Neuro-Rehabilitation OnLine (N-ROL): description and evaluation of a group-based telerehabilitation programme for acquired brain injury

Intense rehabilitation after stroke and other forms of acquired brain injury (ABI) can lead to large clinical improvements. The arrival of COVID-19 in early 2020 influenced stroke presentations but reduced opportunities for rehabilitation. The necessity to avoid facetoface contact and to reach as many patients with as few staff as possible led to a threeway collaboration between University College London, University College London Hospitals NHS Foundation Trust (UCLH) and SameYou charity to set up a comprehensive, multidisciplinary groupbased NeuroRehabilitation OnLine (NROL) programme. NROL involved physiotherapy, occupational therapy, speech and language therapy, neuropsychology and neurology. Here we describe NROL (Template for Intervention Description and Replication (TIDieR) checklist, online supplemental table S1) and report our quantitative evaluation. NROL is registered with UCLH Quality and Service Department as a service evaluation (reference number 55–2 02 021SE). Patients were referred by community or hospitalbased rehabilitation teams and screened via telephone. Inclusion criteria included confirmed ABI, <6 months from hospital discharge, English speaking and willingness to engage in online groupbased sessions. Exclusion criteria included no access to computer hardware. Triage into specific groups was carried out in the same call if participants were suitable and refined in an initial ‘meet the team’ group session. There was no limit to the number or type of sessions individuals could take part in, although the number of participants per session was capped for some groups (online supplemental table S2). Assessments were completed immediately before and after completion of NROL in a repeatedmeasures design. We expected that most patients would participate in a range of groups through which their knowledge and confidence to pursue recovery would be enhanced. Rather than use limited resources on domainspecific outcome measures, we therefore wanted to test the efficacy of NROL as a whole. Our first outcome measure was the Stroke SelfEfficacy Questionnaire (SSEQ), a Likert scale (0–3) questionnaire with 13 questions with good criterion validity. Our second outcome measure, NeuroRehabilitation OnLine Outcome Measure (NROLOM), a novel Likert scale questionnaire with seven questions for patients and two for carers/family (online supplemental appendix). The questions were constructed from themes derived from semistructured interviews with five early participants and two carers and so had good construct validity, reflecting the context (COVID-19 pandemic) in which the NROL programme was being delivered. We tested the hypotheses that NROL would lead to an improvement in these outcome measures using paired ttests. Statistical significance was set at a p value of <0.05. We quantified change using a standardised (Cohen’s d for repeatedmeasures data) and unstandardised measure. The latter is a calculation of how much of the gap between the patients’ baseline score and the highest possible score has been closed: the %maximum possible change. We performed post hoc analyses (paired ttests) to see which questions were driving any significant effects. A total of 144 patients were referred over 15 weeks. Note, 58 referrals did not progress to NROL: 13 did not meet the inclusion criteria; 12 were opposed to groupbased treatment, 13 were opposed to internetbased treatment, 11 felt they had recovered or were receiving enough treatment; and 3 were unwell or uncontactable. Six patients planned to start NROL but never attended due to work/ college commitments, internet difficulties or opposition to groups. Of the remaining 86 patients, predata/postdata were collected on at least one of the outcome measures for 74 patients (online supplemental figure S1). Summary demographic details of the 74 are as follows (median): age (65 years, IQR 54–74); days postinjury (81, IQR 34–174); gender (50% female); cause of ABI, stroke 95% (infarct 60%, haemorrhage 35%), trauma/other 5%; for those with a stroke and an National Institutes of Health Stroke Scale admission score (n=36; 4, IQR 2-9); living alone, 15%. Only 22 participants had additional community rehabilitation during NROL, ranging from 45 min once a fortnight to 4×30 min sessions a week, with a median 1.5 30–45 min sessions a week. Each patient attended on average 27.1 session, a mix of physical and talking therapies (online supplemental figure S2), with an average of 5.4 patients per group. Data for each type of group are shown in online supplemental table S2. The structure of NROL interventions (numbers of sessions and participants per session) remained unchanged throughout the 15 weeks, but the content of each group was iteratively adapted based on the needs and feedback of the participants. Complete predata/postdata were available for SSEQ and NROLOM for 67 and 68 patients, respectively. Carer/family data (NROLOM) were available for just over half of participants (either no carer or unable to contact them). There was a significant improvement on the SSEQ score (t(67)=2.28, p=0.026, pre=25.9, post=27.8). The standardised effect size was small (Cohen’s d=0.28), with a 14% average maximum possible change. The post hoc analyses revealed that this effect was driven by four questions: (1) prepare a meal you would like for yourself (p=0.022); (2) continue to do most of the things you liked to do before your stroke (p=0.030); (3) walk safely outside on your own on any surface (p=0.030); (4) walk a few steps on your own on any surface inside your house (p=0.047). There was a significant improvement on the patientbased NROLOM questions (t(68)=3.97, p<0.0005, pre=23.8, post=26.0). The standardised effect size was medium (Cohen’s d=0.48) with a 20% average maximum possible change (figure 1). The post hoc analyses revealed that this effect was driven by three questions: (1) other stroke/brain injury survivors have helped me understand my own stroke/ brain injury (p<0.0005); (2) I understand why I suffered a stroke/brain injury (p=0.014); (3) my day has a clear structure to it (p=0.032). There was no significant improvement on the carerbased NROLOM questions (t(33)=−0.90, p=0.374). In summary, patients who took part in NROL significantly improved on the two planned quantitative outcome measures. The post hoc analyses suggest that participants gained the most from (1) psychoeducation around ABI, including hearing other people’s stories; (2) gaining advice on how to better structure their day; and (3) perceived improvements in their motor function (meal preparation, balance and walking). NROL, like all therapistdelivered rehabilitation, is complex with many interacting components. Each group was delivered by highly skilled and specialist neurotrained therapists. We speculate that key elements to its success are (1) the multidisciplinary structure of the team; (2) using groups, which allows participants to gain and identify with each other; and (3) Letter