Review author Ibrahim Npochinto Moumeni describes the work as a narrative review prepared with recommendations from SANRA, using purposive searches of PubMed, Scopus and Google Scholar. The initial search covered January 2019 to December 2022 and was updated to December 2025 to capture later publications reporting data collected during 2020 and 2021. Sources included systematic reviews, large multicentre studies, official agency reports and selected French research. The 49-source evidence base was selected thematically rather than through a systematic screening process, and individual studies did not receive formal quality appraisal. First-person observations from the author’s postgraduate training in two French university hospitals were kept separate from the literature and were not used to support quantitative claims.

Health-worker mortality was one of the review’s central subjects. WHO estimated that between January 2020 and May 2021, 80,000 to 180,000 health and care workers died from COVID-19, with a central estimate of 115,500. Over the same period, 6,643 health-worker deaths had been reported through surveillance, less than 6% of the central estimate. Early systematic-review data through 8 May 2020 identified 152,888 infections and 1,413 deaths among health workers. Infections were concentrated among women, who represented 71.6% of cases, and nurses, who accounted for 38.6%; deaths were concentrated among men, who represented 70.8% of fatalities, and physicians, who accounted for 51.4%. In the United Kingdom and United States, front-line workers had an adjusted 3.4-fold higher risk of a positive test than the general community, with risk increasing further where protective equipment was inadequate or reused.

Although the United States did not produce an official national count, an investigative journalism database documented more than 3,600 health-worker deaths during the first pandemic year and found that lower-paid staff, including nurses and support workers, were disproportionately represented. The review also reports psychological distress among health workers, citing a meta-analysis with pooled prevalences of 23.2% for anxiety, 22.8% for depression and 38.9% for insomnia. From the synthesis and the author’s clinical observations, the paper proposes Frontline Abandonment Syndrome as a possible description of temporary or prolonged withdrawal from high-risk duties and its consequences for continuity of care. This is a hypothesis rather than a diagnosis or validated syndrome; it differs from burnout, moral injury and compassion fatigue by focusing on observable withdrawal and organisational conditions such as protective-equipment availability and communication.

Vaccine hesitancy was another major focus. Defined in the review as delay in accepting or refusing vaccination despite its availability, hesitancy was reported in 37% of 4,630 health workers surveyed across 91 countries between February and April 2021. A separate review involving 76,471 workers estimated hesitancy at 22.5%, while a scoping review of 41,098 nurses in 36 countries found a pooled refusal prevalence of 20.7%. The nurse review found refusal prevalence was higher in 2020 than in 2021. Reported reasons included safety concerns, side effects, doubts about efficacy, misinformation and mistrust of authorities or pharmaceutical companies. The figures cannot be compared directly because the studies used different populations, periods and definitions, and the review notes this limitation explicitly.

French data showed an occupational gradient at the beginning of the vaccination campaign. In a February 2021 survey of 1,965 workers at a tertiary centre, 73.1% favoured vaccination, 23.1% were hesitant and 3.9% opposed it. Fewer than 60% of auxiliary nurses and technicians intended to be vaccinated, compared with 60% to 79% of nurses and support staff and more than 80% of medical personnel. Controversy surrounding AstraZeneca tolerability was independently associated with lower vaccination intention. The review also discusses the temporary European pause involving France in March 2021 and the legal requirement introduced in France on 5 August 2021. From these observations, the author proposes the Vaccination Refusal Cascade, a hypothesis in which a salient institutional or media event triggers successive refusals across professional networks. The French association is consistent with that idea but does not demonstrate that such a cascade occurred.

Physiotherapy guidance developed during the pandemic addressed respiratory management, patient positioning, early mobilisation and exercise prescription under strict infection-control conditions. A Stanford Hall consensus described post-discharge rehabilitation, including a graded return to activity, while a rapid living systematic review documented the emerging evidence on patients’ rehabilitation needs. A WHO pulse survey also recorded widespread disruption of essential health services, including rehabilitation, in 2020. The author’s clinical observations from home-based physiotherapy during the first French lockdown described programmes adapted to minimal equipment, greater family involvement and the integration of psychosocial support. These observations illustrate practical adaptations but do not constitute evaluated outcomes, and they come from a single practitioner in a high-resource setting.

For patients with persistent symptoms, the review distinguishes physiological recovery from functional recovery. WHO defines post-COVID-19 condition as symptoms that usually arise three months after probable or confirmed infection, continue for at least two months and cannot be explained by another diagnosis; fatigue, post-exertional symptom exacerbation, cognitive dysfunction and dysautonomia are frequent. The proposed Post-COVID Functional Decoupling describes a pattern in which measures such as oxygenation, imaging and inflammatory markers normalise while functional capacity lags by weeks or months. It is not presented as a diagnosis, but as a rehabilitation-oriented pattern within post-COVID-19 condition and post-intensive care syndrome. The stated practical implication is that functional measures may guide rehabilitation and discharge decisions, while exercise progression must be individualised because post-exertional symptom exacerbation can occur.

The shift to remote rehabilitation produced both promising evidence and limited routine uptake. A rapid overview found telerehabilitation generally comparable to in-person physical therapy for several conditions. A Cochrane review of 15 studies involving 1,904 participants, mostly patients with chronic obstructive pulmonary disease, found pulmonary telerehabilitation achieved outcomes similar to centre-based rehabilitation without reported safety issues, although certainty of evidence was limited. A retrospective study of 164 patients found telerehabilitation non-inferior to in-person rehabilitation 12 weeks after total knee arthroplasty, and a prospective observational study of 23 patients found mixed in-person and remote delivery feasible in cancer rehabilitation. Yet a US database containing 222,680 outpatient physiotherapy episodes recorded telerehabilitation in only 6% of cases, declining from 10% to 5% between the second and third quarters of 2020. The proposed Telerehabilitation Emergency Pivot describes the rapid, improvised system-level transition to remote care and the subsequent persistence of hybrid models.

The review’s four constructs collectively shift attention toward service-level processes: from psychological distress to observable workforce withdrawal, from generic hesitancy to possible network diffusion, from digital transition to rehabilitation-specific constraints, and from physiological normalisation to delayed functional recovery. Proposed tests include linking staffing and deployment data with protective-equipment availability and validated distress measures; interrupted time-series analyses around vaccine safety alerts; adoption and safety comparisons across in-person, remote and hybrid rehabilitation; and cohort studies comparing physiological recovery with functional measures such as the six-minute walk test and activities-of-daily-living scales. These ideas remain hypotheses. The evidence base is non-exhaustive and exposed to selection and publication bias, clinical observations are vulnerable to recall bias, rehabilitation data from sub-Saharan Africa are scarce, and the review focuses mainly on 2020 and 2021. Formal concept analysis and empirical testing are therefore required before the proposed terms should be used beyond research settings.

Subject of Research: Narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation during COVID-19

Article Title: Rehabilitation professionals at the COVID-19 frontline: a testimony-informed narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation

Article References: Npochinto Moumeni, I. (2026). Rehabilitation professionals at the COVID-19 frontline: a testimony-informed narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation. Frontiers in Rehabilitation Sciences, 7, Article 1921614. https://doi.org/10.3389/fresc.2026.1921614

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1921614

Keywords: COVID-19, health workers, mortality, vaccine hesitancy, physiotherapy, telerehabilitation, post-COVID condition, rehabilitation services, narrative review, pandemic preparedness, Rehabilitation, professionals

The review’s central argument is that kinesiophobia is a potentially modifiable barrier, not a fixed personality trait or an inevitable consequence of surgery. That distinction matters enormously for patients and clinicians alike. If the fear that limits walking, stair climbing, and return to work can be identified early and addressed deliberately, the thinking goes, then a meaningful share of disappointing outcomes after knee replacement might be preventable. Until now, however, the evidence on fear of movement has been dispersed across rehabilitation journals, psychological literature, nursing research, and perioperative studies, and it has frequently been conflated with evidence about knee replacement rehabilitation in general. A trial that improves pain and function after surgery is not necessarily a trial that reduces fear of movement, and the review insists on keeping those two categories of evidence separate.

To build the synthesis, the authors searched PubMed/MEDLINE and the Physiotherapy Evidence Database, known as PEDro, from their inceptions through 15 September 2026. They supplemented these searches with the Cochrane Library, current rehabilitation guidance, and both backward and forward citation tracking, applying bibliographic verification to ensure that the evidence base they describe actually exists as cited. Critically, they did not simply pool findings. Each study was interpreted according to its design, how directly it measured kinesiophobia outcomes rather than general recovery measures, the consistency of its results, and the limitations the original authors reported. This layered approach produces a more honest picture than a simple vote-count of positive trials, because it forces a distinction between interventions that were designed to target fear and interventions that merely happened to measure it.

