Poststroke Telerehabilitation

Globally, neurologic disorders are the leading cause of disability and second leading cause of death. Stroke is among the most prevalent of neurologic diseases.¹ The estimated economic cost of neurologic disorders was €798 billion in Europe in 2010 and $789 billion in the US.^2,3 As has been seen readily with the ongoing COVID-19, pandemic, the evolving role of teleneurology is useful for treatment of neurologic conditions, including stroke, which is perhaps the most well-researched application of telemedicine.^4,5

This article gives an introduction to telemedicine, telestroke care, and poststroke telerehabilitation. We examine how these advances can help us meet best practice guidelines.

Telemedicine

Described as “the use of telecommunication systems to deliver health care at a distance,”⁴ telemedicine has the potential to improve health outcomes, increase access to health care, and reduce healthcare costs.⁴ The average estimated cost of a telehealth visit is $40 to $50 per visit compared to the average estimated cost of $136 to $176 for in-person acute care.⁶ Lower out-of-pocket expenses and institutional cost savings were evidenced when telehealth was used for neurologic conditions. The US Veterans’ Healthcare Administration saved approximately $50,000 over 2 years with a telemedicine initiative for more than 300 people with neurologic conditions.⁶ Categories of telemedicine interventions are listed in Box 1.

A systematic review analyzed the barriers to adopting telemedicine globally (Box 2).⁷ This analysis positively reported that these barriers could be addressed with training and change management techniques, commonly used in process and quality improvement efforts. Availability of high-speed internet was also identified as a barrier, with governments encouraged to address these gaps to allow access in rural areas.

Teleneurology

Teleneurology has the potential to improve adherence to treatment and has been shown to improve outcomes in stroke care. For both depression and insomnia, telemedicine achieves similar symptom reduction as in-person cognitive therapy.⁶ Teleneurology apps being used and researched include but are not limited to: WhatsApp mobile application, video conferencing, email consultation, smartphones, smartwatches, clinical video telehealth (CVT), and store and forward telehealth (SFT).⁸ Smartphone apps have been developed to analyze head CT for stroke, measure speed and tremor severity in Parkinson disease, detect and quantify seizures, and treat insomnia.⁹

Telestroke Care

The American Telemedicine Association’s Telestroke Guidelines were published in 2017 to assist in establishing telestroke services and bring special expertise to a larger proportion of people experiencing strokes.¹⁰ Telestroke is among the most commonly used teleneurology applications and may be a model for expanding telemedicine into other areas of neurology (Box 3).⁵

Telestroke research is quite promising with reduced mortality, beneficial health outcomes, and treatment reliability using video consultations and telehealth exchanges.⁶ Studies have demonstrated potential benefit for poststroke rehabilitation through telehealth and virtual reality (VR) systems that aim to bring digital physical therapy to home settings.⁶ The role of telerehabilitation for poststroke care, however, has not been extensively researched and requires large-scale randomized controlled trials with further health economic analyses.¹¹

Telerehabilitation for Stroke

Telerehabilitation is defined as “the use of telecommunication, by either direct video or audio, to deliver rehabilitative interventions.” From the available evidence there is moderate-to-good quality consistent evidence to indicate that telerehabilitation may be as effective as usual care for motor function, activities of daily living (ADLs), independence, and quality of life in adults who experienced stroke.¹² Mobile technology, smartphone, and tablet apps are already assisting with home-based telerehabilitation through symptom tracking, patient education materials, scheduling applications, online support groups, health coaching, and the potential to detect seizure activity in patients with epilepsy.⁸

A systematic review of telerehabilitation efficacy in poststroke care found interventions had better or equal effects compared with conventional face-to-face therapy. The majority of studies evaluated focused on motor recovery and larger effects were seen with interventions that last 6 to 12 months.¹³ A pilot study of home-based telerehabilitation delivered to people with poststroke stable arm deficits demonstrated significant gains in arm motor status from telerehabilitation. Participants performed an average 24,607 arm repetitions over the 28 days of the study, averaging 879 arm repetitions per day during 2-hour sessions. These numbers of repetitions per hour were reported as similar to other studies using high-repetition doses for upper extremity training after stroke. Motor gains were not dependent on the level of computer literacy.¹⁴

The Future of Stroke Rehabilitation

People who have had a stroke are more likely to be sedentary, have mobility impairments, and expend more energy to make everyday movements and benefit from physical exercise rehabilitation. Meta-analysis shows that physical rehabilitation reduces physical disability.¹⁵ Studies previously mentioned show telerehabilitation is a viable avenue to meet the rehabilitation needs of people with chronic neurologic conditions. Telerehabilitation also has the potential to offer services more efficiently to a greater geographical area and with increased options available to patients using this technology.

Early Supported Discharge

The purpose of early supported discharge (ESD) is to improve the transition between hospital and community by both decreasing time in the hospital and providing more continuity of rehabilitation in the home setting. There is moderate grade evidence that ESD services result in a greater likelihood of independent living at home 6 months after stroke compared with usual discharge procedures.¹⁶ Considering that between 30% and 70% of stroke survivors are discharged with some level of disability,^17,18 there is a role for ESD implementation and support of home-based rehabilitation (HBR).

