# New Remote Care Models in Patients with Spinal Cord Injury: A Systematic Review of the Literature
## 4 Discussion
In the first case we can affirm that a remote care model could be more effective on several SCI-related outcome domains: particularly, self-efficacy [37], familiar functioning [36], and lifestyle modification had significant changes in the experimental groups included. This finding reinforces the idea that a remote care model represents a strategy to reach a comprehensive and tailored nursing approach that is able to realize continuous educational intervention. In spite of this, some areas remained unchanged or showed little variations following a remote care approach: quality of life [35; 36; 37], depression [35], social integration [35], and disease perception [35] showed no significant differences following intervention. This data reflects the time span considered in our included studies (at least 1 year), that represents an interval of time too short, especially when compared to SCI natural lasting, to induce active change from a psychosocial point of view. Another barrier to psychosocial benefits is certainly the strategy of conducting intervention remotely: the patient is alone/with an operator in front of an electronic device, provides feedback on their health condition but has no opportunity to socialize with other peers. So a remote care model, although it shows excellent possibilities for empowering SCI patients, is not sufficient to induce radical change in relational and community life. Previous literature shows contrasting findings related to the issue: a systematic review about chronic non-oncological disease [44] showed the efficacy of remote care models on anxiety, pain, and depression. On the other hand, a meta-analysis by [PERSON] et al. [45] regarding colorectal cancer patients showed no significant change in quality of life following remote nursing intervention. In our opinion, given the different natures of the studied disease and due to heterogeneity of intervention (app, web platform, videoconference), future research should expand on the issue through an intervention standardizing strategy. From a clinical point of view, instead, remote care models had greater effect on bladder management [35; 36; 37] and musculoskeletal system [36], and a positive trend regarding pressure ulcer incidence [35; 36]; this is particularly interesting since Neurological Lower Urinary Tract Dysfunction (NLUTD) and motor issues represent the most common causes of long-term impairment related to SCI [46; 47]. Even pressure ulcers have a devastating impact on SCI patients' everyday life, representing a common cause of comorbidity and mortality [48; 49]. Even in this case, we must underline that all studies had a limited follow-up (1-year), and this reduces the ability to generalize the efficacy of remote care as a valid tool to clinical manage SCI patients, since NLUTD and pressure ulcers need longer follow-up during the entire lifespan of these patients. To date we can only discuss preliminary evidence, which seems in line with previous literature on phone-based intervention [50] and the feasibility of recent data [51]. In addition, non-randomized studies were in agreement with our findings [52; 53]. No author in this review, instead, explored the impact of remote care on bowel impairment [54; 55], with a substantial lack of information regarding the potential benefit of continuous educational intervention. Furthermore, another not explored scenario was the quality of life related to bowel and bladder symptoms through specific questionnaires [56; 57]; filling this gap could clarify those aspects which limit the patient in their social and personal relationships (intermittent catheterization or bowel discharge daily management). Finally, no data emerged with respect to chronic neuropathic pain management, which represents a constant challenge in long-term SCI assistance [58] and for sexual wellbeing following SCI. Concerning health policy implications of the present work, no included study described a cost/benefits analysis of remote nursing models.