Tele-Neurorehabilitation During the COVID-19 Pandemic: Implications for Practice in Low- and Middle-Income Countries

Research, education and practice of tele-neurorehabilitation in low and middle-income countries: A Scoping Review

BACKGROUND

Tele-neurorehabilitation (TNR) allows for remote delivery of rehabilitation services for those with neurological disabilities. Despite growing global interest and uptake, its adoption remains challenging in Low-and-Middle-Income-Countries (LMICs).

OBJECTIVE

To explore available literature on the nature of training and education, research and practice of TNR in LMICs.

METHODS

Following PRISMA-ScR guidelines and predefined selection criteria, four databases were screened. Quality assessment was performed using the Joanna Briggs Institute tools. Relevant data was extracted to using a data extraction form in Microsoft Excel and were narratively synthesised under Education/training, Research and Clinical Practice of TNR.

RESULTS

We identified no formal structured training courses/programs for TNR users/providers. Sessions were mainly delivered as part of a research project. The included studies highlighted the need to engage stakeholders in TNR research and improve digital-literacy among healthcare providers/users. Development and use of clinical decision-making-tools, models of TNR suitable for varied populations and prior area-mapping were a few suggestions for clinical/research practice.

CONCLUSION

There is an immense need to develop academic/structured programs for TNR to build capacity among providers/users in LMICs. Practice must adhere to principles of safety, effectiveness, and based on high quality clinical-guidelines suitable to the context to ensure optimal uptake and practice of TNR in LMICs.

Digital Technology Enablers of Tele-Neurorehabilitation in Pre- and Post-COVID-19 Pandemic Era - A Scoping Review

Neurorehabilitation (NR), a major component of neurosciences, is the process of restoring a patient's damaged/disorganized neurological function, through training, therapy, and education, while focusing on patient's independence and well-being. Since the advent of the COVID-19 pandemic, various applications of telecare and telehealth services surged drastically and became an integral part of current clinical practices. Tele-Neurorehabilitation (TNR) is one of such applications. When rehabilitation services were disrupted globally due to lockdown and travel restrictions, the importance of TNR was recognized, especially in developed, low, and middle-income countries. With exponential deployment of telehealth interventions in neurosciences, TNR has become a distinct stand-alone sub-specialty of neurosciences and telehealth. Digital technologies, such as wearables, robotics, and Virtual Reality (VR) have enabled TNR to improve the quality of patients' lives. Providing NR remotely using digital technologies and customized digital devices is now a reality, and likely to be the new norm soon. This article provides an overview of the needs, utilization, and deployment of TNR, and focuses on digital technology enablers of TNR in pre- and post-COVID-19 pandemic era.

Assessing Swallowing and Mastication Using the Swallowing Proficiency for Eating and Drinking Protocol Among Healthy Adults

BACKGROUND

Objective evaluation of swallowing using single bolus consistency are popular among Speech-Language Pathologists (SLPs) but has limited generalization to other bolus consistencies. The Swallowing Proficiency for Eating and Drinking (SPEAD) test assesses the oral and pharyngeal phases of swallowing using three different consistencies.

OBJECTIVES

The aim of this study was to establish normative data for the SPEAD test among healthy individuals aged 20-79 years.

METHOD AND MATERIALS

One hundred and twelve healthy adults recruited from the community were divided into three age groups (20-39.11, 40-59.11, & 60-79.11 years). Participants swallowing 100 g of water and thickened Electral, and 6.67 g of Parle Monaco was video recorded for data analysis.

RESULTS

Cronbachs Alpha test indicated good to excellent internal consistency and inter-class correlation test revealed a high level of inter-rater reliability for all SPEAD parameters. Older adults exhibited a higher number of bites, chews, and swallows, and required more time to swallow compared to younger and middle adults. Similarly, speed of ingestion and SPEAD rate were lowest in older adults. SPEAD indices also showed significant differences across the three consistencies at p < 0.01.

