New Remote Care Models in Patients with Spinal Cord Injury: A Systematic Review of the Literature

Abstract

Background: Spinal cord injury is a multisystem disease which compromises independence and quality of life; remote care models represent an opportunity for long-term management of complications. The aim of this study was to explore remote care models for chronic spinal cord injury patients. Methods: A systematic review of the literature was carried out. Five databases (PubMed, CINAHL, Web of Science, Cochrane Library, Google Scholar) were systematically explored with a time limit of five years. Included studies were assessed using Jadad Score and PEDro Scale. Results: Four RCTs were included in this systematic review. In all studies, multidisciplinary home care supported by technology were compared with in-person models. Remote care models were effective in managing pressure injury, infection, and muscle atrophy and improve quality of life. Conclusions: Remote care models can be a key tool for improving self-efficacy, decreasing hospitalizations and preventing long-term mortality.

1. Introduction

The World Health Organization (W.H.O.) defines spinal cord injury (SCI) as a complex medical and life condition caused by any injury to the spinal cord, the conus medullaris, and the cauda equine [1]. SCI can be either traumatic or non-traumatic, characterized by the loss or impairment of motor, sensory, or autonomic functions below the level of injury [2]. Worldwide, the incidence of traumatic SCI is 250,000–300,000 people each year, and it has been estimated that a person with SCI has 2 to 5 times higher risk of premature mortality compared to a healthy person [3]. Global estimates indicate that approximately 15.4 million people were living with SCI in 2021 [4]. Despite that motor impairment represents the most studied consequence of SCI, a great number of systems and organs are involved in the secondary damage of this condition, respiratory impairment, bladder–sphincter control deficit, neurogenic bowel dysfunction, sexual inability, thermoregulatory dysfunctions, and cardiovascular issues, all of which are common in SCI people [5]. Given clinical complexity, a SCI exposes patients to extremely severe tertiary damages, such as pressure ulcers (PUs), urinary tract infections, sepsis, metabolic disorders with osteoporosis and increased risk of fractures, higher risk of venous thrombosis and embolism, spinal deformities, severe spasticity with enforced postures, and joint limitations. These tertiary damages are often the main long-term cause of serious and fatal complications, significantly impacting life expectancy and care burden for those who suffer a spinal compromission [6]. The psychological, familial, and social consequences of these situations are also complex, causing in most cases a severe quality of life impairment and social reintegration problems [7].

People with more severe SCI often require continuous care and support, provided largely by informal caregivers [4]. SCI, often, represents a sudden event that disrupts individuals, forcing them to reposition themselves within the community with new challenges. Due to the highly disabling nature of this condition, it represents a significant risk factor for social exclusion, poverty, and premature mortality [8]. A spinal cord injury, due to its numerous and varied complications [9], entails a significant care commitment, making it a lifelong disability condition [10], leading to a high healthcare, economic, and social burden for affected individuals and families [2]. The care pathway for an SCI patient requires multiprofessional assistance in all settings, involving nursing, rehabilitation, relational, educational, psychological, and social interventions [11], requiring a coordinated, integrated, and multidisciplinary approach to ensure a smooth transition between inpatient, outpatient, and territorial activities [1]. Prevention, early diagnosis, and treatment of secondary conditions related to SCI are essential to increase life expectancy [4]. The nurse plays a central role throughout the care pathway of an SCI patient, especially in promoting a clinical-care model that goes beyond a task-based work, instead favouring comprehensive and continuous care, in order to achieve a multidisciplinary and tailored assistance [12].

In recent years, the COVID-19 pandemic highlighted the need to introduce new technologies in the context of long-term assistance settings [13]. Technological development, and the consequent expansion of telehealth, represent a great opportunity for patients, allowing them to receive home care without continuous hospitalizations [14]. For people living in rural or medically underserved areas, access to care could be difficult or even nonexistent [15]. Financial limitations, travel and care costs [16], and weather conditions impact access to healthcare assistance [17]. Transportation to hospitals/clinics could be a barrier due to journey length and duration and discomfort [18]. The use of telecommunications is viewed as a beneficial, easy, and efficient way of healthcare delivery [19], representing a potential solution for providing assistive technology services, especially in rural and remote areas [1]. The evolution of telehealth over recent decades has revealed innovative options in telerehabilitation to address unresolved challenges for patients who need rehabilitation [20].

For all these reasons, people with spinal cord injuries (SCIs) represent a group that could benefit from telehealth services [21]. Despite the extensive literature on e-health in healthcare/assistive settings, the landscape of remote care models for SCI patients has not been comprehensively described in terms of characteristics and approaches. It is important to have an overview of these tools to know how to select, further develop, and improve them [2].