What does the assembled evidence actually show? Across available studies, kinesiophobia after total knee arthroplasty is consistently associated with higher pain levels, pain catastrophizing, lower self-efficacy, impaired physical performance, and poorer participation in daily and social life. Patients who fear movement tend to avoid using the operated knee, and that avoidance can compound stiffness, weakness, and deconditioning in a self-reinforcing loop. The review is careful, however, to flag a crucial caveat: most of these associations are cross-sectional or observational, and causal relationships remain uncertain. Fear may drive poor outcomes, poor outcomes may breed fear, or both may spring from shared underlying factors such as preoperative anxiety or uncontrolled postoperative pain. Untangling those directions of effect is one of the field’s outstanding scientific problems.

On the intervention side, the picture is cautiously encouraging but incomplete. Direct studies in knee replacement populations have reported reductions in kinesiophobia with multicomponent fear-focused functional exercise, with selected educational and cognitive-behavioral approaches, and with some technology-supported interventions such as digital programs that guide patients through graded activity. The mechanisms are plausible: education can reframe postoperative pain as a normal signal rather than a sign of damage, cognitive-behavioral techniques can interrupt catastrophic interpretations of sensation, and graded functional practice allows patients to accumulate corrective experiences that disconfirm their worst expectations. Yet the review notes that effects on pain and physical function have been inconsistent across trials, and that many studies are small or single-center, limiting confidence that findings generalize to the broad population of knee replacement recipients.

Perhaps the review’s most methodologically pointed conclusion concerns the broader rehabilitation toolkit. Multimodal analgesia, early supported mobilization, progressive strengthening, and telerehabilitation all remain important, evidence-supported components of knee replacement care. But the authors argue that their general effectiveness should not be interpreted as evidence of a specific antikinesiophobia effect unless fear outcomes were actually assessed in the underlying trials. A program that reduces pain and improves range of motion may or may not touch the psychological barrier of fear, and assuming that it does risks misdirecting clinical resources and overstating what standard rehabilitation can deliver for the fearful patient. The message to trialists is clear: if you want to claim an effect on kinesiophobia, you must measure kinesiophobia.

Assessment itself carries subtleties that the review addresses in detail. The Tampa Scale for Kinesiophobia is the field’s dominant instrument, and its various versions can support repeated, multidomain assessment of fear across the surgical pathway. But the authors warn that threshold scores and clinically important change values are not interchangeable across different versions of the scale, different languages, different populations, or different postoperative time points. A cutoff that flags high fear in one translated version or at one week after surgery may misclassify patients in another context. For clinicians, this means that a single number should never drive a treatment decision in isolation; for researchers, it underscores the need to establish context-specific meaningful change thresholds rather than importing values from unrelated studies.

From this synthesis the authors construct the review’s most practical contribution: a clinically oriented screening schedule paired with a stepped-care pathway. Screening is proposed at defined points across the perioperative period so that rising fear can be caught before it hardens into avoidance. The stepped-care model then organizes treatment intensity to match need. The first steps prioritize excluding medical or surgical barriers to recovery, such as unresolved mechanical problems or infection, before attributing limitation to fear. Next comes realistic education about what to expect after surgery, followed by supported movement and fear-focused functional practice in which patients gradually rehearse the specific activities they dread. For those who need more, the pathway adds self-efficacy enhancement strategies, and for a smaller subset, selective psychological or digital adjuncts deliver formal cognitive-behavioral treatment. The architecture mirrors stepped-care models used in mental health, conserving intensive resources for the patients who demonstrably need them.

The authors are explicit that these frameworks are offered for local adaptation and prospective validation, not as finished clinical guidelines. Their evidence-informed character means they are built from the best available but imperfect evidence, and the review calls directly for more rigorous multicenter studies to establish what constitutes clinically meaningful change in kinesiophobia, to determine which patients benefit from targeted interventions, and to define the optimal dose, durability, safety, and cost-effectiveness of those interventions. Until such trials mature, the pathway functions as a structured hypothesis: that systematically screening for fear of movement and escalating care in deliberate steps will convert a modifiable barrier into a manageable one.

The broader significance extends beyond orthopedics. Total knee arthroplasty is among the most common and consequential elective surgeries worldwide, and even modest improvements in the proportion of patients who fully engage with rehabilitation would translate into large absolute gains in mobility and quality of life. By insisting on fear-specific evidence, flagging the causal uncertainty in the literature, and offering a concrete clinical pathway, the review gives rehabilitation teams both a caution and a compass: fear of movement after knee replacement is real, measurable, and likely treatable, but proving that treatment works, and for whom, is the next chapter of the story.

Subject of Research: Kinesiophobia after total knee arthroplasty: assessment, prevention, and stepped-care management

Article Title: Prevention and management of kinesiophobia after total knee arthroplasty: an evidence-informed narrative review and proposed stepped-care pathway

Article References: Liu, L., Sun, H., & Ni, L. (2026). Prevention and management of kinesiophobia after total knee arthroplasty: an evidence-informed narrative review and proposed stepped-care pathway. Frontiers in Rehabilitation Sciences, 7, Article 1962328. https://doi.org/10.3389/fresc.2026.1962328

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1962328

Keywords: kinesiophobia, total knee arthroplasty, knee replacement, rehabilitation, fear of movement, pain catastrophizing, self-efficacy, Tampa Scale for Kinesiophobia, stepped-care pathway, telerehabilitation, cognitive-behavioral therapy, physical function

The stakes of the question are high. Exercise-based rehabilitation is recommended as part of best-practice cancer care because regular physical activity can blunt the adverse effects of treatment, improve physical and psychological function, and enhance quality of life. Large-scale evidence cited by the researchers suggests that long-term exercise improves disease-free survival by 28 percent and overall survival by 37 percent in people with cancer. Yet survivors entering rehabilitation are typically far below recommended activity levels: previous studies report an average of just 12 minutes of moderate-to-vigorous activity per day, and half say they exercise fewer than two days a week.

Structured, supervised rehabilitation programs are seen as a promising first step toward changing those numbers, but keeping people active once the program finishes has proven difficult. Telerehabilitation — delivered through videoconferencing, wearable devices, and mobile applications — was developed to overcome practical barriers to attending in-person sessions, allowing participants to exercise safely at home while still receiving demonstration, instruction, monitoring, and expert guidance. Group-based cancer exercise telerehabilitation has been shown to be safe and feasible, although earlier work raised concerns that participants may find it harder to build the social connections that make in-person groups motivating.

In the TeleCaRe trial, participants in the experimental arm received an eight-week program of twice-weekly, 60-minute group exercise sessions supervised by a physiotherapist trained in cancer care. The sessions combined seated or standing aerobics, body-weight exercises such as squats, and equipment including resistance bands and free weights, all individually tailored. The program also incorporated information provision, self-monitoring through a Fitbit activity tracker, feedback, goal setting, an online information portal, and an individualized home exercise plan — a package of recognized behavior change techniques. Before starting, and again at discharge, participants discussed ongoing exercise options one on one with the physiotherapist.

To understand the medium-term impact, the researchers purposively sampled 17 trial participants — roughly half female, averaging 58 years old, with ages ranging from 21 to 80 — for semistructured interviews four months after their final session. Interviews were conducted by PhD-qualified physiotherapists not involved in delivering the program, audio-recorded, transcribed verbatim, and independently coded by two researchers using NVivo software. The team analyzed the data inductively within an interpretive description framework, refining a shared codebook through repeated discussion, and returned transcripts to participants to verify accuracy. Data collection ran from June 2022 to December 2023 across a large public health service spanning metropolitan Melbourne to regional Victoria.

The overarching theme that emerged was that telerehabilitation facilitated positive exercise intentions that persisted well beyond the program. Participants described the program as a lifeline that connected them with skilled, empathetic clinicians at a dark point in their recovery, empowering them through knowledge, opportunity, and connection. One participant with breast cancer recalled being weak, having lost her hair, and feeling awful, saying the program pulled her out of that period and calling such services a lifeline for people like her. Others articulated vivid long-term reasons for exercising, from coping better with chemotherapy to reducing the fear of recurrence.

For many, feeling the benefits of exercise during the program — less fatigue, a return to work — created a positive cycle that prompted them to seek further activity once it ended. Some returned to the gym, took up golf, lawn bowls, or swimming, or folded the program’s home exercises into their regular routines. Purposeful walking was the most common activity because it was convenient. Family members reinforced the momentum, sometimes exercising alongside participants or buying them equipment, and for some the program acted as a conduit back into community life, such as volunteering at a bowls club.

But acting on those intentions proved far harder in what participants called the new reality created by cancer. Comorbidities, ongoing treatment side effects such as pain and fatigue, and disrupted life circumstances limited many people’s ability to exercise, and some expressed guilt about not keeping up. Without the structure, accountability, and convenience of scheduled sessions, several described a disconnect between knowing they should exercise and actually doing so. COVID-19 added a double barrier: some participants contracted the infection and were physically unable to exercise, while others avoided community gyms and pools for fear of infection due to immunocompromise.

