Traumatic brain injuries (TBIs) encompass those injuries that cause a disruption in normal functioning of the brain when it is exposed to some direct or indirect external force (bump, blow, jolt) or a penetrating injury. This is a diverse group of injuries ranging from mild, transient perturbations to devastating structural injuries with severe and long-lasting disability. Across injury severity, the clinical presentation can also vary as TBI can cause a wide variety of symptoms in multiple domains including physical symptoms, cognitive challenges, and psychological disturbances. Those that suffer TBI may engage the health care system in one or more clinical environments and interface with many types of providers including emergency rooms, critical care, acute and subacute inpatient rehabilitation, outpatient rehabilitation, and medical outpatient clinics, among others. In addition, those with long-term sequelae will continue to rely on the health care system over their lifetimes to manage chronic disease-related issues and downstream complications.
Telehealth and telerehabilitation are poised to serve an important role in helping to provide care to TBI patients. Given the breadth of needs of those with TBI, the variety of health care providers and settings in which they may seek care, and the chronic nature of some injuries, there are many uses for telerehabilitation. While some of these uses are well established and their effectiveness studied, others may be underdeveloped. The gap between current roles of telehealth and future uses may be related to a multitude of factors, including limitations in technology resources, lack of infrastructure or institutional support, reimbursement for care, and limits of physical examination maneuvers and accurate diagnostic assessments that may portend liability issues. This chapter will explore current and future uses for telerehabilitation in the TBI population by drawing on what is present in the TBI literature, as well as experience in other areas of neurological and rehabilitative care. We will provide practical guidance for deployment of telerehabilitation for people with TBI, examine special populations, and explore clinical caveats to this mode of health care.
Acute Care Emergence and Critical Care Management
Telehealth can play an important role in providing access to specialist care for trauma patients that may have sustained TBI. One such potential role is in providing triage-based care to rural and underserved health care settings in which the need for surgical intervention or higher level of care can be rapidly determined through virtual consultation. This methodology has been best illustrated in the stroke community, in which teleconsultation between local emergency room staff and specialty stroke providers is used to determine injury severity, early interventions, and need for patient transfer when presenting with stroke symptoms. In addition, teleradiology services are used to read emergent neuroimaging studies that may diagnose TBI and aid decision-making for neurosurgical intervention.
While triage of neurocritical care emergencies in TBI is not well studied, teleneurology or telestroke has already been used extensively for neurocritical care and emergent stroke. A study utilizing telestroke technology reported improved triage, faster intervention times, and better functional outcomes in patients evaluated virtually. Teleneurosurgical practice may also have a role in the management of acute brain injuries. Studies performed in the United States have shown cost-reduction benefits while maintaining good outcomes when using telerehabilitation in the setting of neurocritical emergencies such as intracranial hemorrhage. In addition, remote neurosurgical consultation may facilitate cost savings by limiting unnecessary transfers to tertiary care centers from outlying hospitals. In addition, telehealth may have a role in neurosurgical follow-up care as a substitute for an in-person clinic visit. A similar approach has been shown to be clinically valuable and cost-effective in the burn and trauma literature. For neurological intensive critical care units (ICU) with less critical care clinicians available, telemedicine allows the ICU to expand coverage for neurocritical emergencies. A metaanalysis compared outcomes before and after establishing tele-ICU services and found reductions in hospital lengths of stay and mortality with tele-ICU. Thus the care of the acute TBI patient can be enhanced by multiple telerehabilitation adaptations.
Acute Care Rehabilitation Consultation Service
Early access to dedicated and experienced rehabilitation providers is important for those with brain injuries. However, a recent survey of acute care facilities worldwide found there may be limited access to this type of care in the acute hospital environment. Rehabilitation teleconsultations from provider to provider or provider to patient may serve a critical role in expanding opportunities for early rehabilitation specialty care. Options for rehabilitation teleconsultation to the acute care setting can occur in real-time (synchronous), in which the consulting rehabilitation provider can speak to the patient and primary clinician and conduct an assessment. Alternatively, “e-consultation” (asynchronous) allows rehabilitation providers to provide advice to treating providers regarding specific aspects of care, relying on review of the medical records to provide recommendations and guidance.
