Embedding Telerehabilitation in Practice: Adapting NeuroRehabilitation OnLine (NROL) for a New Context Through Co-Production and Implementation Science Knowledge

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Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Embedding Telerehabilitation in Practice: Adapting NeuroRehabilitation OnLine (NROL) for a New Context Through Co-Production and Implementation Science Knowledge View ORCID Profile Suzanne Ackerley , Amy Bastow , Ruth Witham , Louise Jackson , Adam Partington , Helen Vernon , View ORCID Profile Louise A Connell doi: https://doi.org/10.1101/2025.10.13.25337875 Suzanne Ackerley 1 Faculty of Health & Medicine, Health Innovation Campus, Lancaster University , United Kingdom 2 Rakehead Rehabilitation Centre, Burnley General Teaching Hospital, East Lancashire Hospitals NHS Trust , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Suzanne Ackerley Amy Bastow 3 Cheshire West and Chester Integrated Community Stroke and Neuro Service, Countess of Chester and Cheshire and Wirral Partnership NHS Trust , United Kingdom 4 Cheshire and Mersey Integrated Stroke Delivery Network , United Kingdom 5 Adult Speech and Language Therapy Team, Countess of Chester NHS Foundation Trust, Countess of Chester Hospital , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ruth Witham 3 Cheshire West and Chester Integrated Community Stroke and Neuro Service, Countess of Chester and Cheshire and Wirral Partnership NHS Trust , United Kingdom 4 Cheshire and Mersey Integrated Stroke Delivery Network , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Louise Jackson 4 Cheshire and Mersey Integrated Stroke Delivery Network , United Kingdom 6 Liverpool and South Sefton Early Supported Discharge Team, University Hospitals Liverpool Group , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: l.connell2{at}lancaster.ac.uk Adam Partington 2 Rakehead Rehabilitation Centre, Burnley General Teaching Hospital, East Lancashire Hospitals NHS Trust , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Helen Vernon 2 Rakehead Rehabilitation Centre, Burnley General Teaching Hospital, East Lancashire Hospitals NHS Trust , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Louise A Connell 1 Faculty of Health & Medicine, Health Innovation Campus, Lancaster University , United Kingdom 2 Rakehead Rehabilitation Centre, Burnley General Teaching Hospital, East Lancashire Hospitals NHS Trust , United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Louise A Connell Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Background Delivering recommended intensity of neurorehabilitation remains a challenge, with telerehabilitation offering one solution. NeuroRehabilitation OnLine (NROL) is a multidisciplinary, group-based telerehabilitation model embedded within one region in England, showing promise and alignment with healthcare strategic priorities. The importance of scaling successful evidence-informed practices is recognised, however careful adaptation is required to ensure contextual fit and sustainability. This study describes the adaptation of NROL for implementation in a new context. Methods The four-step ADAPT guidance was applied with previously identified implementation strategies to guide the adaptation of NROL from Region 1 to Region 2. Adaptation activities were co-produced. Contextual factors were detailed using the Consolidated Framework for Implementation Research and Intervention Sustainability Assessment Tool. The adapted innovation was described using the TIDieR-Rehab checklist. Results NROL was successfully adapted for Region 2. Step 1 confirmed strategic fit but identified barriers including workforce, infrastructure and resource. Led by an adaptation team and supported by a learning collaborative, Step 2 responded to barriers, retaining core components while tailoring role configuration and materials. Step 3 demonstrated feasibility and acceptability through piloting and phased integration, and improved fit within service pathways. Step 4 focused on sustainment, supported by training, stakeholder engagement, and reporting. Discussion This study offers a transferable approach for scale-up, providing an example of context-sensitive adaptation to a new region, demonstrating how frameworks and co-production can support the adaptation of telerehabilitation models. This example has potential wider use for researchers and implementers tasked with delivering impact, though highlights the effort and resource needed. PLAIN LANGUAGE SUMMARY Stroke and neurological rehabilitation services often struggle to provide enough therapy due to staffing and system challenges. Digital delivery of rehabilitation offers one solution. NeuroRehabilitation OnLine (NROL) is a programme that offers live, group therapy and peer-support remotely for people recovering neurological conditions. It has been delivered within one region of England, showing promise and alignment with healthcare priorities. The importance of spreading successful, evidenced practices is recognised, but requires careful consideration to ensure they fit well and can be continued in the new location. This study explains how NROL was adapted for use in a second region. The four-step process called the ADAPT guidance was used with previously identified practical strategies to guide changes to NROL for Region 2. Relevant staff from both regions worked together to ensure the programme met local needs. Evidenced tools were used to