Previous exercise experience emerged as the strongest determinant of who kept moving. Survivors who had exercised before their diagnosis — swimming, running, gym training, regular walking — described those activities as goals to return to and appeared to bounce back quickly from setbacks, likely helped by higher self-efficacy. Those new to exercise held positive intentions but were less likely to act on them, often managing only incidental activity around the home or occasional walks. The researchers suggest this pattern fits the transtheoretical model of behavior change: telerehabilitation helps people move from contemplation into action, but the leap from action to maintenance is difficult once professional supervision disappears, and health setbacks can push people back toward contemplation even as their positive intent remains.

The authors conclude that telerehabilitation can be a valuable first step toward initiating exercise, but that many survivors — particularly those without previous exercise experience — need ongoing support afterward to convert good intentions into sustained behavior. In real-world clinical settings, resources rarely allow the years-long, phased support used in the landmark trial linking exercise to improved colon cancer survival, so the researchers point to flexible models such as physiotherapy navigators and community-based programs like LiveStrong at the YMCA or the Alberta Exercise Program to bridge the gap. The study has limitations: participants came from a motivated trial cohort who needed internet access, adherence to the program was low, and interviews were short, though no new themes emerged in the final transcripts. Even so, the message is clear — the webcam sessions plant the seed, but the hard work of keeping cancer survivors exercising begins when the screen goes dark.

Subject of Research: Cancer survivors' exercise behaviour after completing a group exercise telerehabilitation program

Article Title: A qualitative study of cancer survivors’ exercise behaviour 4 months after a telerehabilitation program

Article References: Dennett, A. M., Peiris, C. L., Rimayanti, M. U., Barton, C., Taylor, N. F., Harding, K. E., Tan, G., Ezzat, A., & Shields, N. (2026). A qualitative study of cancer survivors’ exercise behaviour 4 months after a telerehabilitation program. Supportive Care in Cancer, 34(10), Article 941. https://doi.org/10.1007/s00520-026-11016-y

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11016-y

Keywords: telerehabilitation, cancer survivors, exercise, behavior change, qualitative research, physiotherapy, cancer rehabilitation, telehealth, physical activity, survivorship, qualitative, cancer

The problem the study tackles is one of the most stubborn in cardiovascular medicine. Cardiac rehabilitation, which combines structured exercise, education, and psychosocial support, carries a Class IA recommendation in international guidelines for patients recovering from bypass surgery, and its benefits are well documented: better exercise capacity, improved cardiac function, and stronger psychological well-being. Yet participation remains dismal. Fewer than half of eligible patients in developed countries attend a program, and in developing nations the figure drops below 10 percent. The barriers are mundane but powerful: distance to the hospital, transportation costs, work schedules, and family obligations. Home-based telerehabilitation, delivered through wearable heart rate monitors, mobile applications, and periodic video or telephone consultations, has been proposed as a way around these obstacles, but rigorous real-world comparisons with careful confounding control have been scarce.

The research team screened the electronic health records of 288 adults aged 30 to 75 who underwent isolated CABG between February 2024 and February 2025, ultimately identifying 195 potentially eligible patients. After excluding 28 whose rehabilitation exposure could not be clearly documented, 167 patients formed the propensity-score estimation cohort: 56 who enrolled in home-based telerehabilitation, 54 in center-based rehabilitation, and 57 who received usual care without any formal program. The primary complete-case analysis then focused on the 105 patients, 35 per group, who completed full 12-week assessments. Because patients were not randomized, the investigators used generalized propensity scores and overlap weighting to adjust for 25 baseline covariates, ranging from age, sex, and body mass index to digital literacy, family support, distance to the rehabilitation center, and baseline fitness measures.

The home program itself was a carefully structured prescription rather than a casual suggestion to stay active. Patients received a wearable Polar H10 heart rate monitor paired with a dedicated mobile application and were asked to complete three aerobic sessions per week for 12 weeks, 36 sessions in total, each targeting 30 to 60 minutes of exercise at 60 to 80 percent of heart rate reserve, plus two weekly resistance training sessions. Intensity was progressed every two weeks based on heart rate response and perceived exertion on the Borg scale. Crucially, the researchers defined a session as completed only when at least 30 minutes of prescribed exercise at target intensity were objectively documented by the wearable device; app entries without valid sensor data did not count. Center-based patients attended the hospital’s outpatient program with the same prescription but under direct supervision with continuous ECG telemetry, and their adherence was verified through physiotherapist-signed attendance records and telemetry logs.

The headline result concerns adherence, the study’s primary implementation outcome. Patients in the home-based arm completed a mean of 87.7 percent of their prescribed sessions, compared with 78.5 percent in the center-based arm, an overlap-weighted difference of 9.1 percentage points with a 95 percent confidence interval of 4.4 to 13.7 and a P value below 0.001. The gap widened at the high end of the distribution: 78.6 percent of home-based patients achieved at least 80 percent completion, versus 44.4 percent of center-based patients, and 46.4 percent of the home group reached 90 percent or more, compared with just 13.0 percent of the center group. Home patients also logged more objectively verified exercise minutes overall, 1,578 versus 1,413, and more minutes at target intensity. Technical failures, such as lost or invalid wearable recordings, affected only 1.7 percent of prescribed home sessions.

On the key clinical outcome, the two delivery models proved remarkably close. Peak oxygen uptake, or VO2peak, measured by symptom-limited cardiopulmonary exercise testing on a cycle ergometer, rose from a baseline of roughly 18.3 to 18.4 mL/kg/min to about 23.1 to 23.6 mL/kg/min at 12 weeks in both rehabilitation groups. The adjusted difference between the home and center arms was a mere 0.17 mL/kg/min, with a confidence interval spanning −0.50 to 0.84 and a P value of 0.616, statistically indistinguishable from zero. Both active groups, however, dramatically outperformed usual care, which saw VO2peak inch up from 18.5 to 19.1 mL/kg/min; the adjusted advantages over control exceeded 4.0 mL/kg/min for both rehabilitation modalities. Given that lower VO2peak is strongly associated with increased mortality in cardiac populations, gains of that magnitude are clinically noteworthy.

Secondary outcomes told a consistent story. Six-minute walk distance improved by roughly 75 meters in both rehabilitation groups compared with control, with no meaningful difference between them. Left ventricular ejection fraction, measured by blinded readers using the biplane Simpson method, rose by about 4 to 5 percentage points in both active arms. Psychological measures moved in parallel: scores on the Hamilton Anxiety and Depression scales fell by 6 to 8 points in both rehabilitation groups while barely changing in usual care, and quality-of-life scores on the SF-36 physical and mental component summaries climbed by 16 to 22 points. Safety findings were reassuring in absolute terms: no major adverse cardiovascular events occurred in either rehabilitation group during the 12-week window, while two occurred among usual-care patients, though the small event counts precluded formal comparative safety inference. Exercise-related adverse events were uncommon and similar in character across both programs, including occasional chest pain, arrhythmia, and musculoskeletal complaints.

The investigators were careful about what their design can and cannot show. Because patients self-selected into each modality, unmeasured differences in motivation and preference may persist despite the extensive covariate adjustment, and the study was not powered or designed to formally test equivalence or non-inferiority between the two delivery models. Selection is a real concern: of the 195 potentially eligible patients, 46.2 percent were excluded from the complete-case analysis, and those excluded patients had fewer years of education, more frailty, lower employment rates, and markedly lower family support scores. The authors also note that the two delivery models differed not only in setting but in supervision intensity, with home patients exercising independently and receiving roughly 12 scheduled tele-consultations, so residual differences in how adherence was ascertained, device verification at home versus direct observation in center, cannot be fully excluded. Sensitivity analyses, including unweighted models, multiple imputation, restriction to a strict 11-to-13-week assessment window, and exclusion of crossovers, all produced directionally consistent estimates for the VO2peak comparison.

An exploratory analysis probing whether higher adherence drove better functional outcomes found a positive but non-significant association: each 10-percentage-point increase in adherence was associated with roughly 0.62 mL/kg/min greater VO2peak gain, with a confidence interval that just crossed zero. The authors explicitly caution against a causal reading, since healthier, more motivated, or faster-recovering patients may both complete more sessions and improve more, a classic healthy-adherer effect that observational data cannot untangle. The adherence-by-modality interaction was also non-significant, suggesting the adherence-outcome relationship did not differ meaningfully between the home and center programs.

What the study does establish is feasibility in routine practice. Among post-CABG patients who chose between the two options in a real clinical setting, home-based telerehabilitation delivered objectively verified adherence that exceeded center-based care and functional recovery that looked essentially identical at 12 weeks. For patients juggling work, travel, or caregiving obligations, the findings support offering a monitored home program as a legitimate alternative rather than a second-best compromise. The authors call for future work on clinical meaningfulness and cost-effectiveness, and longer follow-up will be needed to see whether early fitness gains translate into durable outcomes. But the message for the millions of bypass patients each year who cannot reach a hospital gym is clear: with a chest strap, a smartphone, and a structured prescription, the road to recovery may run straight through their living room.

