Disability is an umbrella term describing a state of decreased functioning associated with disease, disorder, injury, or other health conditions. Disability may be experienced as an impairment, activity limitation, or participation restriction, and refers to the negative aspects of an individual’s health condition and environmental and personal factors. Disabilities are diverse and heterogeneous, encompassing congenital conditions present at birth (e.g., cerebral palsy), developmental conditions (e.g., autism, attention deficit hyperactivity disorder [ADHD]), traumatic injuries (e.g., traumatic brain injury [TBI], spinal cord injury [SCI]), and chronic conditions (e.g., diabetes). Disabilities may be progressive (e.g., muscular dystrophy), static (e.g., limb loss), or intermittent (e.g., some forms of multiple sclerosis [MS]). Individuals with disabilities are vulnerable to deficiencies in health care services, and may experience greater vulnerability to secondary and comorbid conditions.
Advancement in medical care has increased the life expectancy of the general population and persons with disabilities. This increase in life expectancy for persons with disabilities is associated with secondary chronic conditions, which are currently responsible for 60% of the global disease burden, and 80% in developing countries. According to the World Health Organization report on disability in 2011, one billion people globally experience disability; that is, every alternate household has a person with disability. As of 2017 half of the persons with disabilities cannot afford health care and are 50% more likely to suffer catastrophic health expenditure. These individuals have the same general health care needs as others but are twice as likely to experience inadequacy in health providers’ skills and facilities, three times more likely to be denied health care, and four times more likely to be mistreated in the health care system.
The economic burden of disability and associated medical comorbidities has continued to rise at an alarming rate. Individuals with disability are more likely to suffer from obesity, muscle atrophy, osteoporosis, accelerated atherogenesis, type 2 diabetes mellitus, and other complications that increase the risk of stroke, coronary heart disease, and cardiometabolic disorders. Reduction in the level of physical activity and associated sedentary lifestyle are primary factors that lead to the development of secondary complications.
Physical Activity in Individuals With Disability
For several decades, the scientific community has realized the impact of neurological disorders on the well-being of society, families, and individuals. Neurological disorders are diseases of the central and peripheral nervous systems. These disorders include Alzheimer’s disease and other dementias, epilepsy, stroke, MS, Parkinson’s disease (PD), and traumatic disorders due to trauma to the head or spinal cord (TBI and SCI, respectively). These medical conditions can result in a low quality of life, social isolation, and psychosomatic impairment. Individuals with neurological disability require frequent, specialized, and interdisciplinary health care addressing mobility, autonomic function, as well as other potential secondary complications.
Many neurological disorders have common symptoms of reduced motor function, increased fatigue, and reduced physical activity levels. The physical activity levels of individuals with disability are only 40% of the general population. The American College of Sports Medicine and the American Heart Association recommend healthy adults engage in 150 minutes of moderate-intensity exercise per week to maintain cardiorespiratory fitness. Guidelines for individuals with disability have highlighted the importance of improving physical activity levels. For instance, in 2017, the updated guidelines recommended that persons with SCI engage in routine physical activity for at least 20 to 30 minutes two to three times per week, to attenuate cardiovascular comorbidities. A prominent symptom of neurological disorders is progressive neuromuscular weakness. Therefore the recommendations have highlighted the significance of engaging in strength training programs to enhance musculoskeletal integrity. With respect to SCIs, approximately 50% of individuals with SCI engage in no leisure-time physical activity (LTPA) such as sports, wheeling, or walking for pleasure or exercise. Indeed, increased physical activity levels and exercise have been shown to have positive effects on disease outcomes in various neurological disorders.
Several reports have indicated significant barriers to improving physical activity levels and exercise adherence in persons with disabilities. These barriers include costs of exercise facilities, limited access to facilities, lack of adequate transportation, and lack of motivation. For example, a lack of background knowledge on dealing with persons with SCI, and failure to provide appropriate exercise routines based on the individual’s neurological level and spared muscle function act as barriers to exercise. This highlights the importance of improving exercise individualization and physical activity adherence among persons with disability. Telerehabilitation (TR) programs to increase physical activity and exercise have been successfully used in many neurological disorders, including stroke, TBI, dementia, PD, SCI, and MS.
