Clinical Rehabilitation

27(12) 1072 1083

The Author(s) 2013
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DOI: 10.1177/0269215513488001
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CLINICAL
REHABILITATION
Introduction
Telecounselling the application of individual or
group-based counselling services using telecommuni-
cation technology, such as the telephone, video tele-
phone, videoconferencing, email correspondence, or
audio-video transmission via the internet
1
has the
potential to extend mental healthcare to community-
dwelling adults with spinal cord injuries. Specifically,
telecounselling offers the possibility of an equitable,
affordable and accessible mental health service to pro-
vide consultation, monitoring and treatment.
2,3
To date, however, research examining the
potential use of telecounselling in spinal rehabili-
tation has been limited in both quantity and
488001CRE271210.1177/0269215513488001Clinical RehabilitationDorstyn et al.
2013
School of Psychology, University of Adelaide, South Australia
Corresponding author:
D Dorstyn, School of Psychology, University of Adelaide,
North Terrace Campus, Adelaide, South Australia 5000,
Australia.
Email: diana.dorstyn@adelaide.edu.au
Applications of telecounselling
in spinal cord injury
rehabilitation: a systematic
review with effect sizes
Diana Dorstyn, Jane Mathias and Linley Denson
Abstract
Objective: To investigate the short- and medium-term efficacy of counselling services provided remotely
by telephone, video or internet, in managing mental health outcomes following spinal cord injury.
Data sources: A search of electronic databases, critical reviews and published meta-analyses was
conducted.
Review methods: Seven independent studies (N = 272 participants) met the inclusion criteria.
The majority of these studies utilized telephone-based counselling, with limited research examining
psychological interventions delivered by videoconferencing (N
study
= 1) or online (N
study
= 1).
Results: There is some evidence that telecounselling can significantly improve an individuals management
of common comorbidities following spinal cord injury, including pain and sleep difficulties (d = 0.45).
Medium-term treatment effects were difficult to evaluate, with very few studies providing these data,
although participants have reported gains in quality of life 12 months after treatment (d = 0.88). The main
clinical advantages are time efficiency and consumer satisfaction.
Conclusion: The results highlight the need for further evidence, particularly randomized controlled
trials, to establish the benefits and clinical viability of telecounselling.
Keywords
Spinal cord injuries, telecounselling, telerehabilitation, treatment outcome, systematic review
Received: 23 November 2012; accepted: 7 April 2013
Article
Dorstyn et al. 1073
quality. First, most telecounselling research has
examined other physical disabilities (e.g. stroke,
multiple sclerosis),
4
making it difficult to extrap-
olate the findings to spinal cord injury. Second,
these heterogeneous samples often include indi-
viduals with comorbid cognitive problems (e.g.
stroke, traumatic brain injury), who require dif-
ferent psychological assessments and interven-
tions.
5
Third, trials that have evaluated the
application of telecommunication technology
within spinal rehabilitation have incorporated
diverse treatment programmes, including tele-
medicine, telenursing and multidisciplinary
telerehabilitation, making it difficult to isolate
the effectiveness of counselling-only services.
6

Finally, there are very few qualitative or quantita-
tive reviews specific to this area.
4
Faced with
limited available research, we recently attempted
to address some of these problems by conducting
a meta-analysis of telecounselling research
involving people with chronic physical condi-
tions that have a significant disease burden,
7

namely spinal cord injury, limb amputation,
severe burn injury, stroke and multiple sclerosis.
4

