Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial

Telestroke’s Role Through the COVID-19 Pandemic and Beyond

Purpose of review

The goal of this paper is to discuss the role and utilization of telestroke services through the COVID-19 pandemic and to suggest future directions to sustain and increase patients’ access to stroke expertise.

Recent findings

Telestroke is an innovative and effective tool that has been shown to improve access, quality of care, and outcomes of patients with acute stroke syndromes in resource-limited areas for the last two decades. The COVID-19 pandemic posed a significant challenge and strained healthcare systems worldwide, but it created novel and unique opportunities to expand and increase the utilization of telehealth and telestroke services to deliver personalized healthcare across the continuum of stroke care outside of traditional settings. This rapid and widespread increase in telestroke use was facilitated by the removal of many legislative and regulatory barriers which have limited patients’ access to stroke expertise for many years.

Summary

As the public health emergency ends, there exists a unique opportunity to optimize and expand upon the pandemic-related rapid growth of telestroke care. Optimal utilization of telehealth and telestroke services will depend on maintaining and improving required infrastructure, laws, and regulations, particularly those governing reimbursement and licensing.

Recent trends in telerehabilitation of stroke patients: A narrative review

BACKGROUND: Stroke is the main reason for disabilities worldwide leading to motor dysfunction, spatial neglect and cognitive problems, aphasia, and other speech-language pathologies, reducing the life quality. To overcome disabilities, telerehabilitation (TR) has been recently introduced. OBJECTIVE: The aim of this review was to analyze current TR approaches for stroke patients’ recovery. METHODS: We searched 6 online databases from January 2018 to October 2021, and included 70 research and review papers in the review. We analyzed TR of 995 individuals, which was delivered synchronously and asynchronously. RESULTS: Findings show TR is feasible improving motor function, cognition, speech, and language communication among stroke patients. However, the dose of TR sessions varied significantly. We identified the following limitations: lack of equipment, software, and space for home-based exercises, insufficient internet capacity and speed, unavailability to provide hands on guidance, low digital proficiency and education, high cognitive demand, small samples, data heterogeneity, and no economic evaluation. CONCLUSIONS: The review shows TR is superior or similar to conventional rehabilitation in clinical outcomes and is used as complementary therapy or as alternative treatments. More importantly, TR provides access to rehabilitation services of a large number of patients with immobility, living in remote areas, and during COVID-19 pandemic or similar events.

New technologies promoting active upper limb rehabilitation after stroke: an overview and network meta-analysis

INTRODUCTION

The primary aim of this work was to summarize and compare the effects of active rehabilitation assisted by new technologies (virtual reality [VR], robot-assisted therapy [RAT] and telerehabilitation [TR)) on upper limb motor function and everyday living activity during the subacute and chronic phases of stroke. The secondary aims were to compare the effects of these technologies according to the intervention design (in addition to or in substitution of conventional therapy), the duration of active rehabilitation and the severity of patients' motor impairments.

EVIDENCE ACQUISITION

Several databases, namely PubMed, Scopus, Embase and Cochrane Library, were searched. Studies were included if they were meta-analyses with a moderate to high level of confidence (assessed with AMSTAR-2) that compared the effects of a new technology promoting active rehabilitation to that of a conventional therapy program among patients with stroke. Network meta-analyses were conducted to compare the effects of the new technologies.

EVIDENCE SYNTHESIS

Eighteen different meta-analyses were selected and fifteen included in the quantitative analysis. In total these 15 meta-analyses were based on 189 different randomized controlled trials. VR (SMD≥0.25; P<0.05), RAT (SMD≥0.29; P≤0.29) and TR (SMD≥-0.08; P≤0.64) were found to be at least as effective as conventional therapy. During the subacute phase, RAT's greatest effect was observed for patients with severe-moderate impairments whereas VR and TR's greatest effects were observed for patients with mild impairments. During the chronic phase, the highest effects were observed for patients with mild impairments, for all studies technologies. Network meta-analyses showed that VR and RAT were both significantly superior to TR in improving motor function during the chronic phase but revealed no significant difference between VR, RAT and TR effectiveness on both motor function (during the subacute phase) and activity (during both chronic and subacute phase).

CONCLUSIONS

This overview provides low-to-moderate evidence that rehabilitation assisted with technologies are at least as effective as conventional therapy for patients with stroke. While VR and RAT seem to be more efficient during the subacute phase, all technologies seem to be as efficient as one another in the chronic phase.

Optimising rehabilitation and recovery after a stroke

Stroke can cause significant disability and impact quality of life. Multidisciplinary neurorehabilitation that meets individual needs can help to optimise recovery. Rehabilitation is essential for best quality care but should start early, be ongoing and involve effective teamwork. We describe current stroke rehabilitation processes, from the hyperacute setting through to inpatient and community rehabilitation, to long-term care and report on which UK quality care standards are (or are not) being met. We also examine the gap between what stroke rehabilitation is recommended and what is being delivered, and suggest areas for further improvement.

Measured and Perceived Effects of Upper Limb Home-Based Exergaming Interventions on Activity after Stroke: A Systematic Review and Meta-Analysis

After discharge from the hospital to home, stroke patients may experience weakness and reduced movement in their hemiparetic arms that limits their ability to perform daily activities. Therapists can use exercise games (exergames) to maintain functional abilities and daily use of the arm at home. A systematic review and meta-analysis was conducted to determine the efficiency of upper limb home-based rehabilitation, using exergaming on activity abilities in stroke.&nbsp;Randomized controlled trials were reviewed in the CENTRAL, MEDLINE, CINAHL, EMBASE, and SCOPUS online databases. Clinical measures of observation and self-reporting were studied in post-intervention and follow-up. Nine studies were included in this systematic review (535 participants). The Physiotherapy Evidence Database (PEDro) score was 6.6/10 (SD 1.0, range 5-8), indicating good quality. This systematic review and meta-analysis showed that upper limb home-based exergaming interventions were no more effective in terms of activity than conventional therapy after stroke, according to the observational and subjective assessments in post-intervention and follow-up. Using this same approach, future studies should focus on evaluating home-based exergames through subgroup analysis to be able to propose recommendations.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Telemedicine in epilepsy and encephalitis: previous research and indication guidelines in Korea

Telemedicine is an emerging field of medicine that has become more important during the coronavirus disease 2019 (COVID-19) pandemic era and is being studied actively in various medical fields. In neurology, the introduction of telemedicine is accelerating worldwide under the label of teleneurology. So far, few studies have been conducted on telemedicine for patients with epilepsy. In nonmetropolitan areas, video-based clinics have been demonstrated to be effective for seizure control, and smartphone-based diagnosis has also been confirmed to be accurate. Indeed, after the onset of the COVID-19 pandemic, telemedicine has been used to treat patients with epilepsy around the world. Few studies have examined the use of telemedicine for patients with autoimmune encephalitis. One showed that telephone-based evaluation is sufficient to assess the cognitive reserve of leucine-rich glioma inactivated-1-antibody encephalitis patients, thereby diagnosing their dementia. Telephone-based outpatient clinics are temporarily permitted under Korean medical law, and telemedicine can be attempted for clinically stable patients with epilepsy in Korea. In addition, patients with autoimmune encephalitis in stable or improving status may also be candidates for treatment with telemedicine. This review presents evidence for the safety and efficacy of telemedicine to treat epilepsy and encephalitis patients and discusses indication guidelines. Based on our literature review and current Korean medical law, we suggest tentative guidelines for telemedicine in the fields of epilepsy and autoimmune encephalitis.