CONCLUSION

In summary, the SPEAD test was found to be feasible, reliable, and valid in healthy adults of India between 20 and 79 years of age. The age and sex based normative data established in this study will enable SLPs in assessing the presence and / or absence of swallowing difficulties in the oral and pharyngeal phases across different consistencies using one test.

Perspectives of patients with osteoarthritis for using digital technology in rehabilitation at a public community centre in the Cape Metropole area: A qualitative study

Objectives

To explore the perspectives of people with osteoarthritis (OA) on the use of digital technology into their rehabilitation program, including their awareness, views on accessibility, affordability and willingness to accept digital modalities for rehabilitation delivery.

Methods

A qualitative, descriptive design was conducted. Patients with OA who receive care at a public community rehabilitation centre in the Western Cape, South Africa were eligible to participants. Semi-structured interviewed were conducted and Atlas.ti 23 software was used for thematic analysis.

Results

The findings showed that the participants had limited awareness and exposure to telerehabilitation (TR), along with minimal digital literacy and skills. They were sceptical about the effectiveness of TR and concerned about the inherent lack of physical interactions with health professionals. However, some acknowledged TR's potential benefits for accessibility, convenience, family involvement and long-term community health improvement. Participants were willing to learn more about TR.

Conclusion

Considering the benefits of TR in lower resource settings such as South Africa, investment to increase awareness and patient education and training in TR may assist in enhancing access and quality of care. Resources dedicated to TR and management buy-in in low-and-middle income countries (LMICs) is necessary to facilitate the fit-for-context roll-out of TR.

Evolution of rehabilitation services in response to a global pandemic: reflection on opportunities and challenges ahead

The rapidly evolving COVID-19 public health emergency has disrupted and challenged traditional healthcare, rehabilitation services, and treatment delivery worldwide. This perspective paper aimed to unite experiences and perspectives from an international group of rehabilitation providers while reflecting on the lessons learned from the challenges and opportunities raised during the COVID-19 pandemic. We discuss the global appreciation for rehabilitation services and changes in access to healthcare, including virtual, home-based rehabilitation, and long-term care rehabilitation. We illustrate lessons learned by highlighting successful rehabilitation approaches from the US, Belgium, and Japan.

Family Engagement in Services During COVID-19: A Mixed-Methods Study of Caregiver and Staff Perspectives

INTRODUCTION

We examined changes in family engagement before versus during the pandemic in pediatric and family services and perceived facilitators and barriers to family engagement.

METHOD

We employed a mixed-methods assessment of staff and caregiver perspectives related to pediatric and family medicine clinics and family resource centers in rural northern New England. We used narrative synthesis to analyze qualitative interviews (n = 29) and descriptive statistics for quantitative surveys (n = 108).

RESULTS

Staff felt they were not doing as well at engaging families during versus prepandemic, identifying numerous facilitators and barriers. We found differences in resources used by families before versus during the pandemic. We identified discordant perspectives between caregivers and staff regarding how well clinics and centers identified and responded to family needs.

DISCUSSION

Leaders in pediatrics, advanced practice nursing, and related fields can draw on our findings to decide what services and modalities they provide for postpandemic.

Evaluation of the feasibility and acceptability of ReWin-A digital therapeutic rehabilitation innovation for people with stroke-related disabilities in India

Background

Developing culturally appropriate, scalable interventions to meet the growing needs for stroke rehabilitation is a significant problem of public health concern. Therefore, systematic development and evaluation of a scalable, inclusive, technology-driven solution for community-based stroke care are of immense public health importance in India. ReWin is a digital therapeutics platform that was developed systematically. This study aimed to evaluate its feasibility and acceptability in an Indian context.

Objectives

Phase-1: To pilot the intervention for identifying operational issues and finalize the intervention. Phase-2: To assess the feasibility and acceptability of ReWin intervention in an Indian context.