While informative, this analysis was limited to
telephone-based counselling services only, was
not specific to the spinal cord injury population
and, moreover, pre-dated a number of recent tele-
counselling trials that can now be used to narrow
the focus of our analysis to this group.
The current study was therefore designed to con-
solidate the available evidence on the efficacy of
telecounselling in spinal rehabilitation by undertak-
ing a systematic review of this research. The specific
goals were to evaluate the clinical characteristics of
telephone-, video- and internet-based counselling
programmes, namely the: (1) treatment delivery
characteristics (e.g. duration, frequency); (2) short-
term treatment effects (defined as improvements
made from baseline to the period immediately after
telecounselling ceased), and medium-term effects
(defined as any maintenance effects observed after
telecounselling had ceased); and (3) process out-
comes (e.g. attrition rates and cost analyses, where
available). Given the very limited research in this
area, the magnitude of treatment change associated
with telecounselling could not be predicted.
Method
Eligible studies were sourced from six electronic
databases: PubMed, PsycINFO, CINAHL, Scopus,
Cochrane Library, Web of Science (see Appendix for
keywords). The search was restricted to full-text arti-
cles published in English in peer-reviewed journals
between January 1970 (empirical studies of telephone
counselling services dated from that year
8
) and
January 2013. Meta-analytic and systematic reviews
of the telerehabilitation and disability literature,
4,6,911

were also reviewed for additional published empirical
studies, as were the bibliographies of all retrieved
studies and the Spinal Cord Injury Rehabilitation
Evidence database (www.scireproject.com).
Eligible studies had to: (1) target an adult sample
with an acquired spinal cord injury (18 years); and
(2) conduct a telecounselling intervention that
involved healthcare professionals (nurses, social
workers or psychologists) directly interacting with
clients to facilitate psychological recovery follow-
ing injury.
1,4
This included the use of online inter-
ventions where real-time access to a clinician (e.g.
via telephone) was available.
1
Interventions also
had to (3) assess treatment efficacy using one or
more standardized measures of psychological out-
come (e.g. anxiety, depression, quality of life).
Given the very limited research in this area, quasi-
experimental designs that either used a standard-
care control group or no control condition (which is
often necessary in clinical settings),
12,13
were
included in this review.
Studies were excluded if: (1) the sample compo-
sition was heterogeneous and included participants
with a spinal cord injury in addition to those with
another chronic illness or disability (e.g. stroke,
multiple sclerosis), and where the data for spinal
cord injury patients could not be separately extracted;
(2) the telecounselling intervention focused on fam-
ily caregivers and not individuals with a spinal cord
injury; (3) the primary focus of the intervention was
not psychosocial (i.e. only entailed medical, nursing
or physical therapies); (4) the study had a multidisci-
plinary focus and did not specifically evaluate the
counselling component; or (5) treatment efficacy
was only assessed using non-standardized clinical
interviews (N.B. standardized interviews, such as
1074 Clinical Rehabilitation 27(12)
the Centre for Epidemiologic Studies Depression
Scale,
14
were eligible for inclusion).
Data extraction and analysis
The quality of each study meeting inclusion criteria
was evaluated using the Oxford Centre for Evidence
Based Medicine guidelines.
15,16
Accordingly, studies
with greater methodological rigor (e.g. randomized
clinical trials) received a higher rating (level 1 or 2,
depending on the number of participants and statisti-
cal power), meriting a higher grade of recommenda-
tion (grades A or B, respectively). In comparison,
studies received lower ratings (i.e. level 3), and a
lower grade of evidence (C), if they were non-ran-
domized or did not include a control or comparison
group (level 4 or 5). Methodological evaluation
involved consensus ratings by the first and second
authors (DD, JM).
For ease of data collection and interpretation, and
in accordance with the Cochrane Collaboration
17