Physical therapists' perceptions of and satisfaction with delivering telerehabilitation sessions to patients with knee osteoarthritis during the Covid-19 pandemic: Preliminary study

OBJECTIVE

This preliminary study was conducted to explore physical therapists' (PT) perceptions of and satisfaction with delivering telerehabilitation sessions to patients with knee osteoarthritis during the Covid-19 pandemic.

STUDY DESIGN

An exploratory preliminary study using an internet-based survey followed by focus group sessions.

METHODS

A programme of sessions was administered by 12 PTs from the Physical Therapy Department at Prince Sultan Military Medical City. An internet-based survey containing 17 statements was completed by the PTs.

RESULTS

With regard to telephone-delivered care, four statements related to patients' privacy, programme convenience, safe patients time and money achieved consensus agreement (≥75% agreed or strongly agreed), there was majority agreement (≥50% of respondents agreed or strongly agreed) with seven of the statements regarding the effectiveness, affordability and safety of the programme, but there was no consensus with regard to the remaining five statements. In addition, most of the participants (84.6%) believed that a telephone consultation should cost 25% or 50% less than a face-to-face session.

CONCLUSION

Despite the lack of physical contact with patients, the PTs agreed that telerehabilitation would offer patients an easy method of being prescribed a therapeutic programme, save time and money, and maintain patient privacy. Further, the PTs reported barriers and suggested adaptations for this method of service delivery.

Impact of Early Rehabilitation on Outcomes in Patients With Acute Ischemic Stroke After Endovascular Treatment

Background

This study aims to examine the effects of early rehabilitation on functional outcomes in patients with acute ischemic stroke treated with endovascular treatment (EVT).

Methods

Eligible patients with large vessel occlusion stroke treated with EVT, who received early rehabilitation or standard care treatment during hospitalization, were enrolled in a multicenter registration, prospective observational study, a registration study for Critical Care of Acute Ischemic Stroke After Recanalization. Early rehabilitation was defined as rehabilitation interventions initiated within 1 week after acute stroke. The primary outcome was the favorable functional outcome (defined as modified Rankin Scale scores of 0 to 2) at 90 days. Independent association between early rehabilitation and the primary outcome was investigated using multivariable logistic regression in the entire sample and in subgroups.

Results

A total of 1,126 patients (enrolled from July 2018 to May 2019) were included in the analyses, 273 (24.2%) in the early rehabilitation group and 853 (75.8%) in the standard care group. There was no significant difference in favorable functional outcomes at 90 days between the two groups (45.4 vs. 42.6%, p = 0.41). Patients in the early rehabilitation group had a lower death rate within 90 days compared with the standard care group (6.2 vs. 20.5%, p < 0.01). The multivariable logistic regression analyses showed that the early rehabilitation was not significantly associated with the favorable functional outcome at 90 days (adjusted odds ratio, 1.01 [95% CI, 0.70–1.47]; p = 0.95). There was no significant difference between subgroups in the favorable functional outcome at 90 days. No significant interaction was found between subgroups.

Conclusions

Patients with stroke receiving early rehabilitation had a lower death rate. However, these clinically meaningful effects of early rehabilitation did not show on functional outcome at 90 days in patients with large vessel occlusion stroke treated with EVT.

Registration

URL: http://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.

Factors influencing the delivery of telerehabilitation for stroke: A systematic review

Objective

Despite the available evidence regarding effectiveness of stroke telerehabilitation, there has been little focus on factors influencing its delivery or translation from the research setting into practice. There are complex challenges to embedding telerehabilitation into stroke services and generating transferable knowledge about scaling up and routinising this service model. This review aimed to explore factors influencing the delivery of stroke telerehabilitation interventions, including platforms, technical requirements, training, support, access, cost, usability and acceptability.

Methods

MEDLINE, EMBASE, CINAHL, Web of Science and Cochrane Library and Central Registry of Clinical Trials were searched to identify full-text articles of randomised controlled trials (RCTs) and protocols for RCTs published since a Cochrane review on stroke telerehabilitation services. A narrative synthesis was conducted, providing a comprehensive description of the factors influencing stroke telerehabilitation intervention delivery.

Results

Thirty-one studies and ten protocols of ongoing studies were included. Interventions were categorised as synchronous telerehabilitation (n = 9), asynchronous telerehabilitation (n = 11) and tele-support (n = 11). Telephone and videoconference were the most frequently used modes of delivery. Usability and acceptability with telerehabilitation were high across all platforms, although access issues and technical challenges may be potential barriers to the use of telerehabilitation in service delivery. Costs of intervention delivery and training requirements were poorly reported.

Conclusions

This review synthesises the evidence relating to factors that may influence stroke telerehabilitation intervention delivery at a crucial timepoint given the rapid deployment of telerehabilitation in response to the COVID-19 pandemic. It recommends strategies, such as ensuring adequate training and technical infrastructure, shared learning and consistent reporting of cost and usability and acceptability outcomes, to overcome challenges in embedding and routinising this service model and priorities for research in this area.

Influence of Core-Stability Exercises Guided by a Telerehabilitation App on Trunk Performance, Balance and Gait Performance in Chronic Stroke Survivors: A Preliminary Randomized Controlled Trial

Stroke is one of the main causes of disability. Telerehabilitation could face the growing demand and a good strategy for post-stroke rehabilitation. The aim of this study is to examine the possible effects of therapeutic exercises performed by an App on trunk control, balance, and gait in stroke survivors. A preliminary 12-week randomized controlled trial was developed. Thirty chronic stroke survivors were randomly allocated into two groups. Both groups performed conventional physiotherapy, in addition to, the experimental group (EG) had access to a telerehabilitation App to guide home-based core-stability exercises (CSE). Trunk performance was measured with the Spanish-Trunk Impairment Scale (S-TIS 2.0) and Spanish-Function in Sitting Test. Balance and gait were measured with Spanish-Postural Assessment Scale for Stroke patient, Berg Balance Scale and an accelerometer system. In EG was observed an improvement of 2.76 points in S-TIS 2.0 (p = 0.001). Small differences were observed in balance and gait. Adherence to the use of the App was low. CSE guided by a telerehabilitation App, combined with conventional physiotherapy, seem to improve trunk function and sitting balance in chronic post-stroke. Active participation in the rehabilitation process should be increased among stroke survivors. Further confirmatory studies are necessary with a large sample size.