The aim of this work was to conduct a literature review to describe care models supported by innovative technology for long-term assistance on SCI. Particularly, two research queries (RQs) guided the study:

RQ1: Is there evidence in the literature about alternative remote nursing models to standard/in-person care for spinal cord injury patients? What is the role of the nurse in such settings and how does the nurse interface with the multidisciplinary team?

RQ2: From a clinical and psychosocial point of view, do remote care models show differences compared to traditional in-person assistance?

2. Materials and Methods

A systematic literature review was conducted in accordance with the Prisma Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) [22]. The review protocol was registered on the PROSPERO platform (CRD42023450407, last version updated at 3 May 2024) [23], the international prospective register of systematic review, on 14 August 2023.

2.1. Eligibility Criteria and Search Strategy

Inclusion criteria involved randomized controlled trials (RCTs), or (if no RCT was retrieved) observational studies, in which adult patients, aged 18 years and over, were affected by spinal cord injury, in a stable medical condition and were referred to home care provided by a multidisciplinary team. Intervention considered studies in which remote home care was delivered using apps, online platforms, and electronic devices, all compared with standard in-person care. Pain, neurological bladder control, neurogenic bowel, and the occurrence of pressure ulcers were analyzed as the outcome of the included studies and as factors improving quality of life and reducing the number of hospital admissions. Exclusion criteria were (i) studies that included patients aged <18 years or hospitalized patients or affected by other neurological or psychiatric diseases; (ii) studies with care programs not involving the multidisciplinary team; (iii) studies not in English or Italian; (iv) case report or case series, conference acts, book chapters, pre-clinical studies. Grey literature was not specifically searched (

Table 1. Inclusion and exclusion criteria using P.I.C.O. framework.

	Inclusion	Exclusion
Population:	Adult patients aged >18 years, with spinal cord injury diagnosis, with stable medical conditions, and with indication for home care provided by a multidisciplinary team	Adolescents (age < 18 years), hospitalized patients, other neurological diseases without SCI etiology, uncooperative patients, and/or suffering psychiatric disorders
Intervention:	Remote home care using applications, online platforms, electronic devices	Care program not involving the multidisciplinary team
Comparator:	In-person standard care	No comparisons undertaken
Outcome:	Pain, neurological bladder control, neurogenic intestine, and appearance of pressure lesions. Quality of life and reduction in the number of accesses to hospital facilities

).

The search strategy was developed using the P.I.C.O. [24] framework. The conceptual method was used to develop Boolean query and verified with a stakeholder (librarian). Mesh terms were included. The databases searched were PubMed (National Library of Medicine), CINAHL (EBSCOhost), Web of Science (Clarivate, London, UK), Cochrane Library for clinical trials, and Google Scholar (Montain View, CA, USA). The search was conducted on 30 May 2023 (see Supplementary Materials File S1). Forward and backward snowball searching of the included studies was employed for references lists, in addition to including studies of 5 systematic reviews [25,26,27,28,29] to check for other studies accidentally excluded from the search strings that needed to undergo the previously described screening process.

2.2. Study Selection

After the exclusion of duplicates, the screening process selected studies by title and abstract by six reviewers independently. The remaining records were screened by full text reading by the same reviewers independently. Two other reviewers screened full text studies in a double-blind method. All disagreements were resolved through discussion and consensus with the research group.

The whole process of study selection was carried out with the support of the reference manager software Zotero 5.0 [30]. The entire process of study selection was reported using a PRISMA flow diagram [22].

2.3. Data Extraction and Data Synthesis

Data were abstracted to a comprehensive data extraction form including study characteristics such as author’s name, publication year, title, study design, sample, aim of the study, intervention, multidisciplinary of care, outcome measures, and results (see Table 2). Two independent reviewers performed data extraction independently to limit bias, and any discrepancies were discussed and solved through consensus of the research group. Due to the aim, the characteristics of the included studies were summarized in tables and synthesized narratively according to the outcomes.

2.4. Quality Appraisal

To reduce bias in randomized trials, researchers blindly assessed the methodological quality of studies using the Jadad Scale [31] and PEDRO Scale [32]. The Jadad Scale has three questions and each one has two answer options (0 or 1). The questions on randomization and blinding involve the addition or deletion of a point in reason of appropriateness, with a maximum possible score of 5. Each question for the PEDRO Scale has two answer options (“yes” or “no”): 1 point is assigned for “yes” and 0 is assigned for “no”. Higher overall scores of the scales suggested higher quality of the studies. After the assessment the authors discussed any discrepancies and solved them through consensus.

2.5. Reporting Checklist

The PRISMA 2020 statement was used to enhance the transparency of systematic review reporting (see Supplementary Materials File S2) [33].

