Key messages
• The available evidence is limited, and we don't yet know the best way to organize rehabilitation services across health systems.
• Using different providers (such as specialist physiotherapists) may make little to no difference to health outcomes. Telerehabilitation (rehabilitation via video calls or apps) may offer similar results to usual in-person rehabilitation for independence in everyday activities, well-being, depression, arm function, and mobility, but more research is needed.
• Most studies come from high-income countries, so findings may not apply everywhere. More research is needed in diverse settings.
What are delivery arrangements?
Delivery arrangements are about the practical side of rehabilitation: who helps you, when and where you get help, and how services are organized to make sure your care is smooth and effective. This can include things like how quickly you can get an appointment or start treatment; whether it's a doctor, nurse, therapist, or another trained professional providing treatment; the conditions and support for the people delivering your care; how different healthcare providers coordinate with each other so your care feels joined up; and whether you receive rehabilitation in a hospital, clinic, or at home, or through telerehabilitation (where therapy is delivered through video calls or apps).
What did we want to find out?
We wanted to understand:
• the best ways health systems can organize rehabilitation services (things like who provides care, how quickly people get appointments, and whether technology like telerehabilitation helps recovery);
• what research exists worldwide on how rehabilitation services are organized and delivered;
• how this information can guide health system stakeholders when making decisions about rehabilitation; and
• whether new kinds of research and policies are needed to improve rehabilitation services.
What did we do?
This project was part of a larger study on rehabilitation and health policy. We searched three large research databases for systematic reviews (collections of evidence from many individual studies) on how rehabilitation services are delivered.
What did we find?
We found 25 systematic reviews. Of those, just five had results we could use for this project. They covered studies conducted mainly in high-income countries in Europe, the Americas, and the Western Pacific. The reviews involved different populations, including older adults and people recovering from stroke.
Main results
• When care is given by health professionals other than doctors (such as specialist physiotherapists), there is no evidence of a meaningful difference in health outcomes compared with care provided by doctors.
• We found no reliable evidence about whether receiving care in hospitals, clinics, or at home makes a difference. A few studies looked at rehabilitation delivered at home compared with usual in-person care, finding similar results for both approaches, but the number of studies was small, and the evidence is not strong enough to draw solid conclusions.
• For people recovering from stroke, doing rehabilitation at home by video or phone may produce similar results to in-person rehabilitation for independence in everyday activities, well-being, depression, arm function, and mobility, but more research is needed.
What are the limitations of the evidence?
Many of the reviews had some research weaknesses, so our confidence in the results is limited. Where the review authors had formally assessed their confidence in the evidence, they mostly gave low-confidence ratings. This means future studies could change our findings. Nearly all studies were done in high-income countries. There was no evidence from Africa, South‑East Asia, or the Eastern Mediterranean, so results may not apply everywhere.
How up to date is this evidence?
The evidence is current to 17 November 2024.
Read the full abstract
Cochrane Rehabilitation and the World Health Organization (WHO) Rehabilitation Programme have collaborated to produce four Cochrane overviews of systematic reviews synthesizing evidence from health policy and systems research (HPSR) in rehabilitation. Each overview focuses on one of the four HPSR pillars identified by the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy: delivery, financial, and governance arrangements; and implementation strategies. This overview addresses delivery arrangements, which Cochrane EPOC defines as how health services are organized and delivered, including who provides care, how care is coordinated and managed, and where services are provided.
Objectives
This overview aimed to synthesize current evidence on delivery arrangements in rehabilitation from an HPSR perspective. Our series of four overviews has the following overarching objectives.
• To offer a broad synthesis of existing evidence on health policy and systems interventions' effects.
• To direct end-users, including policymakers, towards systematic reviews that may address their health policy questions.
• To identify current research gaps and set priorities for future primary HPSR.
• To pinpoint needs and priorities for new evidence syntheses where no reliable, up-to-date systematic reviews currently exist.
We searched Epistemonikos Health Systems Evidence databases and EPOC Group systematic reviews with no language limitations to identify reviews published between 2015 and 17 November 2024. We included Cochrane systematic reviews (CSRs) and non‐CSRs of randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) evaluating the effectiveness of health policy and systems interventions for rehabilitation in health systems, specifically related to delivery arrangements as defined in the EPOC taxonomy. All four overview teams screened reviews and extracted data. We used AMSTAR 2 to critically appraise the reviews, and we analyzed the results descriptively.