Gamified Neurorehabilitation Strategies for Post-stroke Motor Recovery: Challenges and Advantages

Abstract

Purpose of Review

Stroke is the leading cause of permanent motor disability in the United States (US), but there has been little progress in developing novel, effective strategies for treating post-stroke motor deficits. The past decade has seen the rapid development of many promising, gamified neurorehabilitation technologies; however, clinical adoption remains limited. The purpose of this review is to evaluate the recent literature surrounding the adoption and use of gamification in neurorehabilitation after stroke.

Recent Findings

Gamification of neurorehabilitation protocols is both feasible and effective. Deployment strategies and scalability need to be addressed with more rigor. Relationship between engaged time on task and rehabilitation outcomes should be explored further as it may create benefits beyond repetitive movement.

Summary

As gamification becomes a more common and feasible way of delivering exercise-based therapies, additional benefits of gamification are emerging. In spite of this, questions still exist about scalability and widespread clinical adoption.

Making Best Use of Home-Based Rehabilitation Robots

Large-scale clinical trials have shown that rehabilitation robots are as affective as conventional therapy, but the cost-effectiveness is preventing their uptake. This study investigated whether a low-cost rehabilitation robot could be deployed in a home setting for rehabilitation of people recovering from stroke (n = 16) and whether clinical outcome measures correlated well with kinematic measures gathered by the robot. The results support the feasibility of patients independently using the robot with improvement in both clinical measures and kinematic data. We recommend using kinematic data early in an intervention to detect improvement while using a robotic device. The kinematic measures in the assessment task (hits/minute and normalised jerk) adequately pick up changes within a four-week period, thus allowing the rehabilitation regime to be adapted to suit the user’s needs. Estimating the long-term clinical benefit must be explored in future research.

Data-Driven Classification of Human Movements in Virtual Reality-Based Serious Games: Preclinical Rehabilitation Study in Citizen Science

BACKGROUND

Sustained engagement is essential for the success of telerehabilitation programs. However, patients' lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science-based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR).

OBJECTIVE

This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert.

METHODS

In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users' range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software's response to their movements. During calibration, the time series of the users' movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements.

RESULTS

The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%).

CONCLUSIONS

Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation.

Evaluation of a Digitally Guided Self-Rehabilitation Device Coupled With Telerehabilitation Monitoring in Patients With Parkinson Disease (TELEP@RK): Open, Prospective Observational Study

Background

Parkinson disease is a neurodegenerative disease causing a progressive loss of autonomy. This requires long-term rehabilitation care. Currently, new technologies are being developed for use in daily life, and there is a progressive implementation of telerehabilitation.

Objective

The aim of this study (the TELEP@RK study) is to evaluate the uses of a digital self-rehabilitation device in patients with Parkinson disease and their independent physiotherapists on the scale of a health territory.

Methods

A total of 10 independent physiotherapists and 31 patients with Parkinson disease were followed for 1 year to evaluate the use of a telerehabilitation tool (digital tablet and inertial sensor) via questionnaires of the Unified Theory of Acceptance and Use of Technology (UTAUT). The questionnaires were submitted to participants at 0, 2, and 12 months from the start of follow-up. The averages of the scores of the different determinants and constructs of the UTAUT questionnaires were compared at the different follow-up times.

Results

Among professionals, the averages of the various determinants were generally high at the beginning of the study with an average (out of 5) performance expectancy of 4.19, effort expectancy of 3.88, social influence of 3.95, facilitating conditions of 4, and intention to use of 3.97. These averages decreased over time.

Conclusions

Acceptability, acceptance, and appropriation of the tool were very high among the physiotherapists as well as the patients, despite the tool’s lack of evolution during the study. In the current health care context, these results allow us to envision a new organization of the care pathway for patients with chronic diseases, with the increased use of new technologies associated with telecare.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

Telehealth for rehabilitation and recovery after stroke: State of the evidence and future directions

AIMS

The aim of this rapid review and opinion paper is to present the state of the current evidence and present future directions for telehealth research and clinical service delivery for stroke rehabilitation.

METHODS

We conducted a rapid review of published trials in the field. We searched Medline using key terms related to stroke rehabilitation and telehealth or virtual care. We also searched clinical trial registers to identify key ongoing trials.

RESULTS

The evidence for telehealth to deliver stroke rehabilitation interventions is not strong and is predominantly based on small trials prone to Type 2 error. To move the field forward, we need to progress to trials of implementation that include measures of adoption and reach, as well as effectiveness. We also need to understand which outcome measures can be reliably measured remotely, and/or develop new ones. We present tools to assist with the deployment of telehealth for rehabilitation after stroke.

CONCLUSION

The current, and likely long-term, pandemic means that we cannot wait for stronger evidence before implementing telehealth. As a research and clinical community, we owe it to people living with stroke internationally to investigate the best possible telehealth solutions for providing the highest quality rehabilitation.

Feasibility, acceptability and effects of a group pelvic floor muscle telerehabilitation program to treat urinary incontinence in older women

Introduction

Urinary incontinence (UI) is one of the most prevalent health concerns in women age 65 and over. The recommended first-line treatment for UI is individual pelvic floor muscle training (PFMT). However, healthcare systems worldwide are unable to meet the demand for this resource-intensive approach. Recently, the Group Rehabilitation Or IndividUal Physiotherapy (GROUP) trial showed that group-based PFMT was not inferior to individual PFMT to treat UI in older women, despite using fewer resources. This study aims to assess the feasibility, acceptability and effects on UI-related symptoms and associated quality of life (QoL) of an online adaptation of the GROUP program (teleGROUP) for UI in older women.

Methods and analysis

This pilot study will involve the recruitment of 32 older women with UI. Participants' attendance to online sessions, adherence to weekly home exercises, and side effects, in addition to the physiotherapist's fidelity to the program delivery will be collected to evaluate the program's feasibility. Participants' dropout rates, reasons for dropout, satisfaction and usability scores will be collected to evaluate the program's acceptability for participants. A survey will evaluate the program's acceptability for the physiotherapists. Additionally, at the end of the study, qualitative semi-structured interviews and focus groups will investigate further feasibility and acceptability. To measure the effects of teleGROUP, number of weekly leakages and percentage reduction will be the primary outcomes.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.