Subject of Research: Home-based versus center-based cardiac rehabilitation adherence and functional outcomes after coronary artery bypass grafting

Article Title: Home-based telerehabilitation after CABG: higher objectively verified adherence and 12-week functional outcomes in a single-center observational cohort

Article References: Liu, Y., Wang, X., Wang, C., Zhang, M., Kong, M., Wang, M., Ma, J., & Liu, H. (2026). Home-based telerehabilitation after CABG: higher objectively verified adherence and 12-week functional outcomes in a single-center observational cohort. Frontiers in Cardiovascular Medicine, 13, Article 1947232. https://doi.org/10.3389/fcvm.2026.1947232

Image Credits: AI Generated

DOI: 10.3389/fcvm.2026.1947232

Keywords: cardiac rehabilitation, coronary artery bypass grafting, telerehabilitation, wearable sensors, adherence, VO2peak, observational cohort, cardiovascular medicine, propensity score analysis, exercise capacity, digital health, patient recovery

The research team, led by Alexis Ken Cartajenas of Oslo Metropolitan University in collaboration with colleagues from the Oslo Health Agency, retrieved records from Scopus, Web of Science, PubMed, and the Lens scholarly search platform. After rigorous deduplication and screening, the initial pool of more than 1,800 records was narrowed to 388 peer-reviewed articles and conference papers focused on immersive technologies applied to pediatric rehabilitation. The ten-year window was chosen deliberately: 2015 marks the point when commercially available immersive hardware began to spread widely, while 2024 was the most recent fully indexed year at the time of the search, avoiding the artificial decline that incomplete citation data would have introduced.

The findings show a field in vigorous growth. Publication output increased overall across the decade, with the United States leading productivity at 79 articles, followed by Italy with 44 and China with 36. Institutionally, the University of Toronto topped the list with 55 publications, closely trailed by Stanford University School of Medicine with 52 and the University of Washington with 36. The journal landscape followed Bradford’s law of scattering, a classic bibliometric pattern in which a compact core of 20 journals contributed roughly a third of all publications, while the remaining two-thirds were dispersed across 200 other outlets. Games for Health Journal and the Journal of NeuroEngineering and Rehabilitation emerged as the most prolific core venues, with the latter also showing the highest consistent citation performance in the corpus.

Perhaps the most striking pattern is the overwhelming dominance of virtual reality. The keyword virtual reality appeared 200 times across the dataset, dwarfing augmented reality at 28 occurrences, while mixed reality and extended reality barely registered, with just 3 and 6 appearances respectively. This modality skew mirrors broader trends across medical extended reality research, where head-mounted virtual environments attract far more attention than their augmented and mixed counterparts. The field’s clinical focus is equally concentrated: cerebral palsy appeared as a keyword 84 times, making it the second most frequent term overall, and it was frequently associated with motor rehabilitation, upper limb training, balance, and gait. Autism, hemiplegia, and serious games also ranked among the top terms.

To uncover the field’s hidden conceptual architecture, the researchers employed multiple correspondence analysis, a statistical technique that plots keywords in a multidimensional space based on how often they co-occur. The first two dimensions explained 39.3 percent of the total inertia, a moderate but interpretable representation. The analysis distinguished six thematic orientations: motor- and therapy-oriented work, gamified approaches, remote therapy, cognitive and developmental rehabilitation, immersive technologies, and a core XR rehabilitation cluster anchored by cerebral palsy and autism research. Terms like telerehabilitation, hemiplegia, and immersive virtual reality acted as drivers pulling the axes toward distinct thematic territories, while ubiquitous terms like rehabilitation and children sat near the origin, foundational but non-discriminating.

Thematic evolution analysis, which sliced the decade into five two-year intervals, revealed how the field’s priorities have shifted. Early work from 2015 to 2016 centered on virtual and augmented reality applications for cerebral palsy, upper limb function, and gaming. Autism emerged as a new theme by 2017, followed by motor skills, balance, and executive function around 2019 and 2020. After 2020, coinciding with the COVID-19 pandemic’s disruption of healthcare delivery, output surged and new themes appeared, including artificial intelligence, exergaming, haptic feedback, and participatory design. By 2023 and 2024, extended reality had surfaced with links to memory and physical activity, while augmented reality persisted with connections to social and communication skills.

Yet these emerging themes remain strikingly immature. Gamification, extended reality, and artificial intelligence each appeared only five times as author keywords, with median years of prominence in 2023 or 2024. The researchers caution that these should be read as early signals of future research activity rather than established pillars of the literature. The promise is tantalizing: artificial intelligence could enable adaptive, real-time feedback during rehabilitation sessions, dynamically adjusting therapeutic tasks to a child’s performance, while gamified environments have shown potential for supporting personalized learning and engagement, particularly for children with cerebral palsy or autism. But the bibliometric data show these convergences are still on the horizon.

The social structure of the field proved equally revealing. Author collaboration analysis identified 47 distinct research communities, ranging from domestically concentrated groups to internationally diverse consortia. Three Italian clusters exhibited complete country-level homophily, meaning every author worked within a single nation, while one cluster anchored in Belgium spanned ten countries. A handful of researchers, including Monteiro CBDM, Biffi E, and Levac DE, occupied bridging positions with high betweenness centrality, acting as intellectual brokers between otherwise distant groups. This configuration carries both strengths and risks: central thought leaders can catalyze innovation, but over-reliance on a small set of connectors may limit the field’s capacity for growth and external validity.

One of the study’s most consequential findings concerns where rehabilitation actually happens. Explicit home-, remote-, and telerehabilitation-related terminology appeared in only 41 publications, or 10.6 percent of the corpus, indicating that decentralized delivery remains a minority framing within the broader literature. This is a notable gap given that clinic-based rehabilitation is often limited by cost, accessibility, and engagement, especially for families in remote or underserved areas. Children’s rehabilitation outcomes are shaped by family resources, school participation, and access to care, and the authors argue that immersive technologies could help overcome these barriers if designed for real-world home and community contexts rather than well-resourced clinics alone.

The researchers are careful to emphasize a crucial caveat: bibliometric prominence is not evidence of clinical effectiveness. Publication counts describe patterns of scientific activity, not whether interventions work. Systematic reviews cited in the study report promising findings, including positive pooled effects of virtual reality rehabilitation on balance in cerebral palsy, but small samples, short interventions, and heterogeneous protocols continue to limit generalizability. The authors call for rigorous clinical evaluation, consistent reporting, standardized outcomes, and setting-specific implementation research addressing feasibility, usability, safety, and equity. As immersive technologies converge with artificial intelligence and gamification, the field stands at an inflection point where the challenge is no longer proving that children will engage with virtual worlds, but ensuring those engagements translate into measurable, equitable clinical benefit in the places where children actually live.

Subject of Research: Bibliometric mapping of immersive technology research in pediatric rehabilitation from 2015 to 2024

Article Title: Mapping immersive technologies in pediatric rehabilitation: a multi-database bibliometric analysis

Article References: Cartajenas, A. K., Saidi, T., Gazerani, P., Rosseland, I. K., Bergheim, Å., Selmer-Olsen, K., Mørk, N., Pavel, N., & Pikkarainen, M. A. (2026). Mapping immersive technologies in pediatric rehabilitation: a multi-database bibliometric analysis. Frontiers in Virtual Reality, 7, Article 1821977. https://doi.org/10.3389/frvir.2026.1821977

Image Credits: AI Generated

DOI: 10.3389/frvir.2026.1821977

Keywords: virtual reality, augmented reality, pediatric rehabilitation, bibliometrics, cerebral palsy, telerehabilitation, gamification, extended reality, artificial intelligence, serious games, home-based rehabilitation, science mapping

The review, conducted by researchers at Guangxi Normal University and Sichuan Minzu College in China and registered in PROSPERO, searched six major databases from inception to March 2026, including PubMed/MEDLINE, Web of Science, SPORTDiscus, the Cochrane Library, Embase, and Scopus. The team applied strict eligibility criteria: only randomized studies of remotely supervised exercise- or physical activity-based rehabilitation after ischemic or hemorrhagic stroke qualified, and only if depression, anxiety, or quality-of-life outcomes could be extracted. From 2,457 identified records, after removal of 1,805 duplicates and assessment of 227 full-text reports, just six randomized studies involving 483 participants survived the gauntlet.

That small yield is itself revealing. The six trials, published between 2015 and 2026, spanned the United Kingdom, Spain, the United States, China, Australia, and Ireland, with sample sizes ranging from 30 to 200 participants. Their interventions were strikingly dissimilar: a wearable arm-activity feedback system with self-management coaching, an mHealth walking program with pedometer and WhatsApp feedback, robot-assisted upper-limb practice with telephone monitoring, a multidisciplinary post-discharge telerehabilitation package, caregiver-mediated exercises delivered through an iPad platform with videoconferencing and Fitbit support, and an adaptive mHealth physical activity program comparing structured online exercise against lifestyle physical activity. This heterogeneity precluded any primary pooled meta-analysis, forcing the reviewers to map the evidence rather than distill it into a single number.