Telerehabilitation for Individuals With Disabilities
The World Health Organization defines rehabilitation as a set of interventions needed when a person is experiencing limitations in everyday functioning due to aging or health condition, including chronic diseases or disorders, injuries, or traumas. Rehabilitation requires one-on-one interaction between clinicians and patients. This interaction works toward a number of beneficial outcomes including solving existing medical, social, and psychological consequences via routine physical and diagnostic evaluations, as well as the use of different laboratory and imaging procedures. Rehabilitation is a patient-centered health intervention for individuals with complex needs that may be delivered through specialized rehabilitation programs or integrated into the health care programs and services, such as primary and mental health care.
Telehealth communication has emerged as a promising avenue to improve rehabilitation, and long-term physical activity and exercise compliance. Home TR aims to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits. Overall, TR offers “healing from a distance” by delivering health services remotely through information and communication technologies. TR goes beyond telemedicine, offering clinical and nonclinical services, including providing patients and caregivers with education through distance learning, training, and administrative meetings and presentations.
TR is a relatively new subdiscipline of telemedicine and eHealth where communication and information technology can have a positive impact on health and well-being. This improved care coordination between specialty providers, clients, caregivers, and local clinical providers avoids unguided rehabilitation services offered by paramedical and rehabilitation personnel at remote locations without a physiatrist’s diagnosis and prescription. Most importantly, TR has the potential to exceed traditional care and management strategies for the lifelong care of people with disability.
Advances in videoconferencing software allow for safe and continuous monitoring of at-home exercise regimens. The rapid evolution of TR technologies has led to wearable devices connected to web-based apps on mobile devices that record and store physiological data (e.g., heart rate, blood pressure, glucose levels). Although a relatively new avenue of research, many studies have reported increased physical activity levels, cardiorespiratory fitness, and high exercise adherence levels in individuals using TR programs. Inexpensive home-based telecommunication programs may represent an effective rehabilitation option for clinicians to overcome adherence and commitment issues while improving health following disability. Moreover, these programs may reduce the health costs associated with lengthy rehabilitation for people with disabilities while allowing facilities to connect with patients more effectively by providing services via internet and video technologies.
Applications of Telerehabilitation in Conjunction With Endurance Exercise Training
Spinal Cord Injury
Various forms of home-based aerobic exercise programs have been utilized, including cycle ergometry, functional electrical stimulation lower-extremity cycling (FES-LEC), lower-extremity training, and walking ( Table 22.1 ). A recent study with four participants (chronic SCI, various levels of injury) examined the feasibility of a remotely delivered exercise program. Participants engaged in a web-based home exercise program consisting of 30 to 45 minutes of aerobic exercise using an arm ergometer at moderate intensity (~60% of heart rate reserve) three times per week for 8 weeks. This study had 100% adherence, and the majority of participants demonstrated improved levels of physical activity, aerobic capacity, and life satisfaction. Another study examined a home-based physical activity intervention on health-related quality of life in inactive individuals with chronic SCI (<T4). Participants randomly assigned to the intervention group completed four 45-minute moderate intensity (60%–65% of peak oxygen uptake) arm ergometry exercise sessions per week for 6 weeks. Exercise self-efficacy and the physical and psychological quality of life domains were improved.