understand what made the new region different and to describe the adapted programme clearly. NROL was successfully adapted for Region 2. Step 1 confirmed NROL alignment with healthcare priorities but highlighted challenges including limited staffing and resource. Led by a small team, Step 2 responded to challenges. The core parts of NROL were kept the same, like live group therapy and technology support, but changes were made to the staffing structures and materials. Step 3 tested the changes with small pilot groups and used feedback to improve the programme before wider roll-out and refinement. Step 4 focused on maintaining and reporting the adapted programme. This work offers a transferable approach for spreading evidenced health innovations, providing an example of local needs driving relevant change, and demonstrating how tools and teamwork can support the adaptation process of digital health programmes. This example has potential wider use for researchers and clinical staff tasked with delivering change, though highlights the effort and resource needed. INTRODUCTION Delivering recommended intensity of neurorehabilitation remains a persistent global challenge, 1 – 3 with workforce shortages, geographic disparities, and fragmented care pathways. Telerehabilitation may help address these gaps, offering comparable outcomes to face-to-face therapy and can increase access to specialist rehabilitation through flexible, remote delivery. 4 , 5 NeuroRehabilitation OnLine (NROL) provides real-time, multidisciplinary, group-based, telerehabilitation with dedicated technology assistance. 6 It combines targeted therapy with peer-support aiming to enhance access and opportunity for neurorehabilitation while making efficient use of the workforce. Recent publications provide a comprehensive description of NROL’s components, 6 and successful integration within the National Health Service (NHS) stroke and neurorehabilitation services in one region of England (Lancashire and South Cumbria). 7 , 8 These highlight NROL’s alignment with national guidelines, 9 , 10 healthcare strategic priorities, 11 – 13 and its adaptability to local contexts. Scaling evidence-informed practices, like NROL, is increasingly recognised as a strategic objective for health systems. The World Health Organization reports scale-up as “the deliberate effort to increase the impact of successfully tested health interventions so as to benefit more people and to foster policy and program development on a lasting basis”. 14 Adaptation is a key part of successful scale-up, with careful attention required to how well an intervention will fit and function in the new context, including considering infrastructure, workforce, readiness, patient needs and sustainment. Despite the importance of reporting intervention adaptations, a recent review found many studies lack description in full. 15 The ADAPT guidance was developed to provide a systematic, stepwise approach to support structured and transparent adaptation. 16 Alongside ADAPT, TIDieR checklists provide structured tools for describing interventions in sufficient detail to support replication and fidelity. 17 – 19 Despite their availability, to the authors knowledge no studies have formally applied both ADAPT and TIDieR comprehensively to describe innovation adaptation in the context of telehealth. Combining complementary implementation science knowledge with the ADAPT guidance can help navigate the complexities of transferring interventions across diverse health systems. 16 , 20 The value of concurrent use of implementation science knowledge was also highlighted by Connell et al. (2025), using NROL as an example. 21 They used the ADAPT guidance and the Consolidated Framework for Implementation Research (CFIR), 22 in conjunction with the updated Medical Research Council framework for the development and evaluation of complex interventions 23 to develop, adapt, implement and evaluate NROL as a scalable regional innovation. Of note, incorporation of the CFIR enabled identification of Expert Recommendations for Implementing Change (ERIC) implementation strategies (through the CFIR-ERIC matching tool) to support implementation efforts, including for the adaptation phase. Building on prior work, this paper focuses on adapting NROL for delivery in a new context, a second NHS region within England (Cheshire and Merseyside). Using the ADAPT guidance and TIDieR-Rehab checklist, the adaptation process is documented along with contextual considerations and applied implementation strategies. This publication aims to offer considerations for therapy staff, service leads, and digital health implementers seeking to adapt or scale other telehealth models. METHODS The process was iterative, and grounded in co-production principles with the adaptation of NROL applying complementary implementation science knowledge. Ethical approval was not required for this descriptive study. Stakeholder co-production A key feature of NROL’s development, implementation and adaptation has been co-production, with key stakeholders (including therapy staff, service leads, patients, clinical-academics, and members of the stroke and neurorehabilitation community) actively shaping the innovation. This collaborative model supports contextual relevance, clinician buy-in, and patient engagement; factors known to influence implementation success and sustainability. 