher medical costs in the future
Telehealth is just as effective and produces similar results as routine care

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Education and training of OT students:

Overall, more education and training on telehealth needs to be incorporated into the entrylevel OT curriculum to increase use of telehealth in practice
OT practitioners need to be educated on telehealth service delivery when working with
individuals diagnosed with progressive diseases
OT students need to receive additional training on the various types of technology that may
be utilized in practice for individuals with neurodegenerative diseases
Refinement, revision, and advancement of factual knowledge or theory:
Research on the impact of telehealth for neurodegenerative diseases beyond MS and PD is
scarce
Little research is available on interventions with OT practitioners within the realm of
telehealth based service delivery
Larger and more diverse populations need to be included in the telehealth based research to
better ensure generalization of results
A greater number of objective measurements are needed to increase the validity and
reliability of the research findings

Review Process:

Population identified; selected from AOTA emerging practice areas

Formulated PICO question; submitted to course instructor for review
Formulated inclusion and exclusion criteria
Identified key search terms and phrases
Conducted literature search; applied inclusion and exclusion criteria
Abstracts reviewed to determine if article(s) found fit inclusion/exclusion criteria;
those that did not were discarded; full text articles obtained from abstracts that fit
inclusion/exclusion criteria
Full text articles reviewed and McMaster Critical Review forms filled out accordingly
for each article
Created evidence table highlighting article key points
Information summarized into critically appraised topic (CAT) paper

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Published after 2008

13 years or older
Intervention of telehealth, telemedicine, telerehabilitation, web-based intervention, etc.
Diagnosis of neurodegenerative disease
English

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Exclusion Criteria:

Published before 2008

13 years or younger
Any intervention other than telehealth
CVA, physical disabilities or pain
Languages other than English
Qualitative studies

Search Strategies:
Categories
Patient/Client Population

Intervention
Outcomes

Key Search Terms

Neurodegenerative diseases, Parkinsons disease, multiple
sclerosis, cerebral palsy, Amyotrophic lateral sclerosis, prion
disease
Telehealth, telemedicine, telerehabilitation, web-based
interventions
Improved QOL, increased feasibility, reduction of economic
burden, increased adherence to intervention, increased
independence

Databases and Sites Searched

CINHAL, OT Search, PubMed, Hand Search, GoogleScholar, OTSeeker
Quality Control/Peer Review Process:

PICO question was developed by two students under the guidance of course instructor,
Dr. Donna Costa
Course instructor provided feedback
Search terms were established by students; PowerPoint lecture from librarian was
referenced for effective phrases, terms, and databases
Students completed an exhaustive search of five databases
Hand searching through acquired bibliographies was performed; no additional articles
were found
Search terms and databases reviewed by instructor
CAT Table reviewed by course instructor
CAT paper created after students received feedback from course instructor and made
all necessary changes

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence
I
II
III
IV
V
Other

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g. cohort,
case-control)
One group, nonrandomized (e.g., before and after,
pretest, and posttest)
Descriptive studies that include analysis of outcomes
(single subject design, case series)
Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Qualitative Studies
TOTAL:

Number of Articles
Selected
7
1
2

10

Limitations of the Studies Appraised:

Levels I, II, and III

Small sample size of 20, limiting generalization of results (Asano, Preissner, Duffy,
Meixell, & Finlayson, 2015; Dobkin et al., 2011; Dorsey et al., 2013; Golomb et al.,
2010; Paul et al., 2014; Settle et al., 2015)
Results were not statistically significant and therefore cannot be considered clinically
valid or reliable (Dorsey et al., 2013)
Intervention occurred for only a short period of time and the author believes that
through a longer intervention period, more positive results will be seen (Paul et al.,
2014)
The study was poorly randomized making the participants aware of who was in what
intervention group. This study considers itself a level I but due to the poor
randomization cannot be considered as such (Asano, Preissner, Duffy, Meixell, &
Finlayson, 2015)
Results were evaluated subjectively, leaving room for bias and unreliability (Asano,
Preissner, Duffy, Meixell, & Finlayson, 2015)
Intervention tools were not properly calibrated, leading to inaccurate and false results
(Golomb et al., 2010)
Malfunctioning technology lead to incomplete data sets for one of four participants
(Golomb et al., 2010)
Not enough outcome measures were used to obtain the most accurate results (Golomb
et al., 2010)