and PRISMA
18
statements for reporting of system-
atic reviews, a data extraction sheet was used to
summarize key information from each study,
namely: sample demographics (e.g. sample size,
age, gender, race), methodological variables (e.g.
sample size, sampling method, control condition),
and characteristics of the implemented telecounsel-
ling programmes (e.g. programme aims, session fre-
quency and duration). Data extraction was completed
by the first author (DD).
Effect size estimation. To determine telecounselling
treatment effects, Cohens d effect sizes
19
were calcu-
lated for every outcome measure used by a study. Both
the short-term treatment effects (change in outcome
measures from pre- to post-telecounselling) and the
maintenance of treatment gains (post-telecounselling
to follow-up) were evaluated. Different Cohens d for-
mulae
20
were needed for studies that did and did not
use control groups. The direction of each effect size
was standardized across measures so that a positive
effect indicated that telecounselling was beneficial. A
negative d indicated either a worsening of symptoms
among the telecounselling participants, or signifi-
cantly more improvement in controls.
21
Cohens
d-values of 0.2, 0.5 and 0.8 equate to small, medium
and large treatment effects, respectively,
19
with statisti-
cally significant treatment effects having 95% confi-
dence intervals that do not span zero.
21
The original aim was to perform a meta-analysis
in which the data from multiple studies would be
averaged, however there was insufficient overlap in
the communication technologies (telephone, video
and internet); study designs (randomized controlled
trials vs. quasi-experimental); samples (i.e. inpatient
vs. outpatient); and treatment characteristics (e.g.
assessment intervals, outcome measures) of the
studies deemed eligible for inclusion.
21
Consequently,
the effect sizes from these studies were unsuitable to
pool.
22
Importantly, however, the calculation of
effect sizes for individual studies still provided a
standardized metric by which to compare the magni-
tude of treatment effects from different studies,
thereby providing a valuable contribution to the lit-
erature. Moreover, effect sizes provide the best
method by which to assess clinical, as opposed to
statistical, significance because unlike statistical
tests of significance they are not influenced by sam-
ple size.
21
Results
Participant characteristics
Seven independent clinical studies met all inclusion
criteria
2329
(Figure 1) and in combination they
comprised 272 participants with spinal cord injury
some (n = 52)
23,25
of whom commenced telecoun-
selling during their inpatient rehabilitation, and the
remainder (n = 220)
24,2629
in the community.
Injuries were acquired either recently or in the pre-
ceding 832 years (mean = 20.4; SD = 16.89 years).
The average age of participants was 41 years (SD =
12.2) and most were male (78%, n = 211). Five
studies recruited culturally and linguistically diverse
groups
23,25,26,28,29
(Caucasian: n = 184; 68%;
African-American: n = 75; 28%; Hispanic: n = 12;
4%). One study
29
examined the delivery of a tele-
counselling intervention that was jointly delivered
to individuals (n = 57) and family members (n =
57); however, consistent with the inclusion criteria
for this review, only the data for injured individuals
were considered here.
Dorstyn et al. 1075
Study evaluation
No study had the methodological rigor required for
the highest level of evidence (level 1). Two ran-
domly allocated participants to treatment and con-
trol conditions and were rated level 2.
28,29
Dorstyn
and colleagues
24
also used a randomized design,
but due to low statistical power this study was rated
at level 3. The remaining four studies
23,2527
were
assigned level 4 ratings due to non-randomized
treatment allocation or failure to use a control
group. Importantly, six of the seven studies
2328

were described as preliminary or pilot trials,
designed to evaluate the clinical feasibility of tele-
counselling and inform the power estimates of
subsequent research. The mean sample size was 27
participants per treatment (telecounselling) arm
(SD = 16.84) and 39 participants per control condi-
tion (SD = 20.5), although sample size varied con-
siderably across the seven studies (range: 3104).
Control conditions (N
studies
= 3)
24,28,29
included
standard outpatient care, which involved access to
multidisciplinary care (e.g. medicine, nursing, phys-
iotherapy) when needed (N
studies
= 2; N
participants
=
58),
24,28
and an information only control group
(N
studies
= 1; N
participants
= 60),
29
whereby the control
participants received the same written information
on spinal cord injury and access to community
resources as their telecounselling counterparts. In all
Potentially relevant studies identified
and screened
(n = 1084; duplicates removed)
Studies excluded off topic
(n = 43)
Telecounselling studies excludeddue
to sample characteristics, i.e. included
other chronic illness/disabilities,
>18 years (n = 39)
Studies included in systematic review
(n = 7)
Studies excluded due to intervention
characteristics, i.e. not
telecounselling
(n = 245)
Studies retrieved for more detailed
evaluation
(n = 1041)
Telecounselling studies excluded due to
design, i.e. qualitative or descriptive
stud with no treatment
evaluation (n = 7)
Studies excluded nil intervention
(n = 743)
Figure 1. Flowchart of study selection.
1076 Clinical Rehabilitation 27(12)
three studies,
24,28,29
check-in telephone or face-to-
face contact was available to control participants on
a needs basis.
Twenty different psychological and functional
measures were used to evaluate treatment effi-
cacy. These assessed depression, anxiety, stress,
quality of life, coping, hope, self-efficacy life sat-
isfaction, and aspects of community integration,
such as social and occupational functioning.
14,3046