Many lessons from acute teleneurology can serve as a model for the continued evolution of telerehabilitation in acute settings, especially while performing consults on brain injury patients. Teleneurology has been used to assess patients with stroke, Parkinson’s disease, epilepsy, and other neurological diseases as part of acute inpatient care. In an assessment of hospitals with teleneurology, lengths of stay were reduced and there was no difference in subsequent mortality or additional costs and utilization following discharge. In addition, telemedicine assessment and diagnosis was found to be similar to in-person evaluation. This model could be mirrored in telerehabilitation consultations of the brain injury patient. In brain injury telerehabilitation, real-time videoconferencing providing two-way audiovisual input between patients and clinicians may allow the consulting rehabilitation provider to be most impactful in their consultation recommendations. Asynchronous or e-consultation may be less valuable to answer diagnostic questions or facilitate an overall plan of care but may have utility in triaging a specific treatment question.
There are a variety of new technologies that might serve to enhance telerehabilitation of TBI patients in acute care. Telerehabilitation consultation may be enhanced through the use of technologies such as a movable cart with a pan-tilt-zoom camera, high-resolution screen, and a computer positioned at the site of patient care. Additional features such as the ability to connect via a web browser–based system to control the camera from a remote site may enable better communication with the patient and may allow the provider to perform elements of the neurological examination with or without a telepresenter at the bedside.
In the Field Remote Assessment
While brain injuries that result in prolonged loss of consciousness, amnesia, and profound motor and sensory deficits necessitate evaluation in emergency room settings, there is a large subset of individuals with TBI who may present with more mild symptoms for which the need to seek immediate medical care is less obvious. This is a common scenario in sports environments and military settings in which concussions or mild TBI frequently present with subtle findings. Proper triage of these injuries is important to facilitate removal from high-risk activities and avoid repetitive and overlap head traumas in those that are concussed. Teleconcussion could play a role in triaging those patients that may be symptomatic from mild head injuries.
Remote monitoring for TBI during game play is common in professional sports using spotter and video replay. In addition, teleconcussion sideline assessments have been proposed for cases in which a concussion-trained health provider is not present, which applies in many youth and recreational sporting events. A study by Vargas et al. in 2017 investigated the feasibility of teleconcussion for sideline concussion assessments with a cohort of 11 consecutive male collegiate football players with a suspected concussion. The Standardized Assessment of Concussion, King-Devick test, and modified Balance Error Scoring System were used for remote assessment. A remote neurologist assessed each athlete using a telemedicine robot with real-time, two-way audiovisual capabilities, while a sideline provider performed a simultaneous face-to-face assessment. The results showed a high agreement between remote and face-to-face providers on examination findings, suggesting that teleconcussion assessment may be feasible.
When discussing the acute management of brain injury in the field, there is much to gain from military medicine. For example, in the United States, the Defense and Veterans Brain Injury Center has utilized a remote cognitive assessment system that allows clinicians in the field to gather cognitive information more rapidly. TBI specialists at distant sites then can review this information and work with other clinicians to develop treatment strategies and return-to-duty recommendations.
At present the most readily available and realistic use of remote assessment for acute injuries in the field is likely in the triage process. Performing a complete and thorough neurological examination that provides a high level of accuracy in making a diagnosis may not be feasible at this point. In studies of acute neurological examination and diagnosis in non-stroke patients, there is good interrater reliability for remote examination, though accuracy is less established. Thus remote assessment and examination may assist in determining the need for immediate transfer to a hospital versus watchful observation in the field, when in-person assessment is not available, but it is unlikely to fully replace in-person care.
While examination of the brain-injury patient will be different based on the rehabilitation specialist and the goals of the evaluation, there are some universal themes that may optimize the remote TBI evaluation. Due to challenges with attention, concentration, and impulse control experienced after TBI, both patient and provider should be in a distraction-free environment with limited background noise or interruptions. When possible, technology should be optimized for sensory symptoms such as light and noise sensitivity, hearing loss, and visual impairments. For those with moderate-to-severe physical and cognitive difficulties, visits should be conducted with a caregiver or assistant with the patient. Prior to beginning the assessment, equipment, supplies, or other resources should be obtained. Examples of these may include pencil and paper for cognitive testing, assistive devices such as bracing and other durable medical equipment that may be evaluated for its use and fit, and medication lists or prescription bottles to conduct a medication reconciliation. At the close of the visit, providing written instructions and summary of the visit recommendations can assist those with organization and memory difficulties.