Implementation of a Framework for Telerehabilitation in Clinical Care Across the Continuum During COVID-19 and Beyond

ABSTRACT

The COVID-19 pandemic has propelled an unprecedented global implementation of telemedicine and telerehabilitation as well as its integration into the healthcare system. Here, we describe the clinical implementation of the A3E framework for the deployment of telerehabilitation in the inpatient and outpatient rehabilitation continuum by addressing accessibility, adaptability, accountability, and engagement during the COVID-19 pandemic. By using an organized, coordinated, and stratified approach, we increased our telerehabilitation practice from 0 to more than 39,000 visits since the pandemic began. Learning from both the successes and challenges can help address the need to increase access to rehabilitation services even beyond the COVID-19 pandemic.

Neuroplasticity at Home: Improving Home-Based Motor Learning Through Technological Solutions. A Review

Background: Effective science-based motor rehabilitation requires high volume of individualized, intense physical training, which can be difficult to achieve exclusively through physical 1-on-1 sessions with a therapist. Home-based training, enhanced by technological solutions, could be a tool to help facilitate the important factors for neuroplastic motor improvements.

Objectives: This review aimed to discover how the inclusion of modern information and communications technology in home-based training programs can promote key neuroplastic factors associated with motor learning in neurological disabilities and identify which challenges are still needed to overcome.

Methods: We conducted a thorough literature search on technological home-based training solutions and categorized the different fundamental approaches that were used. We then analyzed how these approaches can be used to promote certain key factors of neuroplasticity and which challenges still need to be solved or require external personalized input from a therapist.

Conclusions: The technological approaches to home-based training were divided into three categories: sensory stimuli training, digital exchange of information training, and telerehabilitation. Generally, some technologies could be characterized as easily applicable, which gave the opportunity to promote flexible scheduling and a larger overall training volume, but limited options for individualized variation and progression. Other technologies included individualization options through personalized feedback that might increase the training effect, but also increases the workload of the therapist. Further development of easily applicable and intelligent solutions, which can return precise feedback and individualized training suggestions, is needed to fully realize the potential of home-based training in motor learning activities.

Home-Based Therapy After Stroke Using the Hand Spring Operated Movement Enhancer (HandSOME II)

We have developed a passive and lightweight wearable hand exoskeleton (HandSOME II) that improves range of motion and functional task practice in laboratory testing. For this longitudinal study, we recruited 15 individuals with chronic stroke and asked them to use the device at home for 1.5 h per weekday for 8 weeks. Subjects visited the clinic once per week to report progress and troubleshoot problems. Subjects were then given the HandSOME II for the next 3 months, and asked to continue to use it, but without any scheduled contact with the project team. Clinical evaluations and biomechanical testing was performed before and after the 8 week intervention and at the 3 month followup. EEG measures were taken before and after the 8 weeks of training to examine any recovery associated brain reorganization. Ten subjects completed the study. After 8 weeks of training, functional ability (Action Research Arm Test), flexor tone (Modified Ashworth Test), and real world use of the impaired limb (Motor Activity Log) improved significantly (p < 0.05). Gains in real world use were retained at the 3-month followup (p = 0.005). At both post-training and followup time points, biomechanical testing found significant gains in finger ROM and hand displacement in a reaching task (p < 0.05). Baseline functional connectivity correlated with gains in motor function, while changes in EEG functional connectivity paralleled changes in motor recovery. HandSOME II is a low-cost, home-based intervention that elicits brain plasticity and can improve functional motor outcomes in the chronic stroke population.

The differential impact of the COVID-19 pandemic on healthcare utilization disruption for community-dwelling individuals with and without acquired brain injury

•

All groups experienced notable disruption in health care utilization.

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Disruption in care for traumatic brain injury or mental health was associated with decreased health-related quality of life.

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Telehealth was a viable alternative to in-person visits.

•

Telehealth is not a panacea and should be adopted using a nuanced approach.

Objective

To delineate health care disruption for individuals with acquired brain injury (ABI) during the peak of the pandemic and to understand the impact of health care disruption on health-related quality of life (HRQoL).

Design

Cross-sectional survey.

Setting

General community.

Participants

Volunteer sample of adults with traumatic brain injury (TBI; n=33), adults with stroke (n=66), and adults without TBI or stroke (n=108) with access to the internet and personal technology (N=207).

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Participants with TBI and stroke reported high rates of disruption in care specific to their diagnosis (53%-54.5%), while participants across all groups reported disruption for major medical care (range, 68.2%-80%), general health care (range, 60.3%-72.4%), and mental health care (range, 31.8%-83.3%). During the pandemic, participants with TBI and stroke used telehealth for care specific to their diagnosis (40.9%-42.4%), whereas all participants used telehealth for major medical care (range, 50%-86.7%), general health care (range, 31.2%-53.3%), and mental health care (range, 53.8%-72.7%). Disruption in TBI or stroke care and type of ABI explained 27.1% of the variance in HRQoL scores (F_2,95=16.82, P<.001, R²=0.262), and disruption in mental health care explained 14.8% of the variance (F_1,51=8.86, P=.004, R²=0.148).

Conclusions

Individuals with and without ABI experienced pronounced disruption in health care utilization overall. However, individuals who experienced a disruption in care specific to TBI or mental health care were most vulnerable to decreased HRQoL. Telehealth was a viable alternative to in-person visits for individuals with and without ABI, but limitations included difficulty with technology, difficulty with comprehensive examination, and decreased rapport with providers.

Case Managers' Perceptions About Synchronous Telerehabilitation versus Clinic-based Physical Therapy Services for People with Spinal Cord Injury

People with spinal cord injury (SCI) require extensive rehabilitation to maximize independence and quality of life. Much of this treatment occurs on an outpatient basis through telerehabilitation or clinic-based services. Synchronous telerehabilitation has become increasingly common in recent years, but many professionals remain reluctant to suggest it when clinic-based services are available. This survey study explored case managers' perceptions regarding advantages and disadvantages of synchronous telerehabilitation versus clinic-based physical therapy services for people with SCI. Respondents were 89 case managers responsible for service provision coordination. Results showed a significant preference for clinic-based rather than telerehabilitation physical therapy services. Relative experience with the two service delivery models significantly affected perceptions. Only facilitating travel convenience differed significantly as a reason for recommending one service delivery method over the other. The incongruity between perceptions about synchronous telerehabilitation and existing literature about its cost, convenience, and efficacy suggests a need for additional education.