Two studies
24,27
supplemented self-report mea-
sures with standardized clinical interviews,
namely the Mini International Neuropsychiatric
Interview
30
and Structural Clinical Interview for
Diagnostic and Statistical Manual of Mental
Disorders IV.
31
Clinical characteristics of telephone-
based counselling
While all seven studies used the telephone to some
degree, six utilized the telephone as a primary treat-
ment modality.
2326,28,29
In addition, Phillips and col-
leagues
28
compared the efficacy of two treatment
arms a telephone programme and an audio-video
counselling programme to each other and to a
usual-care control group (Table 1).
The six telephone programmes
2326,28,29
involved
preventative interventions designed to maximize
psychosocial adjustment in the early transition
period (i.e. 612 months) following injury (Table
1). In contrast, Schulz and colleagues
29
examined
the effectiveness of a telephone counselling inter-
vention 58 years following primary rehabilita-
tion. The telephone interventions were relatively
modest in scope, involving weekly or fortnightly
sessions (N
studies
= 5) or a graduated programme of
weekly, followed by fortnightly or monthly ses-
sions (N
studies
= 1) delivered over a 912 week
period (Table 1).
Telephone-based counselling offered flexible
treatment options, being utilized for different psy-
chological therapies, including supportive counsel-
ling (N
studies
= 3),
23,25,28
cognitive behaviour therapy
(N
studies
= 2)
26,29
and motivational interviewing
(N
studies
= 1),
24
and by various health professionals
(e.g. peers, nurses, social workers, psychologists)
(Table 1). The research predominantly involved
individual-based telephone interventions, with one
study
29
utilizing both individual and group formats
to deliver a psycho-educational and coping skills
programme.
Treatment efficacy and process
outcomes of telephone counselling
Cohens d effect sizes indicate that only one study
achieved a statistically meaningful treatment effect
(i.e. confidence intervals did not span zero) immedi-
ately following telephone counselling (Table 2
online).
29
This study found a moderate improve-
ment in participants ability to manage physical
health symptoms related to spinal cord injury (e.g.
muscle pain, poor sleep patterns).
29
The remaining
studies
2326,28
were associated with moderate to
large, but non-significant, short-term treatment
effects for a range of psychosocial measures.
Interestingly, based on their own calculation of
p-values, some of these studies had reported statisti-
cally significant improvements in coping skills,
24