Performing a complete neurological examination solely via telerehabilitation, particularly when evaluating muscle tone, strength, sensation, and reflexes, is not possible currently. For cases of teleconsultation in which the patient is in a health care facility or clinic, a nurse practitioner, physician assistant, registered nurse, or other allied health professional may be trained to perform a neurological examination (i.e., a “telepresenter”) during the teleconference examination or in front of the camera. In the case of telerehabilitation for patients at home a family member may be able to assist with some physical examination maneuvers such as range of motion. Apart from physical examination, telerehabilitation may play an important role in evaluating the cognitive and psychological aspects of TBI and are discussed below.
Use of Telerehabilitation in Disease Management
There are a variety of opportunities to incorporate telerehabilitation into the management of TBI across the spectrum of disease and the course of care. The evidence to support use of telerehabilitation is explored here but is limited. There are likely uses that are reasonable in this population but have yet to be studied or widely published. The advantage of incorporating telerehabilitation into disease management can include increased access to specialty care, convenience for patients and providers, reduction in care barriers such as time for travel and appropriate transportation, cost-effectiveness, and timeliness of care delivery.
Access to specialty care and appropriate guidance about brain injury is critical to patient success. An important aspect of disease management is education of the patient, family, or other providers. Guidance on expectant management and natural history of the injury can assist with planning care needs, behavioral modifications, environmental adaptation, and treatment interventions. Telerehabilitation allows for ready access to professionals who can provide appropriate education at any stage of brain injury recovery. Particularly as the understanding of brain injury evolves from one of a static injury toward brain injury as a chronic condition, education throughout the duration of recovery may play a role in reducing symptoms and enhancing function.
In a review of existing literature on the effects of education in both mild and moderate-severe injuries, Hart et al. noted increased patient self-efficacy and investment in one’s own rehabilitation in those who received formal education about their injuries. In a broader systematic review of interventions for mild TBI, there was sufficient agreement amongst studies to suggest that patient-centered interaction and the delivery of symptom-related information support recovery from mild TBI symptoms. And in another systematic review of psychological interventions for mild TBI, the authors concluded that, though difficult to quantify, most studies agree that active educational treatment is favored over no treatment. Though there are fewer studies regarding virtual delivery of education, initial results suggest that a web-based format may be a valuable adjunct to traditional education strategies. Active, patient-centered education either remotely or in person seems to be an important factor in recovery from brain injuries along the entire continuum of care.
Another potential role of telerehabilitation in the brain injury population is in assistance with initiation and monitoring of pharmacotherapy. Individuals with acquired brain injuries often experience physical, cognitive, and emotional sequelae including but not limited to seizures, spasticity, pain, fatigue, sleep disturbances, depression, and agitation. One aspect of management is pharmacological—acutely and chronically, with single or multiple pharmacological agents. In one cross-sectional, multicenter evaluation of patients with acquired brain injury admitted to inpatient postacute rehabilitation, 479 of 484 patients were on a medication of some kind, and perhaps even more notably, 80% of patients (387 of 483) were prescribed six or more medications at the examined point in admission. In addition, studies on pharmacotherapy following brain injury demonstrate a high prevalence of prescription medications not only acutely, but also chronically. Yasseen et al. evaluated subjects between 7 and 24 years post-injury, finding that 58.9% (178) continued to take prescription medications, with 44% (70) taking three or more. Most prevalent medication types were anticonvulsants, antidepressants, analgesics, and anxiolytics. Titration of these types of medication requires information from patients and caregivers on current symptoms and side effects. However, much of this can be garnered without in-person assessment and can be completed via telerehabilitation. In other aspects of care, such as spasticity management, in-person physical examination may be needed to determine medication titration. While data are lacking on remote pharmacotherapy intervention and medication titration, one might surmise that ready access to a specialist, as afforded by telehealth, would facilitate timely medication initiation, earlier recognition and reporting of side effects, and reduce unnecessary polypharmacy. Further data are needed to support this use case.