Methods

Design: Mixed-methods research design. Setting: Participant's home and rehabilitation centers. Participants were selected from rehabilitation centers in South India. Participants: Ten stroke survivors and their caregivers, as well as four rehabilitation service providers were recruited for phase 1. Thirty stroke survivors who were treated and discharged from the hospital, and their caregivers as well as 10 rehabilitation service providers were recruited for Phase 2. Intervention: ReWin a digital therapeutic platform with the provider and patient app for the rehabilitation of physical disabilities following stroke was piloted. Process: Evaluation of the intervention was completed in two phases. In the first phase, the preliminary intervention was field-tested with 10 stroke survivors and four rehabilitation service providers for 2 weeks. In the second phase, the finalized intervention was provided to a further 30 stroke survivors to be used in their homes with support from their carers as well as to 10 rehabilitation service providers for 4 weeks. Outcome measures: Primary outcomes: (1) operational difficulties in using the ReWin intervention; (2) feasibility and acceptability of the ReWin intervention in an Indian setting.

Results

Field-testing identified operational difficulties related to 1. Therapeutic content; 2. Format; 3. Navigation; 4. Connectivity, 5. Video-streaming, 6. Language; and 7. Comprehensibility of the animated content. The intervention was reviewed, revised and finalized before pilot testing. Findings from the pilot testing showed that the ReWin intervention was feasible and acceptable. About 76% of the participants had used ReWin for more than half of the intervention period of 4 weeks. Ninety percentage of the stroke care providers and about 60% of the stroke survivors and caregivers felt that the content of ReWin was very relevant to the needs of the stroke survivors. Forty percentage of the stroke survivors and caregivers rated ReWin intervention as excellent. Another 45% of the stroke survivors and caregivers as well as 90% of the stroke care providers rated ReWin intervention as very good based on its overall credibility, usability, and user-friendliness.

Conclusions

ReWin has all the essential components to connect care providers and consumers not just for stroke rehabilitation but for several other health conditions with the use of several other technological features that support rehabilitation of persons with disabilities and strengthen rehabilitation in health systems worldwide. It is critical to amalgamate ReWin and other evidence-based interventions for rehabilitation to innovate scalable solutions and promote universal health coverage for stroke care worldwide.

Systematic Development of the ReWin Application: A Digital Therapeutic Rehabilitation Innovation for People With Stroke-related Disabilities in India

This is a viewpoint paper that aims to describe the systematic approach to the development of a technology-driven stroke rehabilitation innovation to manage disabilities following a stroke at home in India. This paper intends to sensitize public health innovators and intervention development experts about the important aspects that need to be considered to develop a culturally sensitive, patient-centered, scalable solution for stroke care using technology. Stroke has been the second-leading cause of death and the third-leading cause of disability globally for the past 3 decades. The emerging technological innovations for stroke care were predominantly designed and developed by digital technology experts as stand-alone products with very minimal efforts to explore their feasibility, acceptability, and, more importantly, scalability. Hence, a digital therapeutic rehabilitation innovation for people with stroke-related disabilities in India was systematically developed and is being evaluated. ReWin is an innovation that is technologically driven and envisions digital therapeutics as a medium for the provision of rehabilitation to persons with disabilities. It is conceptualized and developed based on the International Classification of Functioning, Disability and Health. ReWin encompasses specific technological aspects to enable its scientific framework and conceptualization to suit the context and needs of stroke care providers and consumers. The framework is built with 2 separate applications, one for the providers and one for the patients and caregivers. Each of these applications has a specific inbuilt design to add data about the demographic details of the user, stroke severity using the National Institute of Health Stroke Scale, and self-assessment of disability measured by the modified Barthel Index. Users can communicate with each other and decide on their therapeutic goals, therapy training information, and progress remotely from where they are. The ultimate outcome expected from the ReWin innovation is a continuum of care for stroke survivors that is effective, safe, and of good quality. Systematic development cannot make the intervention scalable. The intervention needs to be evaluated for its feasibility, acceptability, and effectiveness. Currently, ReWin is being evaluated for its feasibility and acceptability. The evaluation of ReWin will provide an opportunity to develop a scalable solution for empowering therapists and persons with disabilities, in general, to objectively self-manage their treatment. Findings from this study will also provide valuable information about the resources required to deliver such interventions in resource-constrained settings like India.