Home-Based Rehabilitation

Research supports the benefits of HBR, and there is evidence that more therapy improves the rate of recovery and outcomes within the first 6 months after stroke. Interventions of HBR facilitated through new and emerging telerehabilitation is a promising option to help achieve best practice guidelines.

Rehabilitation can be identified as a set of interventions needed when a person experiences or is likely to experience limitations in everyday functioning. Rehabilitation enables individuals to maintain or return to daily life activities, fulfill meaningful life roles, and maximize well-being.¹⁹ For people unable to travel because of individual mobility, lack of transportation, or recent discharge from the hospital, HBR is an important service to offer. An observational study of stroke survivors found individuals undergoing rehabilitation were more active in their own homes in the first week after discharge, spending on average 45 more minutes upright and 12 more minutes walking, and completing 724 additional steps each day at home compared with their last week spent in a rehabilitation hospital.²⁰

Moderate level evidence was shown in a meta-analysis that both exercising at home or at a center improves health and physical function in older adults with cardiopulmonary risk factors or disease or chronic obstructive pulmonary disease (COPD).²¹ Studies included in the review found that home-based programs displayed higher long-term adherence to exercise with 68% adherence at 2-year follow-up compared with 36% in center-based groups. A more recent meta-analysis found that the type of home-based exercise prescribed may not influence adherence but that more importantly, any home-based intervention improved adherence to exercise in people with chronic musculoskeletal conditions.²²

Patients have identified a preference for rehabilitation in familiar environments. HBR is associated with improved goal setting that reflects patients’ daily lives, empowering a person-centered approach, reintegration into the community, and participation up to 1 year after stroke.^23,24

More therapy time has an overall benefit compared with less therapy time.²⁵ There is strong evidence to support high-intensity training after stroke with recommended therapy time of 17 hours over 10 weeks to achieve significant positive effects.²⁶ Intensive (>16 hours) goal-oriented repetitive task practice has been shown to improve the rate of activities of daily living with improvements seen up to 6 months after stroke.²⁷

Achieving Best Practices

The American Heart Association Guideline for Adult Stroke Rehabilitation and Recovery notes that despite rehabilitation often being considered a costly area of care that could be trimmed, the clinical impact of doing so would increase medical morbidity because of resulting immobility, depression, loss of autonomy, and reduced functional independence. This guideline considers comprehensive rehabilitation with adequate resources, dose, and duration an essential aspect of stroke care to be prioritized in stroke system redesign.²⁸

The Royal College of Physicians recommends that after stroke, patients should accumulate at least 45 minutes of physiotherapy daily for as long as they are willing and capable of participating and show measurable benefit from treatment.²⁹ They also recommend structured health and social care reviews at 6 months and 1 year after stroke, then annually, to help patients develop their own self-management plan.²⁹

In Ireland, the National Stroke Audit Reports indicate that over 50% of patients are discharged from the hospital with some level of disability.¹⁸ Physiotherapists reported that approximately half of patients received the appropriate amount of rehabilitation required by best practice guidelines. Following discharge from acute physiotherapy services, only half received further referral to inpatient rehabilitation, community physiotherapy, ESD, or a stroke-specific outpatient department or day hospital.

The Action Plan for Stroke in Europe 2018-2030 identifies telemedicine for acute stroke, rehabilitation, and long-term care in stroke services as a research and development priority.³⁰ How to efficiently implement cost-effective long-term rehabilitation strategies and measures, such as providing ESD to at least 20% of stroke survivors, is also identified as a research and development priority. In terms of community-based services, an action priority is ensuring that all stroke patients and caregivers have a review of their rehabilitation and other needs at 3 to 6 months after stroke and annually thereafter, providing a documented plan for community rehabilitation and self-management support as well as offering physical fitness programs.

Future Research in Telerehabilitation

With increasing need and evidence to support HBR and the empowerment of patients to control their own journey through rehabilitation, there appears to be a certain future for telerehabilitation in all areas of neurology. There needs to be more research on clinical efficacy and cost-effectiveness, along with more robust trials to support its clinical use. Safety considerations for preventing the spread of infectious disease, as needed during the COVID-19 pandemic, also support the use of telerehabilitation. Future research on the best practices for using technology, including activity trackers, smartwatches, smartphones, tablets, and laptops, will be important to improve access to health care by providing more rehabilitation options for people than currently available, whether because of geography, income, or other psychosocial factors.

Conclusion

As prevalence and incidence of neurologic disease and disability grow, the need for treatment, rehabilitation, and support will also rise.¹ As a review published in 2019 concludes, “chronic neurological care symptoms can be long-lasting and complex telehealth services may ease the burden of traveling long distances and dealing with this myriad of symptoms”.⁸

Research and best practice guidelines encourage ESD and home-based interventions for individuals following mild to moderate stroke.^16,28 Patients have identified the benefits of and preference for HBR for real-life goal setting and community reintegration.²³ With the high incidence, cost, and burden of neurologic conditions, telemedicine, teleneurology and telerehabilitation have a growing body of evidence to support their use as a cost-effective and feasible option in the provision of healthcare. The global COVID-19 pandemic and resultant need for the general populace to practice social distancing have further emphasized the need for remote treatment options.