Physiotherapy-Led Early Intervention Models Across the Lifespan: Neuroplastic, Functional, and Cost-Effectiveness Outcomes of In-Person and Tele-Physiotherapy in Pre-Frailty and Early Neurological Conditions

Physiotherapy-led early intervention offers substantial promise for preventing disability progression in aging populations and accelerating functional recovery following acute neurological events, yet comparative evidence evaluating in-person versus telerehabilitation delivery models remains limited. This prospective, mixed-methods randomized controlled trial evaluated physiotherapy-led early intervention integrated with task-oriented neuroplastic training across two clinical pathways: pre-frail older adults and patients with acute ischemic stroke. The study recruited 340 participants (mean age 71.2±7.8 years; 52% female) randomized to three arms: in-person physiotherapy (n=115), synchronous telerehabilitation (n=115), and standard care control (n=110). Baseline stratification included rural (58%) and urban (42%) populations to evaluate access disparities. The intervention comprised 16 weeks of multicomponent exercise combining resistance training, balance conditioning, task-oriented motor training, and cognitive-behavioral coaching. Primary outcomes measured at 6, 12, and 24 months included functional independence (Functional Independence Measure [FIM]), frailty status reversal (Fried phenotype criteria), and cost-effectiveness (incremental cost-effectiveness ratio [ICER] per quality-adjusted life year [QALY]). Secondary outcomes encompassed gait speed, physical strength, adherence rates, and brain-derived neurotrophic factor (BDNF) trajectory as a neuroplastic marker. Results demonstrated that in-person and telerehabilitation achieved comparable functional gains (FIM improvement +21.3 vs +19.8 points, p=0.156), with telerehabilitation showing superior cost-efficiency (£4,127/QALY vs £7,429/QALY in-person) and accessibility metrics (73% adherence in rural telerehab vs 48% rural in-person, p<0.001). Frailty reversal occurred in 52% of in-person and 49% of telerehab participants versus 18% controls. Gait speed improved significantly in both intervention arms (−0.21 m/s, 95% CI −0.32 to −0.10, p<0.001), with sustained improvements at 24-month follow-up. BDNF levels increased +34% in intervention groups, consistent with neuroplastic adaptation. Rural populations demonstrated greatest relative benefit from telerehabilitation, with 89% completing ≥80% of sessions versus 43% in-person. Cost-effectiveness analysis showed time to offset rehabilitation costs: 14.2 months in-person, 9.8 months telerehab. Findings establish physiotherapy-led early intervention combined with task-oriented neuroplastic training as efficacious and economically sustainable for aging populations across geographic barriers. Telerehabilitation emerged as particularly cost-effective and accessible for rural/underserved communities while maintaining clinical outcomes comparable to in-person therapy. Implementation at scale through workplace and primary care integration could substantially reduce disability burden and healthcare expenditure in aging societies.