|Endurance Exercise Studies|
|Author, Year||Design||Disability||TSI||Sample Size||Injury Level||Platform||Exercise||Duration||Outcomes|
|Latimer et al. (2006)||RCT||SCI||19.34 ± 19.79 years||26||Multiple levels||Telephone||Physical activity||8 wks|
|Arbour-Nicitopoulos et al. (2009)||RCT||SCI||44||Multiple levels||Resistance bands||10 wks|
|Dolbow et al. (2012)||Case series||SCI||12 ± 13.26 years||17||C4-T11||Telephone||FES-LEC||16 wks||Adherence|
|Dolbow et al. (2012)||Case study||SCI||18 months||1||C5||Telephone||FES-LEC||9 wks|
|Dolbow et al. (2012)||Case study||SCI||33 years||1||C4||Telephone||FES-LEC||24 wks|
|Arbour-Nicitopoulos et al. (2014)||Prospective||SCI||14.5 ± 12.7 years||65||Multiple levels||Telephone||LTPA||6 months||LTPA|
|Lai et al. (2016)||Case series||SCI||25.8 ± 4.3 years||4||T1-T2, T10-T11, C4-C5, T2-T3||Web-based||Arm ergometer||8 wks|
|Dolbow et al. (2017)||Case study||Tetraplegia||33 years||1||C4||Telephone||FES-LEC||56 months||Body composition BMD|
|Coulter et al. (2017)||RCT||SCI||24||C3/4-L3||Web-based||Aerobic, strength, stretching, balance||8 wks|
|Nightingale et al. (2018)||RCT||SCI||>1 year||19||<T4||In-home||Arm ergometer||6 wks|
|Braga et al. (2018)||Feasibility study||ALS||7.6 ± 4.12 months||10||NA||In-home telemonitoring||Walking||6 months|
|Chatto et al. (2018)||Case report||PD||2 years||1||NA||In-home||Motor learning||4 months|
|Surana et al. (2019)||RCT||Cerebral palsy||NA||24||NA||In-home||Lower-extremity functional training||9 wks||Gait capacity and performance|
|Paul et al. (2019)||RCT feasibility study||MS||NA||90||NA||Web-based||Strength, aerobic, balance||6 months|
|Plow et al. (2019)||RCT||MS||12.7 ± 8.6 years||208||NA||Telephone||Walking program||12 wks|
Several case studies have also demonstrated FES-LEC telephone-based exercise interventions to be feasible and effective long-term exercise strategies (e.g., 56 months) to improve adherence, body composition, and muscle hypertrophy among the SCI population.
Other Neurological Disorders
Additional neurological disorders have benefited from TR, specifically for exercise purposes. A case report of a 67-year-old woman with PD demonstrated that 4 months (16 sessions with four 1-hour sessions/week) of a home exercise program targeting motor symptoms of PD elicited improvements in gait, endurance, balance confidence, and quality of life. The participant’s satisfaction with the program was also high. A randomized controlled trial (RCT) examined the efficacy of a lower-extremity intensive function training (LIFT) compared to an attention control group receiving upper-extremity bimanual training in children with cerebral palsy. Twenty-four children with unilateral spastic cerebral palsy were randomized to receive 90 hours of LIFT or an equivalent dose of attention control (2 hours/day, 5 days/week) for 9 weeks. LIFT showed greater improvement for the 1-minute walk test and overall walking ability compared to an intensity and time-equated control condition.
A recent single-blinded RCT examined the effects of a telephone-delivered intervention on fatigue, physical activity levels, and quality of life in adults with MS. Participants (n = 208) were randomized to one of three groups: a contact-control intervention, physical activity only group, and a physical activity plus fatigue self-management intervention. Over the 12-week training period, the fatigue self-management group significantly improved self-reported fatigue and physical activity levels compared to the contact-control intervention. There were no significant differences between the fatigue self-management group and the physical activity only group. The physical activity only group had significant improvements compared to the control group on moderate-to-vigorous exercise and step count, while there were no significant differences in quality of life between groups. A recent study examining telemonitoring of a home-based exercise program in individuals with amyotrophic lateral sclerosis (ALS) showed improvements in function and high compliance. Benefits of TR have also been reported in dementia and MS.
Home-based telecommunication exercise programs may represent an effective and inexpensive option to improve the health of individuals with disability while overcoming common adherence and commitment issues. Indeed, home-based exercise programs effectively improve exercise endurance and physical activity in individuals with disabilities. However, few RCTs have investigated the effect of endurance exercise in persons with disabilities. The present data suggest TR programs are safe, feasible, and effective at increasing physical activity levels while improving cardiorespiratory health, body composition, and quality of life.