24 A coalition was built between Region 2 (Cheshire and Merseyside) and Region 1 (Lancashire and South Cumbria), facilitated by established connectivity between their regional stroke networks and a shared purpose to improve neurorehabilitation provision, with NROL identified as one possible solution. The adaptation of NROL for Region 2 was shaped by co-production principles emphasising shared power and mutual respect. 25 , 26 Individuals contributed their perspectives and skills with all forms of knowledge valued equally. Fostering reciprocal relationships, prioritising relationship-building and maintaining open communication, ensured the project met the needs of all stakeholders. Positionality statement The author team comprises clinical-academic staff, and operational, service and regional leads, embedded within the stroke and neurorehabilitation services across both regions involved in this study. Our direct involvement in the development, delivery, and adaptation of NROL provided deep contextual insight and facilitated co-production. We acknowledge that our dual roles, as implementers and evaluators, may have influenced interpretation. To mitigate bias, diverse stakeholders were engaged throughout and structured frameworks used to guide and document the process. Process for adapting NROL Adaptation of NROL in Region 2 used a multi-tool approach, with selection of tools informed by complementary strengths in structuring adaptation processes; capturing contextual influences, ensuring transparent reporting, and fit within the larger programme of work previously described. 21 The ADAPT guidance was the overarching tool. 16 NROL was adapted to new contexts informed by four key steps, as outlined in Figure 1 . This guidance was particularly suited to the current project, which aimed to scale-up an existing innovation to a new region while maintaining fidelity to its core components. Adaptation was supported using previously identified ERIC implementation strategies. 21 ERIC strategies help inform actions to support effective implementation. 27 Strategies focused on stakeholder interrelationships, training and education, and evaluation and iteration. 28 Download figure Open in new tab Figure 1. Process for adapting NeuroRehabilitation OnLine (NROL) to new contexts, informed by the ADAPT guidance, 16 Consolidated Framework for Implementation research (CFIR), 22 Intervention Scalability Assessment Tool (ISAT), 29 and reported with the TIDieR-Rehab checklist. 18 Purple boxes = Steps of the ADAPT guidance. Blue boxes = Expected outcomes from each step. Pink boxes = ERIC implementation strategies applied. 21 In Step 1, the CFIR and ISAT supported contextual analysis. CFIR offered a comprehensive lens to systematically detail and compare contextual factors (innovation characteristics, outer setting, inner setting, characteristics of individuals) across regions. 22 The ISAT provided a structured assessment of context-specific factors influencing readiness for scale-up, covering 2 parts: A-Background contextual information and B-Implementation and sustainability considerations (see Figure 2 for Domain headings). 29 Domains were scored between 0 (not at all) and 3 (to a large extent) by consensus and summarised via radar plot. Download figure Open in new tab Figure 2. Intervention Scalability Assessment Tool (ISAT) radar plot depicting factors influencing Region 2’s readiness for NROL implementation. Domains A1-5 focus on background contextual information and B1-5 on implementation and sustainability. Each domain is scored for readiness between 0 (not at all) to 3 (to a large extent), therefore facilitators are depicted nearer the outside of the circle and barriers more centrally. In Step 4, the TIDieR-Rehab checklist, 18 with the Telehealth extension, 19 was used to report the adapted innovation. The TIDieR-Rehab extends the original TIDieR checklist 17 to better capture the complexity of rehabilitation interventions. Content for the TIDieR-Rehab checklist was systematically updated from Region 1’s TIDieR checklist, 6 with region specific content (new/adapted/removed) clearly marked. RESULTS Step 1: Assess rationale for intervention, and consider intervention-context fit of existing innovation Establish rationale, and consider identified innovation and its core components Region 2 faced persistent challenges in delivering the recommended levels of stroke rehabilitation, compounded by workforce shortages and fragmented pathways, and anticipated increased prevalence. 30 Regional Stroke Rehab Leads from the region’s stroke delivery network identified NROL as a promising solution, informed by exposure at meetings, conferences and literature. Map similarities/difference with original region and consider intervention-context fit Table 1 shows the comparison of the similarities and differences between Region 1 (original) and Region 2 (new) and identifies the barriers and facilitators to NROL implementation. This work was led by coalition members: two designated Regional Stroke Rehab Leads (RW,LJ) from Region 2, and the NROL Operational Lead (AP) and Clinical-Academic staff (SA,LC) from Region 1. View this table: View inline View popup Download powerpoint Table 1: Comparison of contextual factors between original and new regions, including barriers and facilitators to NROL implementation Key differences included that Region 2 was larger (population and number of organisations) and had a stroke-specific focus, with future ambition to extend to other neurological conditions. While most eligible organisations (10/14) showed interest in NROL, four opted not to participate due to competing priorities, or hesitancy around new initiatives and technology. Another difference was the absence of an established clinical-academic partnership for the project, contrasting Region 1 where such a partnership was central. Region 2, however, felt they benefitted from Regional Stroke Rehab Lead initiation and leadership, as they had existing knowledge of the ‘people and processes’ covering all organisations and recent technology project engagement, which could help expedite upfront implementation efforts (e.g. stakeholder engagement, governance approvals). Key similarities included recognition that NROL had strong strategic alignment, 11 , 12 a significant facilitator. Both regions identified lack of workforce and resource, and varied service-and infra-structure across organisations as barriers for implementation. There was a preference to maintain dedicated NROL operational roles, however funding was needed to recruit staff. Two Technology Support roles were prioritised due to existing availability of therapy assistance within the workforce and the size of the region. Region 2 recognised NROL’s potential to optimise workforce use and drew on Region 1’s solutions to service challenges. Figure 2 depicts the factors influencing Region 2’s context-specific readiness for NROL implementation. ISAT scoring showed NROL was seen as a valuable innovation, though not a panacea (A2). Funding needs (A5), infrastructure gaps (B4) and long-term sustainability were identified as areas for response, notably highlighting need for dedicated NROL operational staff. Step 2: Plan for and undertake adaptations Accessing necessary resource In response to the identified barriers, seed funding was secured through a national health funding body enabling recruitment of the dedicated NROL operational team (including Lead, AB) and a modest budget for equipment and materials. Form adaptation team and create learning collaborative An adaptation team was formed comprising Regional Stroke Rehab Leads (n = 2, Region 2), NROL Operational teams (n = 8, both regions), and Clinical-Academic staff (n = 2, Region 1). The adaptation team met regularly to iteratively adapt NROL for Region 2. Adaptations were informed by Step 1, ongoing regional, organisational and service needs, and stakeholder feedback. The new region viewed the involvement of the original region positively. A regional NROL learning collaborative was established, and was iterated over time, to support shared decision-making and co-production. This included existing workforce (regional technology project members, therapy staff, local administrators and decision-makers), patients, and members of the stroke community (Stroke Association Support Coordinators) from Region 2, alongside the adaptation team and Region 1’s Stroke and Neurorehabilitation Service Manager (HV). Adapt innovation, materials and procedures Adaptations were planned and undertaken to achieve the best fit of the NROL core and peripheral components within Region 2, and key components are summarised in Figure 3 . The remaining peripheral components were all maintained and are described in the TIDieR-Rehab checklist (Supplementary file). Responsive adaptations are detailed in Step 3. Download figure Open in new tab Figure 3: Core and key peripheral components for NROL adapted for Region 2. Key peripheral components are detailed under TIDieR Rehab sections. Planned adaptations (P) determined during ADAPT step 2 and responsive adaptations (R) during ADAPT step 3. *Remaining peripheral components were maintained and are detailed in the TIDieR-Rehab checklist (supplementary file). All NROL core components were retained. The description of one core component was modified to clarify the model was intended for use in ‘neurorehabilitation’ rather than specifying stroke and neuro-rehabilitation. Key NROL peripheral components were aligned with the relevant TIDieR-Rehab section headings, and categorised as either ‘maintained’ or ‘adaptations’. The basic structure of NROL was maintained (i.e. How/How much). Planned adaptations were made to the ‘Who’ NROL was intended for and ‘Who provided’, and included offering NROL only to patients receiving stroke rehabilitation, and adjustment to operational team and leadership role configuration. Planned adaptations were co-produced to ‘What’ materials with the learning collaborative, including updating key documents (shared by Region 1), gaining relevant governance approvals, and expanding NROL visibility with additional branding materials. Recruit staff to deliver innovation, identify and prepare champions Region 2 NROL leaders in collaboration with the learning collaborative, recruited NROL champions and group facilitators from high-readiness organisations. Innovation champions were key in supporting governance, advocacy, and troubleshooting. Facilitators received targeted training, including technology and procedural sessions, and Region 1 observations. Meetings were held for delivery staff, champions, and leaders, with updates shared to wider teams. Step 3: Plan for and undertake piloting and evaluation of the adapted innovation Ensure readiness Innovation readiness was confirmed by the Region 2 NROL operational team and champions once the infrastructure, training, equipment, regional approvals and staffing were in place. Organisational readiness required local approvals, staff training and baseline service