Telerehabilitation—A Viable Option for the Recovery of Post-Stroke Patients

As the number of stroke survivors is continuously growing, with an important number suffering from consequent functional deficits, the rehabilitation field is facing more complex demands. Technological progress gives us the opportunity to remotely assist patients while they exercise at home through telerehabilitation (TR), addressing the problems of limited medical resources and staff, difficult transportation, or living a long distance from rehabilitation centers. In addition, TR is a way to provide continuity in long-term post-stroke recovery during the COVID-19 pandemic, which limits traveling and human interaction. While the implementation of TR is increasing, the biggest challenges are to raise patients’ acceptability of the new method and their motivation and engagement during the program. In this review, we aimed to find methods to address these challenges by identifying the patients who benefit the most from this therapy and efficiently organizing the space and technology used for telerehabilitation. User-friendly technologies and devices along with therapists’ constant support and feedback are some of the most important aspects that make TR an efficient intervention and an alternative to conventional therapy.

Public attitudes to the use of remote data collection in clinical research

Background/aims

Coronavirus Disease 2019 (COVID-19) has presented an unprecedented challenge for delivering clinical research. The use of technology-assisted data collection for clinical research is desirable for many practitioners, but the acceptability of use in the general population has not been assessed. The aim of the study was to assess attitudes towards using technology-assisted remote methods in the delivery of clinical research in the UK and to understand the barriers to taking part in research with respect to both remote assessments and traditional research methods across different age ranges.

Methods

The study was conducted as an online anonymous survey with a 4-part questionnaire, between August 2020 and December 2020. Participants living in the UK aged 18 years and above were eligible to take part.

Results

A total 351 completed the survey and are included in the data analysis. In all age groups, participants identified that use of online assignments, video calls and telephone calls would make them more likely to take part in clinical research. Overall, the largest barrier to taking part in research was time commitments and timing of the appointment. COVID-19 has had a small, positive influence on the confidence of using technology in the general population.

Conclusions

The study found that there is a large interest in taking part in research using online, telephone and video call appointments, which could facilitate research delivery in light of ongoing COVID-19-related restrictions and also improve the accessibility and inclusivity of research.

Kinect-based rapid movement training to improve balance recovery for stroke fall prevention: a randomized controlled trial

Background

Falls are more prevalent in stroke survivors than age-matched healthy older adults because of their functional impairment. Rapid balance recovery reaction with adequate range-of-motion and fast response and movement time are crucial to minimize fall risk and prevent serious injurious falls when postural disturbances occur. A Kinect-based Rapid Movement Training (RMT) program was developed to provide real-time feedback to promote faster and larger arm reaching and leg stepping distances toward targets in 22 different directions.

Objective

To evaluate the effectiveness of the interactive RMT and Conventional Balance Training (CBT) on chronic stroke survivors’ overall balance and balance recovery reaction.

Methods

In this assessor-blinded randomized controlled trial, chronic stroke survivors were randomized to receive twenty training sessions (60-min each) of either RMT or CBT. Pre- and post-training assessments included clinical tests, as well as kinematic measurements and electromyography during simulated forward fall through a “lean-and-release” perturbation system.

Results

Thirty participants were recruited (RMT = 16, CBT = 14). RMT led to significant improvement in balance control (Berg Balance Scale: pre = 49.13, post = 52.75; P = .001), gait control (Timed-Up-and-Go Test: pre = 14.66 s, post = 12.62 s; P = .011), and motor functions (Fugl-Meyer Assessment of Motor Recovery: pre = 60.63, post = 65.19; P = .015), which matched the effectiveness of CBT. Both groups preferred to use their non-paretic leg to take the initial step to restore stability, and their stepping leg’s rectus femoris reacted significantly faster post-training (P = .036).

Conclusion

The RMT was as effective as conventional balance training to provide beneficial effects on chronic stroke survivors’ overall balance, motor function and improving balance recovery with faster muscle response.

Trial registration: The study was registered at Clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT03183635, NCT03183635) on 12 June 2017.

Telerehabilitation perceptions and experiences of physiatrists in a lower-middle-income country during the COVID-19 pandemic

Background

The COVID‐19 pandemic catalyzed the adoption of telerehabilitation in various health care settings. However, there was neither a preexisting national guideline in the Philippines nor an internationally agreed upon standard for telerehabilitation. The literature lacks nationwide studies documenting how physiatrists perceived and experienced telerehabilitation during the pandemic.

Objective

To determine the perceptions and experiences of physiatrists in the Philippines regarding telerehabilitation.

Design

Online survey originally developed by the authors with inputs from local experts in telehealth or telerehabilitation.

Setting

Nationwide, involving board‐certified physiatrists practicing in the Philippines.

Participants

Fellows of the Philippine Academy of Rehabilitation Medicine (PARM) (N = 259) with Internet access.

Main Outcome Measures

Self‐reported telerehabilitation knowledge, skills, and experience; key concerns; preferred clients, service offerings, and methods (technology, duration, charging).

Results

The respondents (n = 161; 62.2% response rate) had a mean age of 48.1 ± 9.6 years, were mostly female (57.8%), and mostly practiced in private hospitals and urban settings. The majority reported inadequate telerehabilitation knowledge (61.5%), skills (58.4%), and experience (72.1%). The most common sources of telerehabilitation knowledge were colleagues (52.8%), PARM (51.6%), and telemedicine‐related websites (41.6%). Most of the respondents preferred to conduct telerehabilitation with former patients over new ones and prescribe telerehabilitation programs for physical, occupational, psychological, and speech‐language therapy but not for swallowing therapy. Videoconferencing was the most common telerehabilitation method. More than half of the respondents charged lesser fees for telerehabilitation compared to in‐person consultations. Although the majority recognized the need for telerehabilitation, their key concerns included the lack of thorough patient examination and medicolegal liability issues.

Conclusion

Despite their limited baseline knowledge, skills, and experience regarding telerehabilitation, many physiatrists in the Philippines learned to adopt this service delivery method during the pandemic. Their perceptions and experiences could be used in formulating practice‐based guidelines and strategies to improve the conduct of telerehabilitation in the country.

Critical Period After Stroke Study (CPASS): A phase II clinical trial testing an optimal time for motor recovery after stroke in humans

Restoration of postinjury brain function is a signal neuroscience challenge. Animal models of stroke recovery demonstrate time-limited windows of heightened motor recovery, similar to developmental neuroplasticity. However, no equivalent windows have been demonstrated in humans. We report a randomized controlled trial applying essential elements of animal motor training paradigms to humans, to determine the existence of an analogous sensitive period in adults. We found a similar sensitive or optimal period 60 to 90 d after stroke, with lesser effects ≤30 d and no effect 6 mo or later after stroke. These findings prospectively demonstrated the existence of a sensitive period in adult humans. We urge the provision of more intensive motor rehabilitation within 60 to 90 d after stroke onset.