The headline finding concerns depression, and it hinges on a single trial. Sun and colleagues evaluated a 12-week multidisciplinary telerehabilitation program for acute ischemic stroke patients after discharge, which included physical therapy, occupational therapy, speech therapy, videos, games, weekly video consultations, mental-health education, and online psychological counseling. Against standard post-discharge care, the aligned Hedges g for depression measured with the Hamilton Depression Rating Scale was 0.93, with a 95 percent confidence interval of 0.64 to 1.22. By conventional statistical thresholds, that is a large effect. But here is the catch: the program embedded explicit psychological support, and when the reviewers excluded it in a co-intervention sensitivity analysis, no directly analyzable depression effect against standard care remained at all.

The certainty of that lone depression signal was rated very low using the GRADE framework, downgraded for risk of bias, clinical heterogeneity, applicability limitations, small samples, and imprecision. Risk of bias assessment with the Cochrane RoB 2 tool found one trial, a small unblinded Spanish pilot, at high overall risk, while the other five carried some concerns, mainly from subjective outcome measurement in unblinded settings, missing outcome data, and selective or exploratory reporting. Notably, no included trial recruited participants on the basis of a confirmed depressive or anxiety disorder, meaning the evidence base never deliberately targeted the very psychiatric conditions it claimed to treat.

Anxiety fared even worse. No included study provided a separable patient anxiety effect suitable for synthesis. One Australian proof-of-concept trial collected Hospital Anxiety and Depression Scale data from patients and caregivers, but the accessible main report offered no separable patient anxiety estimate, and caregiver results cannot be treated as patient psychiatric effects. Another trial reported only the combined HADS total score, which is not interchangeable with an anxiety subscale. The reviewers are careful to stress that this is an absence of separable outcome data, not evidence that the interventions have no effect on anxiety, but the practical implication is the same: the randomized literature simply cannot answer the anxiety question yet.

Quality of life signals were mixed and instrument-dependent. Against standard care, the UK feasibility trial of wearable arm feedback showed no clear favorable signal on the EQ-5D-5L, while the Chinese telerehabilitation trial reported favorable adjusted coefficients across physical, mental, social, and environmental domains of the WHOQOL-BREF, again within a package that included psychological counseling. Against active conventional rehabilitation, the Spanish pilot yielded a conventionally large standardized effect on a nonstandard EQ-5D problem score, but from a small unblinded high-risk study, while the Australian trial reported mixed Stroke Impact Scale domain findings. In active-versus-active remote comparisons, the American robot-assisted trial found non-significant time-by-treatment interactions across Stroke Impact Scale domains, and the Irish adaptive trial reported no significant first-stage differences between structured exercise and lifestyle physical activity on stroke-specific quality of life or the EQ-5D visual analogue scale.

Why might exercise influence mood after stroke at all? The broader mechanistic literature offers several plausible pathways, which the reviewers carefully distinguish from anything demonstrated by these trials. Exercise-related neurotrophic signaling may support neural plasticity, while changes in inflammatory and hypothalamic-pituitary-adrenal stress-response systems may influence emotional regulation. Behavioral mechanisms may be more proximal: graded activity provides achievable goals and mastery experiences that rebuild self-efficacy after the devastating loss of function, and for anxiety, repeated safe exposure to exertional sensations may reduce fear of bodily arousal and activity avoidance. Improved physical capacity may also facilitate everyday participation, enhancing perceived well-being independently of any change in psychiatric symptoms. But none of the included trials performed a mediation analysis linking these pathways to psychiatric change, leaving them as hypotheses rather than established mechanisms.

The reviewers also emphasize a subtle but critical point about comparators. A remote package tested against standard care includes differences in therapeutic contact, coaching, education, and psychological support, so any observed benefit cannot be attributed to exercise alone. Active-versus-active comparisons, such as robot-assisted telerehabilitation versus a dose-matched home exercise program, estimate only incremental differences between rehabilitation strategies, and a non-significant result does not establish equivalence. Multiple favorable outcomes from one small trial are not independent confirmations of efficacy, and selective emphasis on such findings would overstate this exploratory evidence. The authors argue that feasibility trials, proof-of-concept studies, and adaptive SMART designs are appropriate during early intervention development, but their developmental purpose limits the confirmatory claims that can be drawn from them.

For clinicians and stroke survivors, the message is nuanced rather than dismissive. Remotely supervised exercise and physical activity remain a plausible and potentially valuable component of multidisciplinary stroke rehabilitation, with a logistical rationale for extending monitoring and feedback into the home. But the current evidence does not support these programs as stand-alone treatments for post-stroke depression or anxiety, and survivors with clinically significant psychiatric symptoms should continue to receive evidence-based psychological, psychiatric, and, where indicated, pharmacological care. The reviewers call for confirmatory trials that recruit or stratify participants by baseline psychiatric symptoms, prespecify psychiatric outcomes using validated instruments such as the PHQ-9, HADS subscales, and GAD-7, and use factorial or component designs to separate the contributions of exercise dose, remote supervision, psychological support, education, and coaching. Until such trials deliver, the dream of exercise as a remote antidepressant after stroke remains exactly that: a promising hypothesis awaiting proof.

Subject of Research: Remote supervised exercise- and physical activity-based rehabilitation for post-stroke depression, anxiety, and quality of life: a systematic review, evidence map, and exploratory quantitative synthesis

Article Title: Remote supervised exercise- and physical activity-based rehabilitation for post-stroke depression, anxiety, and quality of life: a systematic review, evidence map, and exploratory quantitative synthesis

Article References: Zhang, C., Zhou, Z., Cai, J., & Li, Y. (2026). Remote supervised exercise- and physical activity-based rehabilitation for post-stroke depression, anxiety, and quality of life: a systematic review, evidence map, and exploratory quantitative synthesis. Frontiers in Psychiatry, 17, Article 1888180. https://doi.org/10.3389/fpsyt.2026.1888180

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1888180

Keywords: stroke, telerehabilitation, post-stroke depression, exercise, systematic review, quality of life, anxiety, remote rehabilitation, Remote, supervised, exercise-, physical

The scale of the rural disparity is striking. Compared with urban residents, rural Americans experience higher rates of chronic pain, pain-related disability, and opioid utilization. The reasons are layered: rural populations skew older, work more physically demanding jobs in agriculture, construction, and manual labor, and show higher rates of obesity and tobacco use, all of which raise the risk of chronic musculoskeletal and neuropathic pain. Add reduced access to preventive care, which delays diagnosis and lets painful conditions progress, and the burden compounds. Meanwhile, pain specialists and multidisciplinary pain programs are concentrated almost entirely in urban academic centers. Rural patients routinely drive hours for appointments, absorbing transportation costs, lost wages, and missed workdays, which fuels delayed evaluation, interrupted treatment, and poor adherence. With physical therapy, behavioral health, and rehabilitation services scarce, rural patients lean heavily on primary care providers to manage complex pain conditions without specialty backup.

Telemedicine entered this landscape as a potential bridge, and the COVID-19 pandemic supercharged its adoption across virtually every medical specialty. The review maps the field across six modalities: synchronous video visits, telephone-based encounters, asynchronous electronic consultations, telerehabilitation, tele-delivered cognitive behavioral therapy, and mobile health applications. Each has distinct strengths. Video allows clinicians to observe affect, gait, gross motor function, and functional movement; telephone encounters offer a low-bandwidth fallback for straightforward follow-up and care coordination; e-consults let specialists review clinical information and respond asynchronously. A 2016 evaluation of a Massachusetts General Hospital telepain service linking Boston to Martha’s Vineyard completed 238 video evaluations over 13 months, with surveyed patients rating every satisfaction item above 4.3 out of 5. Conversely, a Swiss survey of 61 chronic pain patients found telemedicine acceptance averaged just 6.25 out of 10, with higher pain intensity and anxiety correlating with lower acceptance, and a slight majority preferring in-person visits. Notably, patients who had previously experienced telehealth were more willing to continue, suggesting familiarity itself dissolves hesitancy.

The strongest randomized evidence belongs to remotely delivered cognitive behavioral therapy for chronic pain. A phase 3 pragmatic randomized clinical trial by DeBar and colleagues, published in JAMA in 2025, enrolled more than 2,000 patients with high-impact chronic musculoskeletal pain across four geographically diverse U.S. health systems. Participants were randomized to one of two remote, eight-session cognitive behavioral therapy programs, one delivered by a health coach via telephone or video and one completed independently online, or to usual care. Both remote interventions produced clinically meaningful, sustained improvements in pain severity through 12 months, with the health coach-led arm showing the largest effect at the 3-month primary endpoint before the two active arms converged. These findings align with a Cochrane review concluding that remotely delivered psychological therapies likely reduce pain intensity and anxiety immediately after treatment. For rural patients who may live hours from any psychologist trained in pain, this is a scalable route to evidence-based nonpharmacologic care.