3. Results

3.1. Screening of Studies

The process of record selection and screening, according to the Prisma flow diagram, is shown in Figure 1.

By the overall database search, a total of 32,359 records emerged. By duplicate identification through Zotero software, and subsequent merging of studies through identical DOI checks, 28,738 articles were finally identified for screening. Title and abstract screening led to the identification of nine potentially relevant articles for our review; to definitively assess their eligibility according to inclusion criteria, full texts were retrieved and read.

From full text reading, five clinical trials were deemed further excluded for the following reasons: the absence of a nurse in the multidisciplinary team and mixed sampling (pediatric sample, hospitalized patients, patients with heart disease). So, the selection process thus concluded with the inclusion of four RCTs [34,35,36,37] for the present literature review.

3.2. Data Extraction and Synthesis

Extracted data from each article are shown in the data extraction table, where a summary of the included studies’ characteristics was provided (Table 2). Data extracted from each RCT included the following: author and year of publication, title, research design, study objective and results, sample size and type, intervention performed, outcome measures, and multidisciplinary nature of the team. These data described the profile the stable SCI patients followed at home.

Table 2. Data extraction table.

Authors	Year	Title	Study Design	Sample	Aim	Intervention	Multi Disciplinarity	Outcome Measures	Results
Irgens I, Midelfart-Hoff J, Jelnes R, Alexander M, Stanghelle JK, Thoresen M, Rekand [34]	2022	Videoconferencing in Pressure Injury: Randomized Controlled Telemedicine Trial in Patients With Spinal Cord Injury	RCT	56 participants older than 18 years with diagnosis of SCI, PU, and able to participate. EXP [n = 28] CONT [n = 28]	1. To investigate whether video-conferencing consultations can improve health-related quality of life in people with SCI and PUs. 2. To determine whether video-conferencing consultations can improve LDP recovery, team interaction, and patient satisfaction.	EXP: Home care nurses performed LDP medication with remote support from the multidisciplinary team. CONT: Treatment and indications based on existing routines through telephone calls or outpatient visits. Final outpatient follow-up for both groups either at healing of the PU or within 1 year.	PU-trained doctor, home care nurses, PU trained nurses, occupational therapist	PU classification: NPIAP, EPUAP, and PPPIA guidelines. Quality of life: SF-36; EQ-5D questionnaire International Spinal Cord Injury Quality of life Basic Data Set Satisfaction, safety and level of interaction: questionnaires with subjective ratings on a Likert scale 1–5	No significant differences between two groups in terms of health-related quality of life emerged. Videoconferencing-based care appeared to be a safe and efficient method of managing PU in terms of improved quality of life, PU recovery, team interaction, and patient satisfaction compared to standard care.
Kryger MA, Crytzer TM, Fairman A, Quinby EJ, Karavolis M, Pramana G, Setiawan IMA, McKernan GP, Parmanto B, Dicianno BE [35]	2019	The Effect of the Interactive Mobile Health and Rehabilitation System on Health and Psychosocial Outcomes in Spinal Cord Injury: Randomized Controlled Trial	RCT	38 participants aged > 18 years, diagnosed with SCI, attending a rehabilitative outpatient clinic for SCI and living at home. EXP [n = 19] CONT [n = 19]	1. To determine whether the use of the iMHere health platform was associated with better health outcomes over a 9-month period. 2. To determine whether the use of the iMHere health platform was associated with better psychosocial outcomes over a 9-month period.	EXP: Use of the iMHere app, consisting of several modules (medication management, urinary and bowel program reminders, skin monitoring, mood monitoring, messaging to communicate with a doctor). CONT: Standard care (doctor’s visit at the outpatient clinic with follow-up according to patient’s conditions) Follow-up at 9 months.	Nurse, physiatrist, physiotherapist, doctor	Number of UI: number of symptomatic UI with positive culture and treated with antibiotics; number of PU: number of single episodes of LDP from stage 2 to stage 4 based on NPIAP; number of admissions to ED for any reason; number of admissions to the PS for UI or PU; number of hospitalisations due to UI or PU. Independence, mood, quality of life: COPM; AMIS-II BDI-II; PACIC; WHOQOL-BREF; CHART-SF.	1. Significant UI reduction in the EXP group compared to the CONT group. Other outcome measures showed a non-significant decrease in the EXP group. 2. Reduction in depressive symptoms based on the BDI-II scale in the EXP group compared to the CONT group.
Li J, Li QP, Yang BH [36]	2021	Participatory continuous nursing using the WeChat platform for patients with spinal cord injuries	RCT	78 participants diagnosed with stabilized SCI, treated by internal fixation, and able to provide informed consent. EXP [n = 39] CONT [n = 39]	Analyzing the effect of continuous and participative nursing care using the WeChat platform on reduction in PU, UI, joint contractures, muscle atrophy, and improving family function and patient compliance.	EXP: After discharge a team member provided individual continuing care intervention via the WeChat platform to the patient and caregiver: prevention/management of complications, rehabilitation exercises, nutrition education, family and social support, psychological adjustment, and self-care management. CONT: Regular care at the time of discharge. Follow-up at 6 months.	Nurses, psychological counsellors, doctors	FAD HPLPII	At 6 months after discharge, the EXP group showed a lower incidence of PU, UI, and joint contractures. In the EXP group, there was also an improvement in family function and compliance behaviour at 3 and 6 months after discharge.
Liu T, Xie S, Wang Y, Tang J, He X, Yan T, Li K [37]	2021	Effects of App-Based Transitional Care on the Self-Efficacy and Quality of Life of Patients With Spinal Cord Injury in China: Randomized Controlled Trial	RCT	98 participants aged >18 years with a diagnosis of at least 2 years of complete or incomplete SCI managed at home. EXP [n = 49] CONT [n = 49]	Assessing the effects of Together app-based remote assistance on self-efficacy and quality of life outcome of patients with SCI.	EXP: Five follow-ups conducted by the multidisciplinary team via the app: remote health assessment, health education, interdisciplinarity, interaction with patients at week 2, 4, 6, 8, and 12 after discharge. CONT: A single routine telephone follow-up conducted by the nurse at week 12 after discharge.	Nurse team leader and responsible for app-based care, rehabilitation physician, physiotherapist, occupational therapist	MSES SF-36	EXP group showed an improvement in the level of self-efficacy compared to the CONT group. In contrast, no statistical difference was found on the improvement of quality of life between the two groups.