Restoration of human brain function after injury is a signal challenge for translational neuroscience. Rodent stroke recovery studies identify an optimal or sensitive period for intensive motor training after stroke: near-full recovery is attained if task-specific motor training occurs during this sensitive window. We extended these findings to adult humans with stroke in a randomized controlled trial applying the essential elements of rodent motor training paradigms to humans. Stroke patients were adaptively randomized to begin 20 extra hours of self-selected, task-specific motor therapy at ≤30 d (acute), 2 to 3 mo (subacute), or ≥6 mo (chronic) after stroke, compared with controls receiving standard motor rehabilitation. Upper extremity (UE) impairment assessed by the Action Research Arm Test (ARAT) was measured at up to five time points. The primary outcome measure was ARAT recovery over 1 y after stroke. By 1 y we found significantly increased UE motor function in the subacute group compared with controls (ARAT difference = +6.87 ± 2.63, P = 0.009). The acute group compared with controls showed smaller but significant improvement (ARAT difference = +5.25 ± 2.59 points, P = 0.043). The chronic group showed no significant improvement compared with controls (ARAT = +2.41 ± 2.25, P = 0.29). Thus task-specific motor intervention was most effective within the first 2 to 3 mo after stroke. The similarity to rodent model treatment outcomes suggests that other rodent findings may be translatable to human brain recovery. These results provide empirical evidence of a sensitive period for motor recovery in humans.

Effectiveness of telerehabilitation on short-term quality of life of patients after esophageal cancer surgery during COVID-19: a single-center, randomized, controlled study

Background

The occurrence of postoperative complications may lead to delayed recovery and a decline in physical function in the first 3 months after esophagectomy. The outbreak of COVID-19 imposed physical and emotional obstacles for traditional face-to-face rehabilitation. Meanwhile, the effectiveness of telerehabilitation remained unknown. In this study, we aimed to investigate the effectiveness of telerehabilitation.

Methods

A cohort of 86 patients who received minimally invasive esophagectomy between September 2020 and January 2021 was randomly allocated into two groups. The telerehabilitation group received additional online consulting and training, including (I) precautions for nutritional support; (II) swallowing function training; (III) respiratory function training; (IV) guidance and feedback on matters such as patient's current vital signs, wound status, medication, and sleep status. The primary outcome was the change of quality of life (QOL) of each patient at 3 months after surgery.

Results

No serious adverse events were observed in either group. The telerehabilitation group showed significant improvements in pain using the OLQ-C30 scale (P<0.001), and in choking using the QLQ-OES18 scale (P<0.001). The comparison of the QLQ-C30 and QES-18 score changes at three months after discharge revealed that nearly all aspects in the telerehabilitation group displayed more score changes with significant changes in the appetite loss and pain part (P<0.001 and P<0.05, respectively). The score changes in QLQ-OES18 revealed significant improvement in swallowing saliva (P<0.05), as well slight improvements in choking, dry mouth, taste, and cough without significance.

Conclusions

Our study demonstrated that telerehabilitation was at least an important supplement to traditional face-to-face consulting and training for patients after esophageal cancer surgery during the COVID-19 period.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100049186.

Tele-rehabilitation of upper-extremity hemiparesis after stroke: Proof-of-concept randomized controlled trial of in-home Constraint-Induced Movement therapy

BACKGROUND

Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT.

OBJECTIVE

Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis.

METHODS

Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants' homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab.

RESULTS

Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d' = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d' = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants' perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = -0.1, 95% CI = -1.3-1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome.

CONCLUSIONS

This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Determining minimally clinically important differences for outcome measures in patients with chronic motor deficits secondary to traumatic brain injury

OBJECTIVE

To determine minimally clinically important differences (MCIDs) for Disability Rating Scale (DRS), Fugl-Meyer Upper Extremity Subscale (FM-UE), Fugl-Meyer Lower Extremity Subscale (FM-LE), and Fugl-Meyer Motor Scale (FMMS) in patients with chronic motor deficits secondary to traumatic brain injury (TBI).

METHODS

Retrospective analysis from the 1-year, double-blind, randomized, surgical sham-controlled, Phase 2 STEMTRA trial (NCT02416492), in which patients with chronic motor deficits secondary to TBI (N = 61) underwent intracerebral stereotactic implantation of modified bone marrow-derived mesenchymal stromal (SB623) cells. MCIDs for DRS, FM-UE, FM-LE, and FMMS were triangulated with distribution-based, anchor-based, and Delphi panel estimates.

RESULTS

Triangulated MCIDs were: 1) -1.5 points for the Disability Rating Scale; 2) 6.2 points for the Fugl-Meyer Upper Extremity Subscale; 3) 3.2 points for the Fugl-Meyer Lower Extremity Subscale; and 4) 8.4 points for the Fugl-Meyer Motor Scale.

CONCLUSIONS

For the first time in the setting of patients with chronic motor deficits secondary to TBI, this study reports triangulated MCIDs for: 1) DRS, a measure of global outcome; and 2) Fugl-Meyer Scales, measures of motor impairment. These findings guide the use of DRS and Fugl-Meyer Scales in the assessment of global disability outcome and motor impairment in future TBI clinical trials.

Wearable myoelectric interface enables high-dose, home-based training in severely impaired chronic stroke survivors

Background

High‐intensity occupational therapy can improve arm function after stroke, but many people lack access to such therapy. Home‐based therapies could address this need, but they don’t typically address abnormal muscle co‐activation, an important aspect of arm impairment. An earlier study using lab‐based, myoelectric computer interface game training enabled chronic stroke survivors to reduce abnormal co‐activation and improve arm function. Here, we assess feasibility of doing this training at home using a novel, wearable, myoelectric interface for neurorehabilitation training (MINT) paradigm.

Objective

Assess tolerability and feasibility of home‐based, high‐dose MINT therapy in severely impaired chronic stroke survivors.

Methods

Twenty‐three participants were instructed to train with the MINT and game for 90 min/day, 36 days over 6 weeks. We assessed feasibility using amount of time trained and game performance. We assessed tolerability (enjoyment and effort) using a customized version of the Intrinsic Motivation Inventory at the conclusion of training.

Results

Participants displayed high adherence to near‐daily therapy at home (mean of 82 min/day of training; 96% trained at least 60 min/day) and enjoyed the therapy. Training performance improved and co‐activation decreased with training. Although a substantial number of participants stopped training, most dropouts were due to reasons unrelated to the training paradigm itself.

Interpretation

Home‐based therapy with MINT is feasible and tolerable in severely impaired stroke survivors. This affordable, enjoyable, and mobile health paradigm has potential to improve recovery from stroke in a variety of settings.

Clinicaltrials.gov: NCT03401762.

Developing a Framework for Designing and Deploying Technology-Assisted Rehabilitation After Stroke: A Qualitative Study

OBJECTIVE

Many unmet rehabilitation needs of patients with stroke can be addressed effectively using technology. However, technological solutions have not yet been seamlessly incorporated into clinical care. The purpose of this pilot study was to examine how to bridge the gaps between the recovery process, technology, and clinical practice to impact stroke rehabilitation meaningfully.