Telerehabilitation is the second pillar of strong evidence. Physical therapy is established as cost-effective for chronic low back pain, yet only an estimated 7 to 13 percent of people with low back pain ever receive it, and rural communities have roughly 40 percent fewer physical therapists per capita than metropolitan regions. The ARBOR-Telehealth trial, now enrolling 434 patients with chronic low back pain from rural primary care clinics, is testing whether telerehabilitation delivered by trained physical therapists over a web-based video platform can reduce disability and opioid utilization compared with standardized patient education. Earlier randomized evidence found exercise-based telerehabilitation for nonspecific chronic low back pain comparable to conventional outpatient physical therapy, with no significant differences in disability, pain intensity, or fear-avoidance outcomes at 8 weeks. A 2024 scoping review of 28 studies confirmed pain and disability as the most commonly assessed and most frequently improved outcomes, with smartphone apps the dominant asynchronous delivery mode. A longitudinal observational study of videoconferencing-based telehealth physical therapy showed significant improvements in disability, pain, pain interference, and physical function at 10 and 26 weeks, though only 39.5 percent of patients perceived the quality as equal to in-person care.

The Veterans Health Administration offers a real-world laboratory for rural telepain. Its TelePain program serves communities in Alaska, Washington, and Oregon through home-based video visits or telehealth rooms at community clinics. Qualitative evaluations found general satisfaction, appreciation for knowledgeable clinicians, and substantial value from reduced travel, alongside inconsistent follow-up, negative perceptions of behavioral health treatment, and preferences for in-person care among some veterans. The TelePain-Empower Veterans Program, which integrates Whole Health principles, Acceptance and Commitment Therapy, and Mindful Movement through interdisciplinary coaching, improved coping skills, sense of community, and interpersonal relationships, and significantly reduced pain catastrophizing from baseline, though those gains were not sustained at 26-week follow-up. Participants notably did not report self-perceived reductions in pain or medication use. Meanwhile, VHA e-consults completed over 3.1 million consultations across 41 specialties between 2012 and 2018, with only 21.5 percent resulting in an in-person visit within 12 months, and each e-consult saving patients approximately 84.3 miles of driving.

Mobile health applications add another layer. A 2024 systematic review spanning 25 years and 26,429 participants found mobile apps were the most common modality, with generally high usability and acceptability. A separate review of 22 randomized trials confirmed benefits for pain intensity, quality of life, and functional disability across low back pain, neck pain, fibromyalgia, and osteoarthritis. Digital pain diaries capture daily variability patterns tied to fatigue, mood, and morning stiffness that intermittent office visits miss entirely. Encouragingly, a longitudinal cohort study of nearly 10,000 patients found a fully remote multimodal digital care program for musculoskeletal pain achieved equivalent clinical outcomes in rural and urban populations, with rural residents actually showing higher engagement and completion rates. But the review cautions that smartphone-dependent programs are not universally equitable: rural older adults, patients with limited broadband, and those with visual, cognitive, or motor impairments may be excluded entirely, pointing toward stepped approaches using SMS reminders, telephone coaching, mailed materials, caregiver assistance, or loaner devices.

Telemedicine has hard limits. Palpation, assessment of warmth suggesting infection, hip range of motion, and tests for spasticity or rigidity are difficult or impossible remotely, and agreement between telehealth and in-person examinations drops most for palpation and precise range-of-motion measurements, especially in older patients with multiple comorbidities. Assessment of allodynia, hyperalgesia, and detailed sensory mapping remains substantially limited. Interventional procedures such as epidural steroid injections, nerve blocks, and spinal cord stimulation trials cannot be delivered remotely, though telemedicine excels at pre-procedural consultation and post-injection follow-up. Regulatory uncertainty looms largest around controlled substances: the Ryan Haight Act generally requires an in-person evaluation before internet prescribing, but COVID-era federal flexibilities permitting DEA-registered practitioners to prescribe Schedule II-V medications via telemedicine have been extended through December 31, 2026, while permanent special-registration rules remain under development. Privacy is another friction point, since patients may lack a private space to discuss substance use, mental health, or psychosocial stressors, and safety-net clinicians report difficulty monitoring opioid adherence remotely.

The authors propose a hybrid model as the most pragmatic framework for rural chronic pain care in the United States. It uses structured triage to route stable follow-up, behavioral treatment, rehabilitation, education, and routine medication review to remote care while reserving in-person visits for new undifferentiated pain, red flags, unreliable remote examinations, interventional procedures, and situations where opioid safety monitoring cannot be completed adequately. Technology-navigation support, low-bandwidth alternatives, interpreter services, device-loan programs, and standardized controlled-substance workflows round out the design. The review’s own limitations are candid: as a narrative rather than systematic review, study selection was purposive, the evidence is heterogeneous across intervention types and definitions of rurality, and the findings are predominantly U.S.-based and may not transfer directly to other countries. Still, the core message lands with force: telemedicine is not a replacement for multidisciplinary pain care but a component of it, and programs that combine patient choice, technology support, structured hybrid triage, and explicit safety escalation are most likely to expand access without sacrificing clinical quality or widening the digital divide.

Subject of Research: Health and Medicine

Article Title: Telemedicine for chronic pain management in rural populations: a narrative review

Article References: Hasoon, J., Yazdi, C., & Robinson, C. L. (2026). Telemedicine for chronic pain management in rural populations: a narrative review. Frontiers in Pain Research, 7, Article 1907994. https://doi.org/10.3389/fpain.2026.1907994

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1907994

Keywords: chronic pain, telemedicine, rural health, health disparities, telerehabilitation, cognitive behavioral therapy, opioids, digital health, chronic, pain, management, rural

The technical logic behind the study was straightforward. Because no prior research had specifically explored barriers to outpatient occupational therapy access for rural populations, the team built a gap analysis survey grounded in the existing literature on rural healthcare access. The instrument gathered therapist demographics, practice characteristics, and ratings of potential barriers on a four-point Likert scale ranging from strongly disagree to strongly agree, with open text fields inviting respondents to describe supports and solutions. Recruitment ran from February to September 2024 through email lists, including the Certified Stroke Rehabilitation Specialist certification list, and through social media platforms, with recipients encouraged to share the survey within their professional networks. The survey was distributed to 1,072 individuals, although the researchers caution that because the lists spanned multiple disciplines in both rural and urban settings, the true number of eligible recipients is unknown.

Twenty-six occupational therapists from fifteen states ultimately completed the survey, a modest but geographically diverse sample. The respondents were, on average, 36.7 years old with 10.5 years of clinical experience, and most held master’s level qualifications. Notably, roughly two thirds treated fewer than ten stroke patients per week, reflecting the low caseloads that characterize rural practice. Responses were analyzed with descriptive statistics, with Likert results collapsed into agreement and disagreement categories because of the sample size, and open comments were thematically summarized.

The findings on patient-side barriers were striking for their unanimity. Every single respondent, 100 percent, agreed that financial constraints, such as inability to afford co-pays or time off work, and transportation problems, including the absence of public transit or a personal vehicle, barred rural stroke survivors from outpatient occupational therapy. Insurance coverage followed at 96 percent, with distance to clinic at 92 percent. Health literacy was endorsed by 80 percent of therapists, and family or caregiver support and competing roles and responsibilities, such as being unable to leave work or serving as a primary caregiver, each at 73 percent. Interestingly, most respondents did not view stroke survivors’ distrust of the healthcare system as a barrier, a point the authors interrogate carefully in their discussion.

Open comments brought these statistics to life. One therapist wrote that true rural clients do not live close to an outpatient clinic and must travel many miles to reach one, while another observed that resources for stroke survivors are severely limited or poorly advertised and accessible, or both. The transportation problem is compounded by the nature of stroke itself: residual symptoms such as hemiparesis can make entering and exiting a vehicle physically difficult even when a ride exists, and rural infrastructure rarely offers public transportation or ride-share coverage. Previous research cited by the authors shows that patients are often encouraged to drive into larger cities to reach certified specialists, a journey that taxes both exhausted patients and stretched support systems.

But the study’s most provocative finding concerns the therapists themselves. When asked what prevented them from adequately treating rural stroke survivors, the most frequently cited barrier, reported by 69 percent of respondents, was the lack of appropriate clinic equipment for neuro-specific interventions. This is not simply a matter of missing high-end gadgets. As the authors explain, evidence-based neuro-rehabilitation relies on equipment ranging from robotics, neuromuscular electrical stimulation, and functional electrical stimulation bikes to low-tech and no-tech essentials such as appropriately sized therapy plinths wide enough for neuro-facilitatory positions like quadruped, hand paddles, air casts, and mobile arm supports that position a hypertonic upper extremity for functional tasks. A single narrow plinth table cannot safely accommodate a therapist working on a mat with a patient, and improvisation, however creative, has limits when outcomes are at stake.

Further down the list of therapist-side barriers came limited opportunities for direct mentorship or case discussion with colleagues, at 58 percent, followed by lack of facility-sponsored research resources such as librarians or funded continuing education at 54 percent, limited supported time to research best practice at 54 percent, inadequate staffing at 50 percent, and infrequent exposure to stroke cases at 46 percent. These figures resonate with earlier evidence-based practice research: a 2020 survey of 578 occupational therapists cited in the paper found that 42 percent reported zero minutes per week of supported time to search for, appraise, or discuss research relevant to their patients. In clinics where stroke cases are rare and colleagues are few, the machinery of professional learning simply stalls.