Abbreviations: SCI: spinal cord injury; RCT: randomized controlled trial; EXP: experimental group; CONT: control group; PU: pressure ulcer; UI: urinary infection; ED: emergency department; ASIA: American Spinal Cord Association; NPIAP: National Pressure Injury Advisory Panel; EPUAP: European Pressure Ulcer Advisory Panel; PPPIA: Pan Pacific Pressure Injury Alliance; SF-36: Short Form Health Survey 36; EQ-5D: EuroQol five dimensions; COPM: Canadian Occupational Performance Measure; AMIS-II: Adolescent Self Management and Independence Scale; BDI-II: Beck Depression Inventory-II; PACIC: Patient Assessment of Chronic Illness Care; WHOQOL-BREF: World Health Organization Quality of Life Brief Instrument; CHART-SF: Craig Handicap Assessment and Reporting Technique Short form; FAD: Family Assessment Device; HPLPII: Health Promoting Lifestyle Profile; MSES: Moorong self-efficacy scale.

Table 2. Data extraction table.

Authors	Year	Title	Study Design	Sample	Aim	Intervention	Multi Disciplinarity	Outcome Measures	Results
Irgens I, Midelfart-Hoff J, Jelnes R, Alexander M, Stanghelle JK, Thoresen M, Rekand [34]	2022	Videoconferencing in Pressure Injury: Randomized Controlled Telemedicine Trial in Patients With Spinal Cord Injury	RCT	56 participants older than 18 years with diagnosis of SCI, PU, and able to participate. EXP [n = 28] CONT [n = 28]	1. To investigate whether video-conferencing consultations can improve health-related quality of life in people with SCI and PUs. 2. To determine whether video-conferencing consultations can improve LDP recovery, team interaction, and patient satisfaction.	EXP: Home care nurses performed LDP medication with remote support from the multidisciplinary team. CONT: Treatment and indications based on existing routines through telephone calls or outpatient visits. Final outpatient follow-up for both groups either at healing of the PU or within 1 year.	PU-trained doctor, home care nurses, PU trained nurses, occupational therapist	PU classification: NPIAP, EPUAP, and PPPIA guidelines. Quality of life: SF-36; EQ-5D questionnaire International Spinal Cord Injury Quality of life Basic Data Set Satisfaction, safety and level of interaction: questionnaires with subjective ratings on a Likert scale 1–5	No significant differences between two groups in terms of health-related quality of life emerged. Videoconferencing-based care appeared to be a safe and efficient method of managing PU in terms of improved quality of life, PU recovery, team interaction, and patient satisfaction compared to standard care.
Kryger MA, Crytzer TM, Fairman A, Quinby EJ, Karavolis M, Pramana G, Setiawan IMA, McKernan GP, Parmanto B, Dicianno BE [35]	2019	The Effect of the Interactive Mobile Health and Rehabilitation System on Health and Psychosocial Outcomes in Spinal Cord Injury: Randomized Controlled Trial	RCT	38 participants aged > 18 years, diagnosed with SCI, attending a rehabilitative outpatient clinic for SCI and living at home. EXP [n = 19] CONT [n = 19]	1. To determine whether the use of the iMHere health platform was associated with better health outcomes over a 9-month period. 2. To determine whether the use of the iMHere health platform was associated with better psychosocial outcomes over a 9-month period.	EXP: Use of the iMHere app, consisting of several modules (medication management, urinary and bowel program reminders, skin monitoring, mood monitoring, messaging to communicate with a doctor). CONT: Standard care (doctor’s visit at the outpatient clinic with follow-up according to patient’s conditions) Follow-up at 9 months.	Nurse, physiatrist, physiotherapist, doctor	Number of UI: number of symptomatic UI with positive culture and treated with antibiotics; number of PU: number of single episodes of LDP from stage 2 to stage 4 based on NPIAP; number of admissions to ED for any reason; number of admissions to the PS for UI or PU; number of hospitalisations due to UI or PU. Independence, mood, quality of life: COPM; AMIS-II BDI-II; PACIC; WHOQOL-BREF; CHART-SF.	1. Significant UI reduction in the EXP group compared to the CONT group. Other outcome measures showed a non-significant decrease in the EXP group. 2. Reduction in depressive symptoms based on the BDI-II scale in the EXP group compared to the CONT group.