DESIGN

Semistructured interviews were performed using a grounded theory approach with purposive sampling of 17 diverse expert providers in acute care, inpatient, and outpatient stroke rehabilitation settings. Common themes were identified from qualitative analyses of the transcribed conversations to develop a guiding framework from the emerging concepts.

RESULTS

Four core themes emerged that addressed major barriers in stroke rehabilitation and technology-assisted solutions to overcome these barriers: (1) accessibility to quality rehabilitation, (2) adaptability to patient differences, (3) accountability or compliance with rehabilitation, and (4) engagement with rehabilitation.

CONCLUSIONS

The results suggest a four-pronged framework, the A3E framework that stands for Accessibility, Adaptability, Accountability, and Engagement, to comprehensively address existing barriers in providing rehabilitation services. This framework can guide technology developers and clinicians in designing and deploying technology-assisted rehabilitation solutions for poststroke rehabilitation, particularly using telerehabilitation.

Digital health in stroke medicine: what are the opportunities for stroke patients?

PURPOSE OF REVIEW

The European Stroke Organisation published a European Stroke Action Plan (SAP-E) for the years 2018-2030. The SAP-E addresses the entire chain of care from primary prevention through to life after stroke. Within this document digital health tools are suggested for their potential to facilitate greater access to stroke care. In this review, we searched for digital health solutions for every domain of the SAP-E.

RECENT FINDINGS

Currently available digital health solutions for the cerebrovascular disease have been designed to support professionals and patients in healthcare settings at all stages. Telemedicine in acute settings has notably increased the access to tissue plasminogen activator and thrombectomy whereas in poststroke settings it has improved access to rehabilitation. Moreover, numerous applications aim to monitor vital signs and prescribed treatment adherence.

SUMMARY

SAP-E with its seven domains covers the whole continuum of stroke care, where digital health solutions have been considered to provide utility at a low cost. These technologies are progressively being used in all phases of stroke care, allowing them to overcome geographical and organizational barriers. The commercially available applications may also be used by patients and their careers in various context to facilitate accessibility to health improvement strategies.

Computer Game Assisted Task Specific Exercises in the Treatment of Motor and Cognitive Function and Quality of Life in Stroke: A Randomized Control Study

OBJECTIVES

Computer game assisted task specific exercises (CGATSE) are rehabilitation gaming systems (RGS) used in stroke rehabilitation to facilitate patient performance of high intensity, task based, repetitive exercises aiming to enhance neuroplasticity. CGATSE maybe an appealing option in home based rehabilitation of stroke patients, especially during the COVID-19 pandemic. This study aimed to determine the effects of CGATSE on hemiplegic arm-hand function, cognitive function and quality of life in stroke.

MATERIALS AND METHODS

Thirty stroke patients were randomized into two groups. All participants received twenty sessions of physical therapy. In addition, the therapy group undertook thirty minutes of CGATSE using the Rejoyce gaming system; while the control group undertook thirty minutes of occupational therapy (OT). Motor function was evaluated before and after treatment using the Fugl Meyer upper extremity (FMUE), Brunnstrom stages of stroke recovery (BSSR) arm and hand. The CGATSE group also completed the Rejoyce arm hand function test (RAHFT). Cognitive function was evaluated using the mini mental state examination, Montreal Cognitive Assessment (MoCA) and Stroke Specific Quality of Life (SS-QOL) scale.

RESULTS

The FMUE, BSSR arm and SSQOL improved in both groups (p < 0.05). BSSR of the hand improved only in the CGATSE group (p = 0.024). RAHFT scores improved in the CGATSE group (p = 0.008). MoCA scores significantly improved in the control group (p = 0.008).

CONCLUSIONS

CGATSE may be beneficial in providing continuation of care after stroke, especially during the Covid-19 pandemic when home based rehabilitation options are becoming increasingly important. Benefits of CGATSE in improving cognitive function is less clear. RGS aimed at improving motor function may be compared to gaming systems designed to target cognitive development and more detailed higher cortical function deficit tests can be used as outcome measures.

Rapid Implementation of Telerehabilitation for Pediatric Patients During Covid-19

The COVID-19 pandemic necessitated a sudden limitation of in-person outpatient occupational and physical therapy services for most patients at a large, multisite pediatric hospital located in the Midwest, United States. To ensure patient and staff safety, the hospital rapidly shifted to deliver most of these services via telerehabilitation. The purposes of this study were to (1) describe the rapid implementation of telerehabilitation during the COVID-19 pandemic, (2) describe the demographic characteristics of patients who continued in-person services and those who received telerehabilitation, and (3) evaluate the therapists' perceptions of telerehabilitation for physical and occupational therapy. Most of the children (83.4% of n=1352) received telerehabilitation services. A family was more likely to choose to continue in-person visits if their child was <1-year-old, had a diagnosis of torticollis, received serial casting, or was post-surgical. Occupational and physical therapy therapists (n=9) completed surveys to discern their perceptions of the acceptability of telerehabilitation, with most reporting that telerehabilitation was as effective as in-person care.

Telerehabilitation in Italy During the COVID-19 Lockdown: A Feasibility and Acceptability Study

This study examined the feasibility and acceptability of a telerehabilitation program during the COVID-19 pandemic in a sample of adult patients with physical disabilities. Of the twenty-three patients enrolled, 11 agreed to participate in a video-based telerehabilitation program. Barriers and facilitators to the adoption of telerehabilitation were identified and clinical, demographic, and psychological variables were analysed as predictors of success. Age, cognitive reserve, and resilience were significant predictors of satisfaction with telerehabilitation (p<0.05). The telerehabilitation program was perceived as feasible and was well accepted by patients, despite some technology challenges. However, patients who took advantage of telerehabilitation perceived differences in the quality of service and preferred traditional in-person treatment to service delivery via telerehabilitation.

The role of goal adjustment during rehabilitation from stroke

We investigated motivational regulation involving adjustment of recovery goals in post-stroke rehabilitation via standard in-clinic physiotherapy and in-home telerehabilitation (TR). We used a secondary dataset collected at 11 US sites as part of a clinical trial using video games and game control pads designed to induce certain arm movements required for recovery (n = 124; M_age  = 61.44, SD = 13.30). Participants were randomly assigned to either the TR or in-clinic condition and underwent 36 therapy sessions, reporting on their activity-inherent enjoyment for 6-8 weeks. Compared with the in-clinic patients and TR patients with high game performance, TR patients with lower game performance reported lower activity-inherent enjoyment, which is an important motivational resource for successful recovery. The results suggest that these differences occur because TR patients become discouraged by low game score feedback, which may have signaled a poor prospect for recovery. However, the results also suggest that low game performers who successfully adjusted their recovery goals were resilient to the impact of low game score feedback on their motivational resources and satisfaction with therapy. The findings suggest that goal adjustment may be particularly beneficial when patients are discouraged by feedback indicating suboptimal recovery prospects.