The respondents did not stop at cataloguing problems; they proposed solutions that read like a blueprint for rural neuro-rehabilitation. Recommendations clustered around telerehabilitation and remote or mobile therapy sessions delivered in the home, self-management resources such as video training that patients and caregivers could access at any time, expanded caregiver training both during hospitalization and afterward through community support groups, clinic or charity funded transportation, and the addition of outpatient case managers to multidisciplinary teams. One respondent argued that the field must move beyond assuming a therapist must be physically present for therapy to occur, since stroke survivors need to perform therapeutic activities daily rather than a few times a week. The scientific literature offers support for this direction: telerehabilitation and caregiver-led rehabilitation have been extensively studied, and a low-cost hybrid program using telephone calls and text messages showed improvements in physical function, participation, and quality of life immediately after intervention, although effects were not sustained six months later, a signal that longitudinal support models deserve further testing.

The authors are appropriately cautious about their own work. They acknowledge the small sample size, the low response rate, and the untested survey instrument, and they note that surveys carry inherent risks of non-response bias. More fundamentally, the study captured only the therapist’s lens; barriers identified by clinicians may not match those experienced by stroke survivors and caregivers themselves, and therapists may only ever see patients who trust the system enough to seek care. The disagreement among respondents about healthcare system trust illustrates this blind spot: previous work reporting distrust as a barrier drew on people with lived experience, including rural traumatic brain injury survivors who described difficulty finding specialty care and a lack of advocacy and confidence in providers. The authors’ stated long-term goal is to expand this research with larger, more diverse stakeholder groups, using rural community engagement techniques such as targeted recruitment through places of worship, senior centers, primary care offices, and rural therapy clinics.

Still, the study delivers a clear and quantified message at a moment when telehealth reimbursement in the United States hangs on provisional approvals from the Centers for Medicare and Medicaid Services. Money, wheels, and miles stand between rural stroke survivors and the therapy that rebuilds their lives, unanimously according to the surveyed therapists, while those same therapists confront clinics stripped of the equipment and research support that evidence-based neuro-rehabilitation demands. The costs of inaction are not abstract: preventable secondary complications such as falls, skin breakdown, and contractures drive healthcare spending upward while patients deteriorate. Closing the gap, the authors argue, will require research that centers the voices of survivors themselves, sustained investment in equipment and mentorship for rural clinicians, and a willingness to rethink where and how therapy happens, whether through mobile outpatient services, hybrid telerehabilitation built on everyday cell phones, or caregiver training that turns living rooms into recovery spaces.

Subject of Research: Barriers to outpatient occupational therapy access for rural stroke survivors as perceived by occupational therapists in the United States

Article Title: Outpatient occupational therapy access for rural stroke survivors: barriers as perceived by therapists

Article References: Stevens, E. A., Pfeifer, L. J., & Malcolm, M. P. (2026). Outpatient occupational therapy access for rural stroke survivors: barriers as perceived by therapists. Frontiers in Stroke, 5, Article 1850977. https://doi.org/10.3389/fstro.2026.1850977

Image Credits: AI Generated

DOI: 10.3389/fstro.2026.1850977

Keywords: stroke, stroke rehabilitation, occupational therapy, rural health, healthcare access, telerehabilitation, health disparities, transportation barriers, caregiver support, health literacy, neurorehabilitation, survey research

Specialized pro-resolving mediators, often abbreviated as SPMs, are lipid-derived signaling molecules that the body naturally produces to orchestrate the resolution of inflammation. Unlike anti-inflammatory drugs that broadly suppress immune activity, SPMs are thought to actively steer tissues from an inflammatory state back toward homeostasis, promoting clearance of debris and the return of normal cellular function. Because chronic, unresolved inflammation has been repeatedly implicated in the biology of long COVID, researchers hypothesized that boosting pro-resolving pathways with an SPM-enriched marine oil supplement might ease the persistent symptoms that plague patients. The idea is biologically plausible: omega-3 fatty acids such as eicosapentaenoic acid and docosahexaenoic acid serve as precursors for these mediators, and supplementing with concentrated fractions could, in theory, tip the inflammatory balance in a favorable direction.

The trial enrolled 144 adults with a mean age of 50 years, roughly 82 percent of whom were women, all experiencing post-COVID-19 condition lasting more than twelve weeks. The pronounced female predominance mirrors the epidemiology of the condition itself, which disproportionately affects women in midlife. Participants were randomized in a one-to-one ratio to receive either the SPM-enriched marine oil supplement or an identical placebo. Crucially, the study was triple-blind, meaning that participants, clinicians, and outcome assessors were all unaware of group assignment, minimizing bias in both treatment delivery and measurement. Every participant, regardless of supplement allocation, also completed a twelve-week asynchronous telerehabilitation program delivered through the HEFORA digital platform, allowing them to perform prescribed exercises at home on their own schedule.

The researchers chose health-related quality of life, measured with the widely used EQ-5D-5L instrument, as the primary outcome, reflecting the fact that long COVID is fundamentally a condition that degrades daily functioning rather than a single measurable physiological deficit. A battery of secondary outcomes captured the multidimensional nature of the syndrome: fatigue was quantified with the Fatigue Severity Scale, breathlessness with the Modified Medical Research Council dyspnea scale, respiratory muscle strength through maximal inspiratory and expiratory pressures, functional capacity with the six-minute walk test, and limb strength using thirty-second sit-to-stand and arm curl tests. Analyses followed an intention-to-treat approach, meaning every randomized participant was analyzed within their assigned group regardless of adherence, a method that preserves the randomization and gives the most conservative estimate of real-world effect.

After twelve weeks, the headline finding was a null one: there were no statistically significant differences between the supplement and placebo groups on any outcome, with all between-group comparisons yielding p-values above the conventional 0.05 threshold. In plain terms, adding the SPM-enriched supplement to telerehabilitation conferred no measurable advantage over telerehabilitation alone. For a field crowded with unproven remedies marketed to desperate patients, this kind of rigorous negative result carries real scientific value. It signals that, at least in this unselected population of long COVID patients and over a twelve-week window, simply supplying pro-resolving lipid mediators is not sufficient to accelerate recovery beyond what structured exercise and rehabilitation achieve on their own.

Yet the within-group results tell a more encouraging story. Both groups improved substantially across nearly every measure. Participants in the nutritional group walked an average of 37.82 meters farther on the six-minute walk test by the end of the program, a change that reached high statistical significance and that clinicians generally regard as meaningful for daily function. Quality of life scores rose, fatigue severity fell, and both limb strength and respiratory muscle pressures increased significantly. The placebo group showed a strikingly similar pattern of gains, with the sole exception of dyspnea, which did not improve significantly in that arm. The near-identical trajectories of the two groups reinforce the interpretation that the rehabilitation program itself, rather than the supplement, drove the observed recovery.

The trial’s exploratory adherence-stratified analyses added an intriguing wrinkle. When participants were sorted by how faithfully they followed the intervention, those with higher adherence displayed larger improvements than their less compliant counterparts. This pattern is consistent with a dose-response relationship for the rehabilitation component, but it also leaves open the possibility that the supplement might benefit a subset of highly engaged patients. The authors themselves are careful on this point: adherence-stratified analyses are exploratory and vulnerable to confounding, since people who adhere well to supplementation may also adhere better to exercise, sleep recommendations, and other health behaviors. The finding is best read as a hypothesis generator rather than evidence of efficacy.

The study’s design and funding deserve attention when weighing its conclusions. The trial was registered as NCT06063031 in September 2023, approved by the Ethics Committee of Aragón, and conducted with written informed consent under the Declaration of Helsinki. Funding came from the Government of Aragon through an industrial research call in the pharmaceutical sector, with the company SOLUTEX G.C. S.L. as beneficiary and the Aragón Health Research Institute subcontracted to manage the project. One author disclosed participation in the European project where the HEFORA platform was developed. These industry-linked arrangements are disclosed transparently, and the triple-blind, placebo-controlled architecture provides substantial protection against bias, but readers should nonetheless note the commercial interest in the tested product.

What does ARACOV-02 mean for the millions still struggling with long COVID? First, it strengthens the case for rehabilitation as a core intervention. A twelve-week, home-based, asynchronous telerehabilitation program produced measurable gains in walking distance, fatigue, quality of life, and respiratory and limb strength, all without requiring patients to travel to clinics, a significant advantage for a population whose symptoms often make travel exhausting. Telerehabilitation platforms like HEFORA could therefore extend evidence-based care to patients in rural areas or those too debilitated for in-person programs. Second, the trial tempers enthusiasm for SPM supplements as a general remedy, suggesting that unselected supplementation does not reliably outperform placebo in this heterogeneous patient population.