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

All outcome measures relied on self-report, leading to subjective and unreliable data
(Finlayson, Preissner, Cho, & Plow, 2011)
Nearly all participants were male and Caucasian, therefore not accurately representing
the entire population (Fincher, Ward, Dawkins, Magee, Willson, 2009)
Motor changes were not able to be assessed due to the absence of in-person
assessment, further limiting the available outcome data and not including all areas of
improvement (Dobkin et al., 2011)
Long-term benefits were not assessed, therefore limiting knowledge of the possible
achievements made through the telehealth intervention (Dobkin et al., 2011)
Results may not be generalizable due to advanced stages of neurodegenerative diseases
(Dobkin et al., 2011)

Levels IV and V
N/A
Other

Articles Selected for Appraisal:

Asano, M., Preissner, K., Duffy, R., Meixell, M., & Finlayson, M. (2015). Goals set after
completing a teleconference-delivered program for managing multiple sclerosis
fatigue. The American Journal of Occupational Therapy, 69(3), 18.
doi:10.5014/ajot.2015.015370
Dobkin, R.D., Menza, M., Allen, L.A., PsyM, J.T., Friedman, J., Bienfait, K.L., Gara, M.A.,
Mark, M.H. (2011). Telephone-based cognitive-behavioral therapy for depression in
Parkinsons disease. Journal of Geriatric Psychiatry and Neurology, 4, 206-214.
doi:10.1177/0891988711422529

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Dorsey, E.R., Venkataraman, V., Grana, M.J., Bull, M.T., George, B.P., Boyd, C.M.,
Biglan, K.M. (2013). Randomized, controlled trial of virtual housecalls for
Parkinson disease. JAMA Neurology, 5, 565-567. doi:10.1001/jamaneurol.2013.123
Fincher, L., Ward, C., Dawkins, V., Magee, V., & Willson, P. (2009). Using telehealth to
educate Parkinsons disease patients about complicated medication regimens. Journal
of Gerontological Nursing, 35, 16-24. Doi:
Finlayson, M., Preissner, K., Cho, C., & Plow, M. (2011). Randomized trial of a
teleconference-delivered fatigue management program for people with multiple
sclerosis. Multiple Sclerosis Journal, 17(9), 1130-1140.
doi:10.1177/1352458511404272
Golomb, M. R., McDonald, B. C., Warden, S. J., Yongman, J., Saykin, A. J., Shirley, B.,
Huber, M. (2010). In-home virtual reality videogame telerehabilitation in adolescents
with hemiplegic cerebral palsy. Archives of Physical Medicine and Rehabilitation, 91,
1-8. doi:10.1016/j.apmr.2009.08.153
Jelcic, N., Agostini, M., Meneghello, F., Buss, C., Parise, S., Galano, A., Cagnin, A. (2014).
Feasibility and efficacy of cognitive telerehabilitation in early Alzheimers disease: a
pilot study. Clinical Interventions in Aging, 9, 16051611. doi:10.2147/CIA.S68145
Paul, L., Coulter, E., Miller, L., McFadyen, A., Dorfman, J., & Mattison, P. (2014). Webbased physiotherapy for people moderately affected with Multiple Sclerosis;
quantitative and qualitative data from a randomized, controlled pilot study. Clinical
Rehabilitation, 28(9), 924-935. doi:10.1177/0269215514527995
Settle, J.R., Maloni, H.W., Bedra, M., Finkelstein, J., Zhan, M., & Wallin, M.T. (2015).
Monitoring medication adherence in multiple sclerosis using a novel web-based tool: A

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

pilot study. Journal of Telemedicine and Telecare, 0, 0.

doi:10.1177/1357633X15597115
Zissman, K., Lejbkowicz, I., Miller, A. (2012). Telemedicine for multiple sclerosis patients:
assessment using Health Value Compass. Multiple Sclerosis Journal, 18, (4), 472-480.
doi:10.1177/1352458511421918

Other References:
Author? (2005). Telehealth. The American Journal of Occupational Therapy, 67, (6). S69-S90.
doi:10.5014/ajot.59.6.656
Gardner-Nix, J., Barbati, J., Grummitt, J., Pukal, S.,& Newton, R. R. (2012). Exploring the
effectiveness of a mindfulness-based chronic pain management course delivered
simultaneously to on-site and off-site patients using telemedicine. Mindfulness.
doi:10.1007/s12671-012-0169-

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05