While some aspects of the diagnostic physical examination may not be amenable to telerehabilitation, psychological and cognitive diagnostic assessments may be reasonable to conduct using telerehabilitation. This is of particular significance to the brain injury population, who commonly experience neurobehavioral, cognitive, and emotional changes following injury. Regarding cognitive screening tools, studies have found that the Mini-Mental State Examination performed remotely versus in-person did not differ significantly either in scoring or in interrater reliability. Broader neuropsychological testing batteries, too, appear reliable via the virtual domain. In one study, 32 subjects underwent a total of 12 visual, verbal, and performance tests; most measures ultimately demonstrated high correlation between in-person and remote assessment. A larger validation study by Cullum et al. in 2014, the largest of its kind at the time, included 202 subjects and utilized the Mini-Mental Status Examination, Hopkins Verbal Learning Test-Revised, Digit Span forward and backward, short form Boston Naming Test, Letter and Category Fluency, and Clock Drawing. This study demonstrated highly similar results when comparing virtual to in-person assessments. Importantly, this study included 83 individuals with cognitive impairment, with no significant difference in conclusions. This is certainly of significance when extrapolating to the brain injury population, where cognitive impairment may be a perceived barrier to the utilization of telerehabilitation resources. A 2020 systematic review across teleneuropsychology summarized that virtually conducted neuropsychological assessments, although challenging, appear valid and present an opportunity to increase accessibility to cognitive services and support.
Use of Telerehabilitation for Therapy
There is a robust collection of literature demonstrating the effectiveness of virtual physiotherapy in general rehabilitation, but a paucity specific to brain injury. A systematic review by Ownsworth et al. acknowledged the limitations of brain injury–specific telerehabilitation research, identifying only 13 eligible studies, with significant heterogeneity amongst them. Conclusions noted promising feasibility, cost-effectiveness, and improvement in certain functional outcomes—though more studies were needed for definitive efficacy statements. Another systematic review focusing on improving cognitive function and quality of life in individuals with TBI also denoted limitations in the current literature on remote cognitive rehabilitation due to lack of standardized protocol between studies. Despite these limitations, the authors concluded that remote cognitive therapies may be beneficial regardless of the specific interventions utilized between therapists. Similar difficulties exist in tele-based physical therapy, in which individual studies have reported benefits of remote physiotherapy in the brain injury population, but standardized protocol and parameters have yet to be established, limiting generalizability and application on a wider scale.
While data in telerehabilitation therapies are lacking in brain injury, data from non–brain injury studies could be extrapolated and applied to the brain injury population. A systematic review of poststroke telerehabilitation deemed telerehabilitation at least as effective as in-person therapies for motor and higher cortical deficits as well as poststroke depression. In another study including 81 individuals with brain injury, stroke, or multiple sclerosis, subjects were randomized to month-long programs either utilizing a computerized activity desk directed at upper extremity retraining versus a “usual care” group. Improvements in the Action Research Arm Test and Nine Hole Peg Test were similar between treatment arms, indicating that the home-based training might be an equivalent alternative to in-person therapies. Of note, individuals with serious cognitive and behavioral problems were excluded from this trial. Though studies focused specifically on brain injury are needed, research in other areas of neurorehabilitation offers guidance and encouraging results thus far.
Importantly, remote opportunities for ongoing therapy appear to be an area of interest to affected individuals and their caregivers: in a survey of 71 individuals with acquired brain injury in the community, a majority indicated strong interest in a variety of telerehabilitation options including instructing home-based physical therapies, activities of daily living (ADL) training, and cognitive exercises. In addition, patients reported satisfaction with teletherapy interventions. A recent survey issued to 205 patients undergoing virtual therapy indicated an overall positive response from subjects. Across patient demographics and patient-centered metrics, the large majority of responses were “excellent” or “very good” (93.7%–99%), indicating a high degree of patient acceptance, and suggesting value in future telerehabilitation. Patient interest, support, and satisfaction are critical factors of therapeutic relationships and virtual care appears to be an acceptable, even desirable or preferable option, to patients.