data to provide a reference point for evaluation. Conduct small tests of change Pilot testing was initially conducted at group-level through two pilot groups: a fatigue management group and a speech and language therapy group. These allowed assessment of acceptability and practicality. Staff and patient feedback informed iterative refinements to processes, logistics and group content. Phased integration of interested organisations Following successful group-level piloting, block-level piloting began. This involved phased integration of organisations with high-readiness into 6-week NROL blocks running seven groups (Cognitive education, Emotional adjustment, Dysarthria, Aphasia, Balance and Mobility, Upper limb, Community peer-support). All interested organisations were integrated. Seven organisations (8 teams) adopted the programme initially, one further organisation (3 teams) was added in the second block and two more (2 teams) in the third. Five teams remained pending. The learning collaborative expanded to ensure regional representation. Evaluation ran alongside implementation and centred on reviewing key peripheral components, using routinely collected clinical and service-delivery metrics and stakeholder feedback and was consistent with Region 1 evaluation. Region 2 NROL leaders co-produced summaries for stakeholders, including Region 1. Document and classify responsive adaptations Regular review meetings allowed iterative tailoring. Responsive adaptations are summarised in Figure 3 and included in the TIDieR-Rehab checklist (Supplementary file). Key responsive adaptations included tailoring to fit within the pathway such as supported inpatient participation and extended time in the community-based service when appropriate. Existing workforce influenced group content and facilitator roles (e.g. Allied health staff trained to lead well-being group). IT access issues prompted new resolution procedures, and breakout rooms (new functionality) were introduced, with procedures shared with Region 1. Step 4: Implement and maintain the adapted innovation Conduct ongoing training Findings from pilot testing and evaluation informed ongoing training. Staff were encouraged to observe live NROL sessions, in both regions, to support referral decisions and experiential learning. Cross-region observation fostered shared learning and networking. New staff were introduced to NROL during orientation. New group facilitators received targeted training in both technology and procedures. General information about NROL was regularly disseminated by local and regional NROL staff and champions. Consider sustainment Sustainment was considered from the out-set and involved continued dialogue with wide stakeholders, including decision-makers. Presentations were made to organisation transformation and improvement leaders. Advantages of the programme were identified and included staffing efficiencies, increased therapy contact, and savings in travel time, cost, and carbon emissions. A co-produced blueprint outlined full implementation and evaluation plans. Further fixed-term funding was secured, providing time to develop a business case for long-term regional investment. NROL delivery is ongoing. Report adapted innovation described using TIDieR-Rehab checklist The adapted NROL model for Region 2 was documented using the TIDieR-Rehab checklist, updated from Region 1’s version 6 to reflect adaptations (see supplementary file). This co-production process involved the Region 2 learning collaborative to ensure accuracy and resonance. DISCUSSION This study illustrates how the NROL telerehabilitation model was adapted for a new region using a structured, co-produced process. Core components were retained, while adaptations tailored role configuration, materials and fit within service pathways. The ADAPT guidance alongside implementation science knowledge provided a systematic approach to planning, piloting, implementing, and reporting the adapted model. The adaptation process was initiated and led by Region 2 Stroke Rehab leaders who had relationships with local organisations and deep community knowledge facilitating implementation efforts. Involving the original region (Region 1) accelerated implementation by transferring tacit knowledge, tested materials, and credibility. While the ADAPT guidance warns working with innovation developers could risk fixed views or power imbalances, 16 this did not materialise. The new region viewed the involvement positively, likely due to co-production principles, open dialogue, and mutual recognition. This approach provided a trusted environment to explore viable adaptations to meet local needs. Creative solutions were fostered. Adjustments to role configurations and recruitment reflected the wider workforce landscape and leveraged diverse skill-sets. For example, Region 2 prioritised recruitment for two NROL technology support roles. The opportunity was harnessed to establish a patient-facing technology job creation, and capitalised on dual skill-sets (e.g. assistant workforce), that could help sustain digital practice. Another example, in response to a system-wide lack of psychology staff, involved allied health staff being trained to deliver a well-being group with oversight from a clinical psychologist. This role agility aligns with the recent UK stroke guideline emphasis on what needs to be done rather than who does it. 9 Creative solutions were also found for promoting NROL access, such as optimising fit within the service pathways (e.g. early exposure through inpatient participation) and introducing new materials (e.g. QR-coded keyring to share a patient information video). 