hope,
26
social functioning
26
or cognitive ability.
23

This discrepancy (effect sizes versus statistical test-
ing: confidence intervals versus p-values) confirms
the importance of examining both clinical and sta-
tistical significance.
21
Very limited data were available to evaluate
medium-term treatment effects (i.e. 312 months
post-telecounselling). Only two studies addressed
this question,
24,28
and their effect sizes varied con-
siderably (range: d = 0.160.88; Table 2 online). In
fact, the telecounselling programme used by Phillips
et al.
28
produced the only significant positive change
in quality of life ratings that was maintained 12
months after treatment cessation. All other treat-
ment effects, although positive, were small to mod-
erate in size and non-significant when followed up
at 3 and 12 months.
Clinical outcomes were reported by five stud-
ies
2426,28,29
and were generally favourable. The
mean attrition rate was 28%, although the range was
broad (SD 23.3%; range: 335%). The cost analy-
ses provided by Dorstyn et al.
24
indicate that tele-
phone counselling is cost-efficient, with the total
treatment cost per participant estimated at AU$150.
Participants in some studies also commented that
Dorstyn et al. 1077
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Dorstyn et al. 1079
the intervention increased their sense of interper-
sonal support and reduced isolation.
23,26,28
Also interesting are the findings relating to tele-
counselling for diverse cultural groups. Participants
in Lucke and colleagues trial,
26
which targeted
Hispanics and African-Americans, reported that
telecounselling provided much-needed social sup-
port following primary spinal cord injury rehabilita-
tion. Similarly, Balcazar and colleagues
23
claimed
that matching their peer-mentors to mentees (n =
28) on the basis of race maximized improvements in
community integration (e.g. social roles and rela-
tionships). However, these qualitative data need to
be interpreted cautiously, given that both studies
examined small samples and were uncontrolled
(Table 2 online).
Clinical characteristics of video-based
counselling
Only one study examined the specific application of
video technology to counseling services in spinal
rehabilitation.
28
This study utilized videoconferenc-
ing to provide a nine-week nurse-led supportive
counselling programme to individuals with a newly
acquired injury who were not otherwise accessing
mental health services (Table 1).
Treatment efficacy and process
outcomes of video counselling
The short-term efficacy of video-based counsel-
ling could not be determined from this single trial,
because only post-intervention assessments were
conducted.
28
At 12-month follow-up, d-values
indicated that participants who completed the vid-
eocounselling programme reported significantly
more depression symptoms than those in the tele-
phone-only or standard-care conditions (Table 2
online).
28
Medium-term improvements were, however,
noted in relation to videoconferencing. Specifically,
these participants reported the lowest rehospitaliza-
tion rates, averaging 3 hospital-days per year, com-
pared with participants who received telephone
counselling (5 days per year) or standard care (8
days per year).
28
Thus, although there did not appear
to be any sustained psychological benefits from vid-
eocounselling, there appear to have been some
broader medical benefits. The authors
28
also
reported that videoconferencing was cost effective,
although formal costings were not included.
Clinical characteristics of internet-
based counselling
The study by Migliorini et al.
27
was the only evalu-
ation of an internet-delivered psychological pro-
gramme. Unlike the programmes reviewed above,
this intervention targeted a very small number of
adults (n = 3) in the chronic stage of spinal rehabili-
tation (mean time since diagnosis = 32.3 years, SD
= 11.9; range: 2745 years) but has informed a
larger scale randomized controlled trial that is cur-
rently underway.
27
The online programme, known
as ePACT, involved 10 self-administered modules,
addressing symptoms of depression and anxiety
using cognitive behavioural therapy and positive
psychology (Table 1). In addition to the standard-
ized intervention, email and telephone access to a
therapist were available, as needed.
Treatment efficacy and process
outcomes of internet counselling
Although the short-term treatment gains associated
with ePACT were moderate to large, they were not
statistically significant across the measures of
depression, anxiety and stress (Table 2 online).
27

Similarly, large to very large but non-significant
improvements were noted for injury-specific coping
strategies, including participants attitude towards
their disability and reduced sense of helplessness
(Table 2 online). Notably, these results were associ-
ated with large confidence intervals, indicating wide
variation in the treatment effects for individual cases
and rendering otherwise important treatment effects
non-significant. Nevertheless, the findings from this
study are promising, with all three participants
reporting non-clinical levels of depression, anxiety
and/or stress at the end of the intervention compared
to baseline.
27
Whether these clinical gains were
maintained over time remains unanswered because
follow-up assessments were not conducted.
1080 Clinical Rehabilitation 27(12)
Qualitative data from this study indicated that
participants considered the intervention to be con-
venient and acceptable, commenting that they
would not have otherwise accessed psychological
therapy due to the perceived stigma associated with
mental health services and/or transport access issues
related to physical disability.
27
Furthermore, partici-
pants reported that the availability of a therapist by
telephone contributed to the programmes appeal.
27