Li J, Li QP, Yang BH [36]	2021	Participatory continuous nursing using the WeChat platform for patients with spinal cord injuries	RCT	78 participants diagnosed with stabilized SCI, treated by internal fixation, and able to provide informed consent. EXP [n = 39] CONT [n = 39]	Analyzing the effect of continuous and participative nursing care using the WeChat platform on reduction in PU, UI, joint contractures, muscle atrophy, and improving family function and patient compliance.	EXP: After discharge a team member provided individual continuing care intervention via the WeChat platform to the patient and caregiver: prevention/management of complications, rehabilitation exercises, nutrition education, family and social support, psychological adjustment, and self-care management. CONT: Regular care at the time of discharge. Follow-up at 6 months.	Nurses, psychological counsellors, doctors	FAD HPLPII	At 6 months after discharge, the EXP group showed a lower incidence of PU, UI, and joint contractures. In the EXP group, there was also an improvement in family function and compliance behaviour at 3 and 6 months after discharge.
Liu T, Xie S, Wang Y, Tang J, He X, Yan T, Li K [37]	2021	Effects of App-Based Transitional Care on the Self-Efficacy and Quality of Life of Patients With Spinal Cord Injury in China: Randomized Controlled Trial	RCT	98 participants aged >18 years with a diagnosis of at least 2 years of complete or incomplete SCI managed at home. EXP [n = 49] CONT [n = 49]	Assessing the effects of Together app-based remote assistance on self-efficacy and quality of life outcome of patients with SCI.	EXP: Five follow-ups conducted by the multidisciplinary team via the app: remote health assessment, health education, interdisciplinarity, interaction with patients at week 2, 4, 6, 8, and 12 after discharge. CONT: A single routine telephone follow-up conducted by the nurse at week 12 after discharge.	Nurse team leader and responsible for app-based care, rehabilitation physician, physiotherapist, occupational therapist	MSES SF-36	EXP group showed an improvement in the level of self-efficacy compared to the CONT group. In contrast, no statistical difference was found on the improvement of quality of life between the two groups.

Abbreviations: SCI: spinal cord injury; RCT: randomized controlled trial; EXP: experimental group; CONT: control group; PU: pressure ulcer; UI: urinary infection; ED: emergency department; ASIA: American Spinal Cord Association; NPIAP: National Pressure Injury Advisory Panel; EPUAP: European Pressure Ulcer Advisory Panel; PPPIA: Pan Pacific Pressure Injury Alliance; SF-36: Short Form Health Survey 36; EQ-5D: EuroQol five dimensions; COPM: Canadian Occupational Performance Measure; AMIS-II: Adolescent Self Management and Independence Scale; BDI-II: Beck Depression Inventory-II; PACIC: Patient Assessment of Chronic Illness Care; WHOQOL-BREF: World Health Organization Quality of Life Brief Instrument; CHART-SF: Craig Handicap Assessment and Reporting Technique Short form; FAD: Family Assessment Device; HPLPII: Health Promoting Lifestyle Profile; MSES: Moorong self-efficacy scale.

3.3. Critical Appraisal

In order to assess the methodological quality of the included studies, the Jadad Scale (

Table 3. Quality appraisal—Jadad Scale.

Study	Randomisation	Blinding	Withdrawals and Dropouts	Total Score
Irgens et al. (2022) [34]	1 + 1	0	1	3/5
Kryger et al. (2019) [35]	1 + 1	1	1	4/5
Li et al. (2021) [36]	1 + 1	0	1	3/5
Liu et al. (2021) [37]	1 + 1	1	1	4/5

) and the PEDro Scale (

Table 4. Quality appraisal: PEDRO Scale.