Main results
We included 25 systematic reviews. Three overlapped, and for 17 the AMSTAR 2 rating was low or critically low confidence. Five systematic reviews (2 CSRs and 3 non-CSRs) contributed to our synthesis. Most outcomes focused on patients, caregivers, or service use (e.g. access to rehabilitation). Equity-related outcomes were absent, and quality of care, adverse events, and our important outcomes were rarely reported.
Below, we report the results of three of the five reviews judged to have moderate to high confidence for our outcomes of interest, in which authors conducted meta-analysis and assessed the certainty of the evidence.
Who provides care
One review analyzed advanced practice physiotherapy (APP) models, which may result in little to no difference in health-related outcomes measured by the Pain Disability Index and EuroQol 5-Dimension questionnaire after the intervention, compared with usual care in adults with spinal pain (standardized mean difference [SMD] 0.05, 95% confidence interval [CI] −0.32 to 0.42; 2 studies, 225 participants; low certainty).
Information and communication technology
We included two reviews in this category. One compared telerehabilitation with usual care in older adults, finding that telerehabilitation may have little or no effect on quality of life after seven to 20 weeks (SMD −0.09, 95% CI −0.23 to 0.40; 3 studies, 179 participants; low certainty). There was very low-certainty evidence on mobility after seven to 26 weeks (SMD 0.63, 95% CI −0.25 to 1.51; 5 studies, 302 participants), strength after 12 and 26 weeks (SMD 0.73, 95% CI −0.10 to 1.56; 4 studies, 226 participants), and balance after seven to 26 weeks (SMD 0.40, 95% CI −0.35 to 1.15; 3 studies, 199 participants).
Another review on stroke survivors living in the community found that telerehabilitation compared with usual care probably has little or no effect on independence in activities of daily living (ADL) after 24 weeks (SMD 0.00, 95% CI −0.15 to 0.15; 2 studies, 661 participants; moderate certainty), self-reported quality of life after six to 24 weeks (SMD 0.03, 95% CI −0.14 to 0.20; 3 studies, 569 participants; moderate certainty), and depression after six to 24 weeks (SMD −0.04, 95% CI −0.19 to 0.11; 6 studies, 1145 participants; moderate certainty); and may have little or no effect on upper limb function after 12 weeks (SMD 0.33, 95% CI −0.21 to 0.87; 2 studies, 54 participants; low certainty) and mobility after six weeks (mean difference 0.01, 95% CI −0.12 to 0.14; 1 study; 144 participants; low certainty).
This review also compared telerehabilitation with in-person rehabilitation and found that there may be little to no difference in independence in ADL, measured with the Modified Barthel Index at four to 12 weeks (MD 0.59, 95% CI −5.50 to 6.68; 2 studies, 75 participants; low certainty); balance, measured with the Berg Balance Scale at four to 12 weeks (MD 0.48, 95% CI −1.36 to 2.32; 3 studies, 106 participants; low certainty); and upper limb function, evaluated with the Fugl-Meyer Assessment (Upper Extremity) four weeks after intervention (MD 1.23, 95% CI −2.17 to 4.64; 3 studies, 170 participants; low certainty).
Authors' conclusions
Current evidence on delivery arrangements in rehabilitation is limited, mostly of low certainty, and derived from high-income countries. Reviews covered five EPOC categories, but reliable evidence for our outcomes of interest was available for only two categories. Most evidence was on telerehabilitation. Compared with usual care, APP models may have little to no effect on health outcomes in adults with spinal pain. In people with stroke, telerehabilitation compared with usual care probably has little or no effect on independence in daily living, quality of life, and depression, and may have little to no effect on upper limb function and mobility. Compared with in-person care, telerehabilitation may have little to no effect on ADL, balance, and upper limb function.
Further high-quality research using well-defined frameworks is needed, especially in low- and middle-income countries, to identify effective strategies and evaluate organizational, implementation, and equity outcomes. Future Cochrane overviews in HPSR should consider a broader range of study designs, such as observational, qualitative, and mixed-design evidence, to better capture evidence on delivery arrangements in rehabilitation.
Funding
PC, CK, and SN were supported and funded by the Italian Ministry of Health (Ricerca Corrente). The funder played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Registration
Protocol (2025): DOI 10.23736/S1973-9087.24.08833-6.