Interventions such as physical and occupational therapy and speech-language pathology also play an important role in the assessment and modification of the home environment. From initial transition home to ongoing, unfolding developments, therapists provide evaluation and counseling to optimize the home setting. Such home modifications have been shown to improve the health and safety of subjects with a variety of health conditions. These home evaluations are traditionally done in person, which may be limited by personnel, location, time, and other resources. Several studies have assessed the feasibility of performing these assessments remotely, utilizing both novel and existing technologies. Initial results suggest at-home versus remote assessments are nearly equivalent, and at least worth exploring as potential adjuncts or alternatives when in-person evaluations are not feasible. Individuals who have sustained brain injuries may benefit from an assortment of home modifications for ease, efficiency, and safety, from installation of new equipment (e.g., railings, ramps) to modifying an existing setup (e.g., reorganizing shelves, removing tripping hazards). Beginning or continuing this process remotely may be an opportunity for increased therapist presence in the home, and in turn, an improved home environment.
There are unique populations who may necessitate special considerations in discourse of telerehabilitation. For example, the pediatric population poses additional challenges in terms of their functional abilities to utilize technology. Depending on developmental age, caregiver presence may be required to facilitate virtual visits, provide collateral, or assist with examination techniques. Despite these barriers, initial studies suggest both feasibility and efficacy of virtual interventions for youth with brain injuries. One randomized controlled trial relying on an online problem-solving intervention even demonstrated long-term benefits in everyday executive function following its use. Some studies have attempted to utilize computerized games as aids to the rehabilitation process, which might be a favorable option to the adolescent population in particular; however, generalizability has not been definitively confirmed. Telehealth may also be an opportunity to foster family or friend engagement, with a chance for parents, siblings, and other caregivers to partake in the rehabilitation process of a pediatric patient. This is an area of remote medicine that would benefit from further investigation.
Members of the military are another population meriting special attention in this discussion. Telerehabilitation is already widely utilized in the military for diagnosis, acute treatment, and long-term rehabilitation. TBIs, particularly mild TBIs, are common in modern warfare due to increased exposure to powerful weaponry and explosives. For example, the United States estimates that 15% to 20% of veterans from the Iraq and Afghanistan wars have sustained at least one TBI. For this reason, there may be greater demand for TBI services in active duty military and veterans that can be alleviated by telehealth.
Caregivers of patients with brain injuries may also benefit from telehealth. Caregivers share in the burden of injuries and illnesses affecting their loved ones, particularly those caring for people with TBI. It is estimated that 28.5% of the US adult population or 65.7 million people provide “informal” caregiving for an adult relative. Caregiver socialization and support could be an area of opportunity for remote interventions. There also may be educational or training benefits for caregivers as they learn to tend to an individual with brain injury. As questions, concerns, and challenges arise in the home environment, caregivers may look for advice from professionals and peers. As such, this too may be a population who would benefit from the accessibility, continuity, and social opportunities made possible by remote medicine. A 2012 systematic review concluded that telehealth programs for families of individuals with brain injuries are both feasible and effective, with the large majority reporting positive outcomes. Though there were limited direct comparisons to face-to-face encounters, those that did include in-person encounters as a control found no significant difference in caregiver outcome.
Behavioral Disturbances, Psychosis, or Self-Harm
In some types of brain injuries, patients may have co-occurring severe behavioral disturbances, mood disorders with psychotic features, self-harm behaviors, or even suicide risk. Using telerehabilitation with brain injury patients suffering from these types of psychological sequela presents a unique challenge for patient safety. There are little data on telerehabilitation in this subpopulation of brain injury. Yet, in patients with psychosis without TBI, videoconferencing afforded patients a higher degree of comfort because the perceived distance of the interaction was less anxiety-provoking and may reduce overstimulation triggered by some in-person interactions. In addition, telerehabilitation may allow better insight into the patient’s daily life by assessing their homes and living environments, thus better informing diagnosis and treatment. Nevertheless, it is critical for the clinician to weigh the benefits of the telerehabilitation visit with the potential risks of remotely triaging or managing unstable and serious mental health symptoms. If telerehabilitation is used, additional precautions may be considered for a patient at risk of harming himself/herself or others; for example, this may include confirming a patient’s location at the beginning of the visit, having a plan for maintaining the telerehabilitation connection to the patient, and knowing how to guide emergency services to a patient in the event of crisis.