Study	Criteria 1	Criteria 2	Criteria 3	Criteria 4	Criteria 5	Criteria 6	Criteria 7	Criteria 8	Criteria 9	Criteria 10	Criteria 11	Score
Irgens et al. (2022) [34]	Y	Y	N	Y	N	N	Y	Y	Y	Y	Y	7/10
Kryger et al. (2019) [35]	Y	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
Li et al. (2021) [36]	Y	Y	N	Y	N	N	N	Y	Y	Y	Y	6/10
Liu et al. (2021) [37]	Y	Y	N	Y	N	N	Y	Y	Y	Y	Y	7/10

Abbreviations: Y: yes; N: no. Criteria 1: eligibility criteria; Criteria 2: random allocation; Criteria 3: hidden allocation; Criteria 4: baseline comparability; Criteria 5: blind subject; Criteria 6: blind clinician; Criteria 7: blind assessor; Criteria 8: adequate follow-up; Criteria 9: intention-to-treat analysis; Criteria 10: between-group analysis; Criteria 11: point estimates and variability.

) were employed. Both scales were utilized to assess the four eligible RCTs, which presented medium–high methodological quality, thus preventing the risk of individual/confronting bias.

The included studies received the following scores:

Irgens et al. [34]: Jadad score: 3/5; PEDro Scale: 7/10.

Kryger et al. [35]: Jadad score: 4/5; PEDro Scale: 8/10.

Li et al. [36]: Jadad score: 3/5; PEDro Scale: 6/10.

Liu et al. [37]: Jadad score: 4/5; PEDro Scale: 7/10.

The only critical issue that emerged was the non-applicability of blinding strategies to healthcare professionals and patients performing teleassistance: given the nature of interventions (presence vs. distance), it was indeed impossible to apply selective blinding strategies.

3.4. General Characteristics of Included Studies

Four RCTs, involving a total population of 270 SCI adults, were included in the present review; based on the overall population, 191 patients were male (70.7%) and 79 were female (29.3%). The minimum age was 18 years and the maximum was 75 years. Studies were conducted in three different countries: China [36,37], Norway [34], and the USA [35]. In three cases [34,35,37], the RCT was preceded by a pilot study on a limited sample [34,37] or involving a population other than SCI patients [35].

All samples [34,35,36,37] involved patients over 18 years old, with a diagnosis of stabilized SCI and indication for home care provided by nurses as part of a multidisciplinary team. Criteria to enrol SCI patients [34,35,36,37] (complete or incomplete, of traumatic or non-traumatic origin) were to conform to the International Standards for Neurological Classification of Spinal Cord Injury by the American Spinal Injury Association (ASIA). A precondition for eligibility in all considered studies [34,35,36,37] was the presence and ability to use electronic devices (cell phone, computer, tablet) with internet access at home.

3.5. Interventions

All four examined RCTs [34,35,36,37] compared home care for SCI patients supported by innovative technology with standard in-person care; technologies employed included two applications [36,37]: a web-based platform [35] and a real-time service based on an encrypted software [34].

Specifically, in the study by Irgens et al. [34], 56 SCI patients were randomized for two different treatment strategies for pressure injuries: in the experimental group, district nurses acted at patients’ homes with the support of a real-time videoconference (CISCO Telepresence system) with a multidisciplinary team (formed by a wound care doctor, a wound care-trained nurse, and an occupational therapist). Patients in the control group continued their regular in-person care; both study arms were followed until the complete healing of the pressure injuries (or for a maximum of 52 weeks).

In the study by Kryger et al. [35], 19 participants in the intervention group were followed using an application called iMHere to address major SCI complications (urinary tract infections, pressure injury, assessment of independence, mood, and quality of life). The remaining 19 patients received in-person care without any technological device. In this study, a multidisciplinary team was composed of a nurse, physiotherapist, physiatrist, and doctor. Outpatient follow-up, based on participants’ health status and doctor decision, were conducted 9 months after the start of the study.

In the study by Li et al. [36], 78 participants were randomized in two groups: in the experimental one, through a web-based platform, patients had direct communication with the multidisciplinary team (composed of nurses, doctors, and psychological consultants). The WeChat platform was used to perform one-on-one continuous care intervention; moreover, patients were facilitated to communicate their health status by uploading photos or videos, allowing the multidisciplinary team to quickly evaluate any red flags. Participants in the control group had a regular follow-up at 6 months.

