Introduction
Stroke is defined as an acute episode of focal dysfunction of the brain, retina, or spinal cord which lasts for more than 24 hours or where imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) displays a focal infarction or hemorrhage consistent with the symptoms. This is in contrast to a transient ischemic attack (TIA) where the dysfunction is present for less than 24 hours and there is no evidence of infarction upon imaging. Data show that the incidence rate of stroke is relatively stable over time; this has been attributed to better prevention and management of stroke in higher income countries. However, the prevalence of stroke is increasing and is mostly related to the aging of the world’s population. Some studies suggest that the incidence of stroke is higher in rural and remote areas. This must be addressed by policy makers as inequities arise when people in rural and remote areas have poorer access to specialized stroke care and rehabilitation.
Stroke is a leading cause of disability in developed countries. People with stroke may experience a range of symptoms including hemiplegia (weakness on one side of the body), numbness, changes in vision, and changes in speech. These symptoms result in difficulty managing everyday activities and impact the person’s abilities to fulfill their life roles. While stroke commonly affects older people (aged 65 or more), approximately 25% of people who experience a stroke are of working age and likely to be involved in paid or volunteer work. Not all of these people will return to work, with research reporting a range of different outcomes varying from 19% to 73% return to work.
Over the last 20 years, there have been improvements in acute therapies and treatments for stroke. However, most people still experience symptoms that may last for weeks, months, or for the rest of their lives. Rehabilitation addresses impairment, activities, and participation with the overarching goal of maximizing quality of life. It should involve goal setting to identify relevant goals of therapy and individualized care to assist the person to achieve their goals with the support of a multidisciplinary team. Rehabilitation programs are resource intensive as they involve a number of different health professionals often providing individualized (1:1) therapy. Where resources are scarce not all people who would benefit from rehabilitation are able to access such programs, with data suggesting that access to inpatient rehabilitation ranges between 13% and 57%. Inequities in access exist internationally and may be influenced by the severity of the stroke, predicted discharge destination, cognitive impairment, and whether the person lives in a regional or remote area.
Rehabilitation therapies aim to both maximize function in areas of the brain (on the basis of neuroplasticity theories) and use compensatory approaches to maximize independence despite deficits. Research suggests that recovery is dose dependent and clinicians are encouraged to offer services that provide ample opportunity for practice. This remains a challenge in clinical practice and studies suggest that people in rehabilitation spend much of the day inactive and alone. Providing self-directed or home-based exercise programs is often recommended; however, a number of barriers to self-directed exercise programs exist.
Organization of stroke care and health services varies by country. In most Western countries, people are initially admitted to an acute stroke unit. Pathways from acute care may include home (with or without follow-up rehabilitation services), inpatient rehabilitation, or a long-term care facility. People with stroke have reported that transitions in care (e.g., hospital to home) can be difficult and that they feel abandoned and unsupported when they are discharged home. People have also reported that there are gaps in the rehabilitation offered after formal services cease. Of those that survive the stroke and are alive 1 year following stroke (62%), most (80%) remain impaired and require help from informal carers (family) or professional carers.
Telerehabilitation Models for Stroke
Telerehabilitation may be used to aid in assessment, rehabilitation, and support following discharge from an acute hospital or inpatient rehabilitation service. It is commonly used around the times of transition to provide support and rehabilitation in the home upon discharge. It may also be used as a way of offering rehabilitation services to who are people in the chronic phase after stroke yet still have stroke-related symptoms and ongoing rehabilitation goals. Important trials are presented in Table 4.1 .
| Study, Country | N | Intervention | Comparison | Findings |
|---|---|---|---|---|
| 124 | Telerehabilitation program that was designed to improve upper limb function and utilized on-screen games | Clinic-based therapy (matched dose) | Therapy participation resulted in improved arm function in both those who received home-based telerehabilitation and those who received clinic-based rehabilitation. Telerehabilitation was not inferior to in-person rehabilitation. |
| 300 | The intervention group used technological devices to address mobility and physical activity goals, individually prescribed by a physiotherapist. Devices included virtual reality video games, activity monitors, and handheld computer devices for 6 months in hospital and at home. | Usual care |
|
| 536 | Case management after discharge from hospital: three telephone calls and a home visit over a duration of up to 24 weeks | Usual care | No significant difference between groups except for one item on the SF36 measure of quality of life |
| 190 | Case management: home visits and phone calls for 6 weeks after discharge from hospital | Usual care | No significant differences between groups |
| 186 | Phone calls to discuss family functioning and risk factors after discharge from hospital (WE CALL) | Phone number provided and patient asked to call if they had any queries (YOU CALL) | Both groups improved over time; however, people in the WE CALL group reported high satisfaction with the intervention, whereas those in the YOU CALL group rarely made contact. |
| 53 | Aphasia therapy provided via telerehabilitation | Aphasia therapy provided in person | Both groups showed beneficial effects of training and the difference between telerehabilitation and in person was not significantly different with the exception of one measure, the confidence rating scale for aphasia where the in-person group reported higher scores. |
| 31 | Virtual reality system used within the home which aims to improve balance. Includes remote monitoring and phone call checks | Virtual reality system used within the clinic | No significant difference between groups in terms of patient outcomes |
| 46 | Modified version of the Monash Memory Skills Group delivered via videoconferencing | Same program delivered in the home or clinic | Participants in both groups had improvements in goal attainment and key subjective outcomes of everyday memory and prospective memory. |
| 63 | Caregiver-mediated training program with support via telehealth, a tablet, and exercise applications | Usual care | Patients who received telerehabilitation had higher scores on a measure of instrumental activities of daily living, fewer readmissions, and caregivers reported higher levels of self-efficacy. |
Telerehabilitation services for stroke to date can be categorized around the following key themes.