Why Are Stroke Rehabilitation Trial Recruitment Rates in Single Digits?

Background: Recruitment of patients in early subacute rehabilitation trials (<30 days post-stroke) presents unique challenges compared to conventional stroke trials recruiting individuals >6 months post-stroke. Preclinical studies suggest treatments be initiated sooner after stroke, thus requiring stroke rehabilitation trials be conducted within days post-stroke. How do specific inclusion and exclusion criteria affect trial recruitment rates for early stroke rehabilitation trials?

Objectives: Provide estimates of trial recruitment based on screening and enrollment data from a phase II early stroke rehabilitation trial.

Methods: CPASS, a phase II intervention trial screened ischemic stroke patients in acute care (18-months, N = 395) and inpatient rehabilitation (22-months, N = 673). Patients were stratified by upper extremity (UE) impairment into mild (NIHSS motor arm = 0, 1); moderate (NIHSS = 2, 3); severe (NIHSS = 4) and numbers of patients disqualified due to CPASS exclusion criteria determined. We also examined if a motor-specific evaluation (Action Research Arm Test, ARAT) increases the pool of eligible patients disqualified by the NIHSS motor arm item.

Results: CPASS recruitment in acute care (5.3%) and inpatient rehabilitation (5%) was comparable to prior trials. In acute care, a short stay (7–17-days), prior stroke (13.5% in moderately; 13.2% in severely impaired) disqualified the majority. In inpatient rehabilitation, the majority (40.8%) were excluded for “too mild” impairment. The next majority were disqualified for reaching inpatient rehabilitation “too late” to participate in an early stroke trial (15% in moderately; 24% in severely impaired). Mean ARAT in the “too mild” showed significant impairment and potential to benefit from participation in select UE rehabilitation trials.

Conclusions: Screening of ischemic stroke patients while they are still in acute care is crucial to successful recruitment for early stroke rehabilitation trials. A significant proportion of eligible patients are lost to “short length of stay” in acute care, and arrive to inpatient rehabilitation “too late” for an early rehabilitation trial. Additional screening of mildly impaired patients using a motor function specific scale will benefit the trial recruitment and generalizability.

Trial Registration Number:http://www.clinicaltrials.gov Identifier: NCT02235974.

Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic

(1) Background: Due to the pandemic caused by the SARS-CoV-2 virus, rehabilitation centres have become less available for neurological patients. This is the result of efforts to physically distance society, to try to slow the spread of the pathogen. Health care facilities were mainly restricted to urgent cases, while most physiotherapy treatments, mainly for patients with chronic conditions, were suspended. Some countries have seen a reduction in acute stroke hospital admissions of from 50% to 80%. One solution to the above problem is the use of telerehabilitation in the home environment as an alternative to inpatient rehabilitation. (2) Aim of the study: The purpose of this review is to analyse the benefits and limitations of teletherapy in relation to the functional condition of post-stroke patients. (3) Methods: Selected publications from 2019 to 2021 on the telerehabilitation of stroke patients were reviewed. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. (4) Results: Studies have proven that teletherapy significantly improves the functional condition of post-stroke patients, resulting in improved quality of life and faster return to independence (while maintaining maximum possible precautions related to the SARS-CoV-2 virus pandemic). (5) Conclusions: Analysis of the study results showed comparable effectiveness of rehabilitation in the tele system to inpatient therapy. However, it should be emphasised that patients undergoing telerehabilitation must meet strict conditions to be eligible for this type of treatment program. However, the strength of the evidence itself supporting the effectiveness of this method ranks low due to the limited number of randomised control trials (RCT), small number of participants, and heterogeneous trials.

Upper Limb Home-Based Robotic Rehabilitation During COVID-19 Outbreak

The coronavirus disease (COVID-19) outbreak requires rapid reshaping of rehabilitation services to include patients recovering from severe COVID-19 with post-intensive care syndromes, which results in physical deconditioning and cognitive impairments, patients with comorbid conditions, and other patients requiring physical therapy during the outbreak with no or limited access to hospital and rehabilitation centers. Considering the access barriers to quality rehabilitation settings and services imposed by social distancing and stay-at-home orders, these patients can be benefited from providing access to affordable and good quality care through home-based rehabilitation. The success of such treatment will depend highly on the intensity of the therapy and effort invested by the patient. Monitoring patients' compliance and designing a home-based rehabilitation that can mentally engage them are the critical elements in home-based therapy's success. Hence, we study the state-of-the-art telerehabilitation frameworks and robotic devices, and comment about a hybrid model that can use existing telerehabilitation framework and home-based robotic devices for treatment and simultaneously assess patient's progress remotely. Second, we comment on the patients' social support and engagement, which is critical for the success of telerehabilitation service. As the therapists are not physically present to guide the patients, we also discuss the adaptability requirement of home-based telerehabilitation. Finally, we suggest that the reformed rehabilitation services should consider both home-based solutions for enhancing the activities of daily living and an on-demand ambulatory rehabilitation unit for extensive training where we can monitor both cognitive and motor performance of the patients remotely.

Effects of Tele-Rehabilitation Compared with Home-Based in-Person Rehabilitation for Older Adult's Function after Hip Fracture

This study aimed to examine the effect of a multidisciplinary tele-rehabilitation program on functional recovery of older adults with hip fracture compared with home-based in-person rehabilitation. In this single-blinded, non-randomized clinical trial, we included older with hip fracture. The tele-rehabilitation group received a 12-week tele-rehabilitation program (supervised by their family caregivers). The control group received the usual postoperative rehabilitation provided by the Andalusian health system (Spain). The primary outcome was the patient-reported functional status assessed with the Functional Independence Measure. We also measured performance-based functional recovery using the Timed Up and Go Test and Short Physical Performance Battery. We performed both a per-protocol (62 participants; 28 tele-rehabilitation and 34 control groups) and an intention-to-treat analysis (71 participants; 35 tele-rehabilitation and 36 control groups). Participants who used the tele-rehabilitation program had higher Functional Independence Measure scores (high effect size: 0.98 Cohen’s d; p < 0.001) and better performance in the Timed Up and Go Test (medium effect size: 0.63 Cohen’s d; p = 0.025) compared with the control group. Differences between groups post-intervention were not statistically significant in the Short Physical Performance Battery. The tele-rehabilitation intervention proposed in this study is a valuable treatment option in the recovery process for older adults with hip fracture. ClinicalTrials.gov Identifier: NCT02968589.