The authors point toward the next logical step: biomarker-guided studies that identify which phenotypes of post-COVID-19 condition, if any, are most likely to respond to pro-resolving nutritional strategies. Long COVID is almost certainly not a single disease but an umbrella term covering several mechanistically distinct subtypes, including those dominated by viral persistence, autoimmunity, dysautonomia, and unresolved inflammation. A supplement targeting inflammatory resolution might help the inflammatory subgroup while leaving others untouched, an effect that would be diluted to invisibility in an unstratified trial of 144 participants. Until such biomarker-driven trials are completed, patients and clinicians should view SPM supplementation for long COVID with measured skepticism, while taking genuine encouragement from the demonstrated power of structured, remotely delivered rehabilitation to restore function and quality of life.

Subject of Research: A randomized controlled trial of specialized pro-resolving mediators and telerehabilitation for post-COVID-19 condition

Article Title: Effects of specialized pro-resolving mediators and telerehabilitation on fatigue, dyspnea, and quality of life in post‑COVID‑19 condition: the ARACOV-02 randomized controlled trial

Article References: Carpallo-Porcar, B., Jiménez-Sánchez, C., Calvo, S., Kolesnyk-Sumskaya, E., Aller-Blanco, A. I., Gómez-Barrera, M., & del Corral Beamonte, E. (2026). Effects of specialized pro-resolving mediators and telerehabilitation on fatigue, dyspnea, and quality of life in post‑COVID‑19 condition: the ARACOV-02 randomized controlled trial. BMC Complementary Medicine and Therapies. https://doi.org/10.1186/s12906-026-05630-w

Image Credits: AI Generated

DOI: 10.1186/s12906-026-05630-w

Keywords: post-COVID-19 condition, long COVID, specialized pro-resolving mediators, telerehabilitation, randomized controlled trial, fatigue, dyspnea, quality of life, nutritional supplement, omega-3 fatty acids, functional capacity, respiratory muscle strength

The research team set out with a broad ambition. Neurodevelopmental disorders, a category that includes cerebral palsy, autism spectrum disorder, attention deficit hyperactivity disorder, and developmental coordination disorder, affect motor, cognitive, and social functioning in children and adolescents, often limiting autonomy and quality of life. For many families, limited access to specialized rehabilitation services is a persistent barrier, and the COVID-19 pandemic dramatically accelerated interest in remote delivery models as a way to keep therapy going when in-person care became impossible. The Spanish team therefore asked a focused question: in individuals aged 3 to 18 years with neurodevelopmental disorders, does home-based telerehabilitation improve motor function compared with usual care, conventional face-to-face rehabilitation, or other non-telehealth interventions?

To answer it, the researchers conducted a rigorous search across five major databases — PubMed, the Cochrane Library, PEDro, CINAHL, and Scopus — covering the period from database inception to January 2026, with the earliest eligible trial dating from 2014. They restricted their inclusion to randomized controlled trials, the gold standard for testing whether an intervention actually causes an effect, rather than merely coinciding with one. Methodological quality was assessed with the Cochrane RoB 2.0 tool, which evaluates bias in randomized trials across domains such as randomization, deviations from intended interventions, and outcome measurement. The certainty of the pooled evidence was graded using the GRADE framework, and the results of individual trials were combined into standardized mean differences, or SMDs, using a random-effects model that allows the true effect to vary from study to study.

What emerged from the search was revealing in itself. Eight randomized controlled trials met the criteria, encompassing a total of 419 participants. Although the review was designed to cover neurodevelopmental disorders in general, every single included trial involved children or adolescents with cerebral palsy. That mismatch between the review’s broad aim and the narrow evidence base is one of the study’s most important findings, because it means the conclusions can only speak with confidence to the cerebral palsy population, leaving open questions about conditions such as autism or developmental coordination disorder. The trials themselves spanned a decade of technological change, from motion-interactive video games and Wii-based upper limb training to web-based multimodal therapy programs and home-based virtual reality systems designed to prevent regression after intensive constraint-induced movement therapy.

The headline result concerns gross motor function — the large-muscle abilities that underpin walking, balance, and transfers. Pooling the trial data, the meta-analysis suggested possible improvements with a standardized mean difference of 1.29, with a 95 percent confidence interval stretching from 0.11 to 2.47. In plain terms, the point estimate points to a large benefit, but the confidence interval is strikingly wide, and its lower bound sits barely above zero, meaning the data are compatible with anything from a trivial effect to a very large one. The statistical heterogeneity across studies was extreme, with an I² value of 96 percent, indicating that almost all of the variability between pooled results reflects genuine differences between the trials rather than random chance. The authors note that the estimates were influenced by this heterogeneity and by outlier studies, individual trials whose results pulled the pooled estimate in particular directions.

Fine motor function — the precise, small-muscle control needed for grasping, writing, and manipulating objects — told a different story. Here the pooled effect was smaller and statistically non-significant, with a standardized mean difference of 0.62 and a confidence interval spanning from minus 0.25 to 1.49, crossing the line of no effect. Heterogeneity was again very high, at 90 percent. This pattern is clinically plausible: fine motor skills are notoriously harder to train remotely, since they often require hands-on facilitation, careful grading of task difficulty, and immediate physical correction of movement patterns that a therapist can deliver in person but struggles to replicate through a screen. Many of the included trials, such as those testing computer-assisted arm rehabilitation gaming and Wii Sports Resort-based training for hemiplegic cerebral palsy, targeted the upper limb, yet the aggregated evidence for distal, precise control remains unconvincing.

Why does heterogeneity matter so much here? When I² approaches 100 percent, the pooled number becomes less a single truth than an average of very different experiments. The eight trials varied in the technology used, the dose and duration of therapy, the age and severity of participants, the comparison conditions, and the outcome measures chosen to capture motor function. A trial comparing telerehabilitation against no additional therapy may show large effects that would shrink dramatically against an equally intensive in-person program. Outlier studies with unusually large effects can dominate a random-effects meta-analysis, inflating the summary estimate. The authors’ decision to flag these influences rather than simply report the large SMD reflects a mature reading of the evidence, and it is precisely why the GRADE assessment delivered a verdict of low certainty.

The low-certainty rating deserves emphasis, because it changes how the findings should be used. GRADE downgrades evidence for risk of bias, inconsistency, indirectness, imprecision, and publication bias, and this evidence base ticks several of those boxes: extreme inconsistency, wide confidence intervals signaling imprecision, and a population narrower than the review’s intended scope. What the review supports is not a claim that home-based telerehabilitation works, but a hypothesis that it may support gross motor rehabilitation in youth with cerebral palsy, strong enough to justify further high-quality trials. The authors explicitly call for research to confirm effectiveness, determine clinical relevance, and understand implementation factors such as adherence and how interventions are actually delivered in families’ homes.

The broader context makes the question urgent. Rehabilitation science has established that motor learning depends on practice intensity and repetition, and recent dose-response meta-analyses in cerebral palsy suggest that both overall and modality-specific exercise doses matter for motor skill improvement. Yet access barriers — geographic, financial, and logistical — keep many children from receiving enough therapy. Telerehabilitation offers a potential solution, and its track record in adult neurology and musculoskeletal care, along with economic evaluations suggesting favorable cost-utility profiles, has fueled enthusiasm for pediatric applications. The pandemic-era literature documented rapid implementation of pediatric telerehabilitation and continuity of care during lockdowns, but enthusiasm has often outrun controlled evidence. This review is valuable precisely because it applies the strictest study design filter — randomized trials only — and refuses to overstate what those trials show.

For clinicians and families, the practical takeaway is one of tempered optimism. Home-based telerehabilitation appears to be a credible complementary approach for supporting gross motor development in children and adolescents with cerebral palsy, one that could extend therapy dose, reduce travel burdens, and reach families in rural or underserved regions — a model already being tested in settings such as rural Bangladesh. But it should not yet be treated as a replacement for conventional rehabilitation, particularly for fine motor goals where the evidence is weakest. The 419 participants across eight trials represent a beginning, not an endpoint. As sensor-based systems, motion-interactive games, and virtual reality platforms grow more sophisticated and more affordable, the next generation of trials — larger, better standardized, and designed to disentangle which delivery formats work for which children — will determine whether the living room can truly become an extension of the rehabilitation clinic.

Subject of Research: Effectiveness of home-based telerehabilitation for motor function in youth with cerebral palsy and neurodevelopmental disorders

Article Title: Home-based telerehabilitation on motor function in youth with cerebral palsy: systematic review and meta-analysis

Article References: Domínguez-López, P., Lirio-Romero, C., Coello-Villalón, M., López-Muñoz, P., Martínez-Olagüe Jácome, M., & Palomo-Carrión, R. (2026). Home-based telerehabilitation on motor function in youth with cerebral palsy: systematic review and meta-analysis. Pediatric Research. https://doi.org/10.1038/s41390-026-05382-w

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05382-w

Keywords: telerehabilitation, cerebral palsy, neurodevelopmental disorders, gross motor function, fine motor function, pediatric rehabilitation, systematic review, meta-analysis, randomized controlled trials, telehealth, motor function, Pediatric Research