Applications of Telerehabilitation in Conjunction With Resistance Exercise Training
Spinal Cord Injury
Skeletal muscle atrophy is associated with disuse and resultant reductions in physical activity levels, mechanical loading of bone, and subsequent decline of bone mineral density (BMD). Specifically, in SCI, maintaining lean mass below the injury level is associated with improvements in body composition, metabolic health, and mitochondrial density and activity. Therefore the preservation of skeletal muscle size and function is necessary for proper metabolism and has clinical implications. Adherence to a long-term exercise program is vital to achieve and maintain increases in muscle size and function. Longitudinal changes in exercise studies indicate that fat and lean mass are favorably altered in response to exercise, but these alterations regress to that of preintervention levels following 2.5 years of exercise cessation. Home-based TR exercise programs may offer a strategy for improving adherence to long-term resistance training programs to attenuate the health risks and secondary complications. Various forms of home-based resistance exercise programs have been utilized, including neuromuscular electrical stimulation resistance training (NMES-RT) and upper body resistance band exercises ( Table 22.2 ). A recent pilot study found favorable changes in muscle hypertrophy and intramuscular fat following 8 weeks of twice-weekly NMES-RT. Another study evaluating electrical stimulation training over 2 years found favorable changes in torque, fatigue, and BMD.
|Resistance Exercise Studies|
|Author, Year||Design||Disability||TSI||Sample Size||Injury Level||Platform||Exercise||Duration||Outcomes|
|Mahoney et al. (2005)||Before-after trial||SCI||13.4 ± 6.5 years||5||C5-C10||Telephone||NMES||12 wks|
|Sabatier et al. (2006)||Longitudinal||SCI||13.4 ± 6.5 years||5||C5-T10||Telephone||NMES||18 wks|
|Nawoczenski et al. (2006)||Clinical trial||SCI Spina bifida||41||Multiple levels||Resistance bands||8 wks||Shoulder pain and function|
|Shields and Dudley-Javoroski (2006)||Case series||SCI||6 wks||7||C5-T10||In-home||NMES||2 years|
|Dudley-Javoroski and Shields (2008)||Case report||SCI||7 wks||1||T4||In-home||NMES||4.6 years|
|Kern et al. (2010)||Longitudinal prospective||SCI||9 months to 9 years||25||T12-L5 conus/cauda equina||In-home||FES||2 years|
|Kemp et al. (2011)||RCT||Paraplegia||>5 years||80||Multiple levels||In-home||Resistance bands||12 wks|
|Mulroy et al. (2011)||RCT||Paraplegia||17.9 ± 9.2 (INT) 22.3 ± 11.8 (CON) years||80||Multiple levels||In-home||Resistance bands||12 wks|
|Sasso and Buckus (2013)||Case study||SCI||28 years||1||T12||In-home||Resistance band circuit||12 wks|
|Van Staaten et al. (2014)||Repeated measures||SCI 1 post-polio||16 (3.7–41.8) years a||16||C6-T8 and below||Videoconference||Resistance bands||12 wks||Shoulder pain and function|
|Chumbler et al. (2015)||RCT||Stroke||<24 months||52||NA||In-home||Strength and balance exercises||3 months|
|Gorgey et al. (2017)||Case series||SCI||>1 year||5||C5-T11||Web-based||NMES||8 wks|
|Dodakian et al. (2017)||Repeated measures||Stroke||24 (21–36) wks||12||NA||Videoconference||Arm motor therapy games||28 days|
|Vloothuis et al. (2019)||RCT||Stroke||36 (28–57) (INT) 37 (26–55) (CON) days||66||NA||In-home caregiver-mediated||Individualized exercises||8 wks|
|Cramer et al. (2019)||RCT||Stroke||132 ± 65 (INT) 129 ± 59 (CON) days||124||NA||In-home||Arm motor therapy||6–8 wks||Motor function|