Evaluation of the Impact of the First Wave of COVID-19 and Associated Lockdown Restrictions on Persons with Disabilities in 14 States of India

BACKGROUND

There is a paucity of data to assess the impact of the COVID-19 pandemic on persons with disabilities (PwDs) in India. About 27.4 million cases were reported as of 27 May 2021. The continuing pandemic in the form of subsequent waves is expected to have negative repercussions for the disabled globally, particularly in India, where access to health, rehabilitation, and social care services is very limited. Therefore, this study aimed to assess the impact of the COVID-19 pandemic and lockdown restrictions on PwDs in India.

OBJECTIVE

To determine the level of disruption due to COVID-19 and the associated countrywide lockdown restrictions on PwD in India during the first wave.

METHODS

Using a cross-sectional, mixed-methods approach, data were collected from a representative sample of 403 persons with disabilities in 14 states in India during the COVID-19 first wave at two different points in time (Lockdown and post-lockdown phase). Factors associated with the negative impact were examined using the Chi-square test for associations. The paired comparisons between 'lockdown' with the 'post-lockdown' phase are presented using McNemar's test and the marginal homogeneity test to compare the proportions. Additionally, a subsample of the participants in the survey was identified to participate in in-depth interviews and focus group discussions to gain in-depth insights on the study question and substantiate the quantitative findings. The framework approach was used to conduct a thematic analysis of the qualitative data.

RESULTS

About 60% of the PwDs found it difficult to access emergency medical services during the lockdown, and 4.6% post lockdown (p < 0.001). Likewise, 12% found it difficult to access rehabilitation services during the lockdown, and 5% post lockdown (p = 0.03). About 76% of respondents were apprehensive of the risk of infection during the lockdown, and this increased to 92% post lockdown (p < 0.001). Parents with children were significantly impacted due to lockdown in the areas of Medical (p = 0.007), Rehabilitation (p = 0.001), and Mental health services (p = 0.001). The results from the qualitative study supported these quantitative findings. PWDs felt that the lockdown restrictions had negatively impacted their productivity, social participation, and overall engagement in everyday activities. Access to medicines and rehabilitation services was felt to be extremely difficult and detrimental to the therapeutic benefits that were gained by them during the pre-pandemic time. None of the pandemic mitigation plans and services was specific or inclusive of PWDs.

CONCLUSIONS

COVID-19 and the associated lockdown restrictions have negatively impacted persons with disabilities during the first wave in India. It is critical to mainstream disability within the agenda for health and development with pragmatic, context-specific strategies and programs in the country.

Therapy services for children and youth living in rural areas of high-income countries: a scoping review

PURPOSE

To identify and describe therapeutic services provided to children and youth with disabilities living in rural areas of mid- and high-income countries and to summarize the benefits, positive outcomes, and challenges related to these services.

METHODS

This scoping review involved a systematic search of four academic electronic databases: MEDLINE, EMBASE, CINAHL, and Psych INFO, using a combination of subject headings and keywords related to (1) child disabilities; (2) rehabilitation: occupational therapists, speech-language pathologists, physiotherapists, audiologists, and recreation therapists; (3) multidisciplinary care team; (4) rural areas. Charting involved an iterative process whereby the full text articles meeting the inclusion criteria were abstracted using the charting form by two independent reviewers.

RESULTS

Thirty-seven articles from seven high-income countries were included in the analysis. Twenty-seven articles reported on in-person services, and 19 on telepractice (nine evaluated in-person and telepractice). In person services included outreach programs and specialized on-site programs. Positive outcomes and challenges of in person and telepractice services in rural areas are described.

CONCLUSIONS

Findings of this review highlight the need for further research on service delivery models offered in rural areas of upper middle and high-income countries, especially those focusing specifically on the rural communities, with a clear description of services. IMPLICATIONS FOR REHABILITATIONThis scoping review helps to advance the understanding of how therapy services are offered in rural areas of high-income countries.Telepractice was found to enhance ease of access to services for families living in rural areas.The findings of this review suggest that telepractice may be an effective means of providing therapy services to children and youth with disabilities living in rural areas of high-income countries, pending families' access to technology.