Cognitive and Sensory Deficits
Patients with brain injuries can often present with hearing loss, visual impairment, or other sensory difficulties that could impede virtual care. For example, patients with reduced hearing are at a disadvantage if using telephone communication, mainly due to the absence of visual cues and a narrower range of speech frequencies. Sound quality and visual input can vary widely across different telecommunication devices such as landline, cellular phone, and videoconference. Low-quality sensory input may affect a brain-injured person’s ability to provide a history, perform physical examination maneuvers, or participate in cognitive testing. Lighting quality and the patient’s screen size are also important factors when assessing this subset of patients with visual impairments or symptoms. When testing these patients, providers should not assume intact sensory abilities. At a minimum the examiner should inquire about hearing and vision prior to a telerehabilitation visit. Patients should be prompted to use hearing aids, glasses, and other assistive devices during the examination.
Older adults with TBI experience higher morbidity and mortality and tend to have a slower recovery. On average, they also have worse functional, cognitive, and psychosocial outcomes months or years post-injury than their younger counterparts. It is commonly believed that elderly patients may show reluctance to adopt a novel technology and this could be compounded by the effect of a brain injury. However, a recent study has found that 65% of the geriatric population would be willing to trial current technological advancements such as virtual reality. In addition, telerehabilitation can easily be extended to elder care centers and residential facilities, where staff can assist with the technology required to complete a telerehabilitation visit successfully. It also appears that establishing videoconferencing integrated with a local health care service such as a primary care physician may significantly improve elderly persons’ behavior and also reduce the caregivers’ burden. Findings suggest that the delivery of videoconferencing is feasible, acceptable, and beneficial to older adults in the chronic phase after TBI and stroke.
Underserved Populations with TBI
Increasing access to specialty care is an important benefit of telerehabilitation and can improve health care disparities in underserved TBI populations. Recent research has shown that non-Hispanic Black and Hispanic patients are less likely to receive follow-up care and rehabilitation following a TBI compared with non-Hispanic White patients. Compared with insured White patients, insured Black patients had reduced odds of discharge to rehabilitation as did insured Hispanics and insured Asians. Telerehabilitation has also been shown to reduce location-based disparities in care. Not only can telerehabilitation make care more accessible to patients who live in remote or inaccessible areas, but it also can improve access to those who are unable to drive following their injuries and can reduce reliance on family members and caregivers to attend medical and therapy visits. In addition, telehealth may assist patients of lower socioeconomic status who have limited means to afford adaptive transportation, sick leave from work, or childcare. While reducing some barriers to underserved populations, telehealth may also create barriers with socially or economically disadvantaged groups. Those of lower socioeconomic status or who suffer financial hardship may have limited access to technologies (internet access, tablets, smartphones, computers) needed to participate in their visit. Every effort should be made to reduce barriers to telehealth care for these groups, including but not limited to offering telehealth platforms that are verbal only and do not require a camera, using telehealth applications that do not require downloads or an email address, and providing technical support or orientation to technology prior to the visit.
Telerehabilitation in the rehabilitation setting is in its infancy. While some diagnoses and domains of care are developing quickly, such as stroke care, TBI telerehabilitation has had comparatively little research to validate its use. Nonetheless, the uses for telerehabilitation in TBI are many, spanning early triage through the acute care, inpatient rehabilitation, and outpatient rehabilitation settings. Future work is needed to determine the most impactful telerehabilitation uses and compare them to in-person care. In addition, there is a need to develop technology interfaces that may assist or improve physical examination assessment and therapeutic interventions such as robotics and virtual reality. Finally, more work is needed to improve access to telehealth services, including wider adoption of telerehabilitation by private and government health care organizations, optimization of regulations to broaden telerehabilitation services, and development of telerehabilitation interfaces that are accessible to all including underserved and marginalized TBI specialty populations.