Finally, in the study by Liu et al. [37], a population of 98 SCI patients was randomly assigned to experimental/control groups. At the beginning of the study, an application called Together, accessible both to the team and the patients, was designed. In the experimental group (49 SCI patients), the app was used to provide remote assistance through health-education, case sharing, and interaction with the patient, while the control group had a single routine telephone follow-up conducted 12 weeks after the start of the study. The multidisciplinary team was composed of a nurse, doctor, physiotherapist, and occupational therapist.

3.6. Outcome Measures

As shown in Table 2, a wide range of tools was employed to evaluate the effects of remote assistance among the included RCTS; particularly, several domains emerged: self-efficacy, quality of life, psychosocial wellbeing, perception of chronic care, and disease-related clinical variations.

As for self-efficacy, two authors [35,37] examined two different perspectives about the concept. The first author employed the following:

The Canadian Occupational Performance Measure (COPM) is a self-reported measure of autonomy, productivity, and leisure [35]. This scale, validated on SCI patients, showed a slight improvement in the experimental group, without any significance.

The Adolescent Self-Management and Independence Scale-II (AMIS-II) measures independence and self-management skills in a defined age range (18–25 years) through 17 items [35]. Even in this case there was a non-significant improvement in favour of remote care patients.

Liu et al. [37], instead, quantified changes in self-efficacy through the Moorong self-efficacy scale, which is validated on SCI patients, and comprises several items related to social interactions; remote care population showed a significant change in this tool.

Quality of life represents the second most common item that authors included in this review [34,35,37] systematically evaluated. Reported results, in this case, were consistent across studies; in particular:

Irgens et al. [34] applied three different tools: Short Form-36 (SF-36), EuroQol 5-domains (Eq-5D), and the International Spinal Cord Injury Quality of Life Basic Data Set ISCI-QoL-BDS. None of them, however, showed between-group changes.

Kryger et al. [35], instead, used the World Health Organization questionnaire for quality of life (WHO-QoL), which showed slights and non-significant improvements in the experimental group.

Liu et al. [37], finally, showed no differences in terms of SF-36 between the study and control groups, in accordance with Irgens’s findings.

Regarding psychosocial wellbeing, one research team [35] evaluated depressive symptoms (guilt, disappointment, satisfaction, and suicidal ideation) through Beck Depression Inventory-II (BDI-II). Even in this case, the experimental group showed a positive but not significant trend. The same conclusion was reached about CHART-SF (Craig Handicap Assessment and Reporting Technique) administration, which described a positive trend for the experimental group about perceived disability.

The study by Li et al. [36], instead, evaluated psychosocial variations based on the perspective of family functioning (FAD-Family Assessment Device scale) and changes in lifestyle (Health Promoting Lifestyle Profile-HPLP II scale). In both cases, the authors reported a significant improvement in the continuous nursing group.

An interesting in-depth analysis about chronic care perception was conducted by Kryger et al. [35] using the Patient Assessment of Chronic Illness Care (PACIC) scale, a 20-items self-reported scale that measures the patient’s perception to being central in the chronic care model developed by specialists and health professionals. This questionnaire had minimal variations between groups.

3.7. Disease-Related Clinical Variations

Clinical aspects were evaluated in three studies [34,35,36] in order to explore the effectiveness of a remote care approach. Incidence of pressure ulcers, classified according to international guidelines, was evaluated in all cases, with different endpoints: the study by Li showed significant results in terms of incidence and grading, while the other two studies reported only positive trends. Another interesting data emerged by urinary tract infection incidence, which was demonstrated by Kryger [35] and Li [36], showing significant reduction in the experimental groups. Finally, in the study by Li et al. [36], a lower incidence of joint contractures and muscle atrophy was reached, with statistical significance.

4. Discussion

This literature review, as declared in the published protocol, was conducted in accordance with the PRISMA Statement [22]. The research aim was to analyze the best current scientific evidence regarding the use of teleassistance in the multidisciplinary home management of SCI patients. The focus was on alternative nursing models to in-person care, reconstructing the nurse’s role in these settings and their interactions with the multidisciplinary team.

Regarding the first RQ, the literature, although limited in number, reveals alternative care models to in-person care. In all four examined RCTs [34,35,36,37], the authors compared home assistance for SCI patients supported by innovative technology (apps, online platforms, and electronic devices) with standard in-person care. Different teleassistance approaches were found:

• In one case, a real-time video conference service based on an encrypted software was used [34].
• Two RCTs [35,36,37] used a patient-managed application.
• In one RCT [36], teleassistance was managed through a freely accessible platform for patients and teams.