However, there was a high attrition rate, with 63%
(n = 5) of eligible participants withdrawing from the
programme due to conflicting time commitments or
a perception that they did not require psychological
support.
27
Consequently, these results should be
treated with caution.
Discussion
Results from the seven independent clinical stud-
ies
2329
included in this review are clinically promis-
ing, with telecounselling contributing to significant
short-term improvements in health symptoms for
individuals with spinal cord injuries.
29
However, the
longer term impact of telecounselling has yet to be
adequately evaluated. The few trials
24,28
that report
this data suggest that early treatment gains may not
be maintained.
Where available, the clinical outcome data sug-
gest that telecounselling can improve psychological
outcomes of this population in a time- and cost-
efficient way, with the majority of treatments (N
studies

= 5)
2326,28
delivered within the first three months
post discharge from primary rehabilitation.
However, these findings can only be considered ten-
tative: based on a small number of studies, most of
which utilized non-randomized and uncontrolled
trials (N
studies
= 4)
23,2527
with highly variable sample
sizes (sample size range: 3104).
Our results are largely consistent with those of
other telecounselling trials within chronic illness and
disability groups, which report that telephone- and
video-based counselling services provide an effec-
tive and efficient treatment option for managing
mood disorders in individuals with traumatic brain
injuries
47
or chronic medical conditions.
48,49

Telecounselling may facilitate routine psychological
follow-up of individuals with a newly acquired
injury, who often experience increased apprehension
and distress during the transition from primary reha-
bilitation.
4,28
However, additional information on the
delivery-related outcomes of telecounselling is
needed, with very few cost analyses currently avail-
able. These cost analyses need to include the total
amount of therapist contact time per participant, and
investigate clinician and patient attitudes towards the
different technology-assisted counselling services.
4
Given these potential clinical benefits, it may
be argued that telecounselling can provide com-
munity-based practitioners more opportunity to
efficiently monitor patients long-term psychologi-
cal health.
50
This is consistent with current models
of mental healthcare, favouring a biopsychosocial
approach in which periodic maintenance sessions
allow psychological problems to be monitored and
treated before they become more serious and
established.
1,50,51
Although the findings of this review are both
interesting and important, some limitations need to
be considered. First, the research designs that were
used by the current studies limit any causal state-
ments that can be made about the effectiveness of
telecounselling.
21
In particular, Balcazar et al.,
23

Ljungberg et al.,
25
Lucke et al.
26
and Migliorini
et al.
27
did not use control groups, consequently
spontaneous recovery/decline and the impact of hav-
ing some on-going contact (regardless of its content)
could not be assessed. A suitable control condition
might involve delivering the same tele-programme
in a face-to-face setting, which would control for
both of these effects while also enabling an evalua-
tion of whether the intervention content can be suc-
cessfully delivered via telecommunication
technology. Indeed this design has been adopted
among other telecounselling trials targeting, care-
givers of individuals with a spinal cord injury,
52
but
was only adopted by one reviewed study.
29
Moreover,
the four quasi-experimental studies
23,2527
all used
relatively small samples, limiting their statistical
power to detect significant effects.
19,21
Future trials
should therefore compute post-hoc power analy-
ses.
53
Estimates of treatment effects (i.e. Cohens d),
and tests of statistical significance (i.e. confidence
intervals for d-values), should also be routinely
Dorstyn et al. 1081
Clinical messages
Telecounselling has potential to provide a
community-based method by which to man-
age and treat a range of psychological issues
following spinal cord injury; thus reducing
depression and improving quality of life.
Telecounselling is practical to deliver and
generally accepted by consumers.
Further research using randomized controlled
trials and well controlled case studies are
needed to confirm the efficacy of telecounsel-
ling in the psychosocial care of people with
spinal cord injury and to define the minimum
requirements needed to achieve efficacy (e.g.
number and duration of sessions).
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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