31 It may be that these adaptations actively enhanced joint decision-making between therapist and patient about service delivery preferences. 32 Frameworks were applied selectively to help navigate the complexities of transferring across regions. The ADAPT guidance structured the adaptation process; CFIR and ISAT supported contextual analysis; and TIDieR-Rehab enabled transparent reporting. The process was non-linear, with evolving priorities. While these tools added rigour, they also introduced complexity. Overlapping constructs and terminology created challenges, requiring interpretive effort. 23 , 33 Co-production, including clinical-academic involvement, helped translate conceptual guidance into practice-relevant actions. 24 , 34 , 35 Insights are summarised in the “Key Considerations for Adaptation” box, which may be helpful for researchers and implementers seeking to scale telehealth models. Key Considerations for Adaptation Embed co-production and shared learning: Engage stakeholders throughout. Retain core functions, use creative solutions to meet needs: Tailor staffing models, materials and fit within pathway. Use structured guidance flexibly: Apply frameworks to support planning and contextual fit. Anticipate complexity: Expect evolving roles and shifting priorities. Plan for sustainment early: Co-produce a blueprint and highlight efficiencies. A limitation was that the project focused on a single adaptation case within well-connected national health system regions. Findings may not generalise to less resourced or less connected contexts. The use of embedded teams and qualitative feedback limits external validation but offers rich, practice-based insights. Further evaluation is needed to assess sustainability, cost-effectiveness, and equity. This paper highlights the complexity and effort required to adapt and sustainably scale interventions, a challenge often under-recognised in healthcare and funding agendas. It showed the value of working across silos and with the original region to share information, evaluation and know-how, including with decision-makers. Working as a cross-regional learning health system provided a means to accelerate the integration of NROL in the new context. 36 The resource demands of thorough adaptation underscore the need for sustainable, bottom-up funding models. The results affirm that strategic adaptation must address clinician, patient, service, and system-level factors, with clinical-academic partnerships a potential mechanism for translating frameworks into scalable, context-sensitive tools. 37 Conclusion This study offers a transferable approach for scale-up, providing a real-world example of adapting a complex telerehabilitation model using structured implementation science knowledge. It offers practical insights into how core components can be maintained while adapting elements to new contexts. As digital models expand, structured and context-sensitive adaptation grounded in co-production and implementation science approaches, will be essential for sustainable scale-up across diverse health systems. These findings may inform broader efforts in digital transformation, workforce redesign, and service innovation beyond telerehabilitation. Data Availability All data produced in the present study are available upon reasonable request to the authors STATEMENTS AND DECLARATIONS Declaration of Conflicting Interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: NROL implementation in Cheshire and Merseyside was supported by NHS England Stroke Quality Improvement for Rehabilitation (SQUIRE) Catalyst funding (2023-2024). The funders had no role in writing the manuscript. Ethical considerations Not applicable. Consent to participate Not applicable. Supplementary file 1: TIDieR-Rehab Checklist for NeuroRehabilitation OnLine (NROL) at Cheshire and Merseyside The TIDieR-Rehab checklist 1 was used, informed by the Telehealth extension 2 , to report the adapted NROL innovation at Cheshire and Merseyside (new region, Region 2). Content was systematically updated from the TIDieR checklist described for Lancashire and South Cumbria (original region, Region 1) 3 : The TIDieR checklist content for NROL at Lancashire and South Cumbria was reallocated into the sections of the TIDieR-Rehab checklist. Each TIDieR-Rehab checklist section was updated to reflect components maintained and adapted with edits clearly marked to enable comparison: - Bold font for new/adapted content for NROL at Cheshire and Merseyside - Strikethrough for removed content - Italics for additions/amendments relevant to both regions View this table: View inline View popup Supplementary Table 1: TIDieR-Rehab Checklist for NeuroRehabilitation OnLine (NROL) at Cheshire and Merseyside ACKNOWLEDGMENTS We gratefully acknowledge the contributions of staff, patients and carers from the participating stroke and neurorehabilitation services within the Cheshire and Merseyside and Lancashire and South Cumbria Integrated Care Systems, along with their affiliated Integrated Stroke and Neuro Delivery Networks and the Stroke Association. Our thanks also go to the charity SameYou for their ongoing partnership. REFERENCES 1. ↵ Kings College London . Stroke Sentinel National Audit Programme (SSNAP) . 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