These three modalities to build the model show profound differences in terms of usability, accessibility, and adherence. Mobile apps offer interactive and customizable features that support self-monitoring and engagement, particularly among younger or tech-savvy users; their disadvantage is that patients’ digital literacy and motivation could interfere with the results [38]. Video consultations replicate a traditional in-person appointment, and generally are perceived as more personal, improving therapeutic relationship and adherence, especially in chronic care settings [39]. Yet, they require stable internet connections and audio-video devices, so this may limit accessibility in low-resource settings. Finally, messaging platforms are simple, low-cost, and widely accessible—even among older adults—and have shown good results in supporting medication reminders or checks. However, they may be less effective for complex interventions that require real-time feedback or clinical nuance [40].

Deepening nurse’s position among multidisciplinary team members, in one study [34], home nurses interfaced with the multidisciplinary team through a real-time videoconferencing, while in Liu et al.’s [37] study, the nurse led the team as the direct manager of the app-based care. This last model enhanced the role of the follow-up nurse as coordinator of a multidisciplinary teamwork where a physical medicine and rehabilitation specialist, a physiotherapist and an occupational therapist were involved. The nurse had the responsibility to perform regular in-person assessments in order to ensure via the app that the patient was stable (the input was then converted accordingly to ICF taxonomy), or, in the case of complications, send messages to the competent team member, who had three days to answer the alert. In addition, the nurse ensured regular scanning of patients’ messages every Monday.

In the remaining studies [35,36], it was not detailed how the nurse interfaced with the rest of the team, but the nurse was present as an equal member. In three RCTs [35,36,37], the patient remotely interfaced with the team by uploading data, photos, and videos into the applications used, allowing professionals to quickly assess the patient’s condition and identify early signs of complications. This communication model between patient and team was in line with previous studies about telenursing for lung cancer patients [41,42] and for chronic obstructive pulmonary disease (COPD) patients [43].

Regarding our second RQ, we investigated the reported effects of the remote care model compared to a traditional in-patient approach for SCI, even from a psychosocial point of view and for the clinical dimension. 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 Kim 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. This represents a limit to fully comprehend telenursing effectiveness, since precedent literature suggests that these interventions—requiring initial investments in staff training, digital platforms, and infrastructure—may offer long-term cost benefits: reductions in avoidable hospitalizations, improved medication adherence, and earlier detection of complications [59,60]. On the other hand, a significant challenge regarding the implementation of remote assistance models remains, particularly in relation to staff resistance, variability in digital literacy among patients and caregivers, and unequal access to reliable internet connectivity or devices [61].

In conclusion, our review highlights the fundamental role of a home nurse within the multidisciplinary team in caring for SCI patients; a home nurse is a health promoter focused on collaboration with the patient, jointly established goals, and trust in the specialized personnel with whom they collaborate. Based on our findings, it can be deduced that a coordinated, integrated, and multidisciplinary remote approach, with the collaboration of family members and caregivers of SCI patients, contributes to promoting self-efficacy, lifestyle changes, and diminishing the impact of physical symptoms related to chronicity.

For future research, it will be interesting to deepen the models of integration between the nurse and multidisciplinary team, particularly recognizing the pivotal role of nurses’ competencies to signal complications early and prevent major events, as shown in the study by Liu [37]. Then, future studies should deepen the aspect of the impact remote care on bowel symptoms and bladder- and bowel-related quality of life; moreover, researchers should standardize outcome tools. Chronic neuropathic pain, in addition, should be deepened, even for the efficacy of remote care models and for nurse contribution within the multidisciplinary team. Finally, there is a strong need for long term data, since a SCI presents a disease history which can last for decades, with progressive impairment and a higher degree of expertise requested for physicians.

5. Strength and Limitations

Our work was guided by the definition of a highly specific P.I.C.O. framework, which included adult patients with SCI diagnosis for at least a year, stable medical conditions, and an indication for home care provided by a multidisciplinary team. Further strengths of this review were represented by the high methodological level of the included RCTs, evaluated by the PEDro Scale and Jadad scores (which limited the risk of bias), and the reproducibility of the review process. We must underline, however, that bias risk still remains, since there was an included study with medium methodological scores due to the lack of blinding: this introduces a comparative bias among high level studies vs. a medium one.

Some critical points were also highlighted: besides the small number of participants in the primary studies included (269 cases in total), all studies verified outcomes during short-term follow-up, at most one year, lacking long-term results. This represents an important limitation concerning the chronic nature and lifelong care needs of SCI. Moreover, studies were limited to three different health systems (China, USA, Norway); this represents a limit for the generalizability of our conclusions, since interesting data could have emerged by different health contexts, in which nurses’ familiarity with digital tools has a great impact on every day work, or assistance for SCI patients is conceived differently.

Another limitation was the partial study of SCI complications in the remote care setting: pain, cardiovascular, gastrointestinal, pulmonary, and sexual issues, despite being common disorders among most SCI patients, were not studied in the included RCTs.