Assessment
Researchers and therapists have shown interest in developing new techniques or methods to remotely assess people after stroke. For example, the eHAB program involves a suite of measurement tools including goniometers to measure range of movement. A variety of home monitoring systems also exist and may monitor health status, including blood pressure, heart rate, blood sugar, and mood (through patient-completed surveys). Researchers and clinicians are also interested in whether existing assessment tools or outcome measures can be administered using telerehabilitation communications. For example, the Chedoke-McMaster Stroke Assessment Activity Inventory is one tool that is used in stroke rehabilitation settings which has been adapted for telephone administration.
Delivery of Traditional Models of Rehabilitation in the Home Environment
Several studies have examined how traditional rehabilitation services could be delivered using information and communication technologies. In these studies, therapists undertake the traditional rehabilitation process (goal setting and therapy interventions) but use simple videoconferencing techniques as the medium rather than being in the clinic or the person’s home. Telerehabilitation is desirable as an alternative to clinic- or home-based rehabilitation as it may be more cost-effective (reduces travel time) and can be offered to people who live great distances from rehabilitation services (so more accessible). Forducey and colleagues reported that a telerehabilitation program involving 12 treatment sessions with a physiotherapist and occupational therapist was as effective as when delivered in person. This study was conducted several years ago and involved use of a desktop videophone. Results showed that there was no significant difference between groups on key functional outcomes, suggesting that telerehabilitation was as effective as in-person rehabilitation.
Trialing Innovative Models of Care
Coaching
Changing the mode of service delivery provides an opportunity to also change the model of service delivery. It has been suggested that telehealth provides an opportunity to think about what should be done rather than what is currently done in practice. As people who receive telerehabilitation services are typically living in their own home, there is an opportunity to focus on rehabilitation goals and activities that are more relevant and contextually appropriate. It is also an opportunity to use approaches that empower the person after stroke to take control of their recovery and rehabilitation.
A telerehabilitation initiative in Canada introduced and evaluated several different models of telerehabilitation. In one study a Stroke Coach program was evaluated. The Stroke Coach program was designed to meet key principles, including being patient centered, highly accessible, timely, and community based. The telephone was chosen as the preferred mode of intervention delivery based on statistics that showed that telephones were one of the most widely used technologies in that population and that people were interested in receiving health education via the phone. The program commenced with two phone calls in the first month after discharge and then monthly calls for 6 months. The program included lifestyle coaching, stroke self-management, and self-monitoring and was offered over seven phone consultations and five follow-up calls. People who received the intervention reported that it was helpful in overcoming low mood, encouraging them to be more physically active, and making better diet choices.
Use of Avatars to Promote Engagement
Clinical practice does not necessarily adjust to the speed of changes in technology. People are still discharged home after stroke with paper-based educational leaflets or written home exercise programs. Avatar technology is being trialed as a more innovative method of educating people about their condition and healthy behaviors. Some work has been done to develop mHealth applications that utilize avatars to encourage patients to remain engaged in rehabilitation activities after stroke. Aljaroodi and colleagues described a process of co-design in which they set out to design the “Regain” app that was able to communicate in a way that promoted engagement, selected appropriate rehabilitation activities, and contained features that nudged the user to complete the prescribed activities. The research group designed a program that involved self-avatars (avatars that visually resembled the user); however, the program has not yet been evaluated. There is great potential to develop this area of stroke rehabilitation; however, significant evaluation will be necessary and the issue of human versus avatar interaction should be considered.
Transition Support to Improve Mood and Quality of Life
Depression is common after stroke, with approximately 25% of people experiencing depression within 2 years of having a stroke. Clinical guidelines recommend that people who appear to have changes in their mood after stroke should be assessed and that antidepressants, psychological therapies, and exercise should be considered as part of intervention. Services have been trialed to support people after discharge with the aim of improving mood and supporting the transition home. Kirkness et al. showed that a brief psychosocial intervention (the Living Well with Stroke program) could be delivered effectively over the phone and that people who received the intervention reported fewer depressive symptoms over time. It should be noted that while several telerehabilitation interventions have tested transitional support, few have reported positive outcomes. Our metaanalysis containing six randomized trials with 1146 participants showed that telerehabilitation services to support the person upon transition home were not more effective than usual care in altering depressive symptoms. Researchers should also consider whether alternative approaches or more intense support is required to show a beneficial effect.
Promoting Stroke Recovery at Scale
The incidence of stroke in developing countries has increased over time. The consequences of stroke are long term and often significant levels of disability mean that low- and middle-income countries are unable to offer widespread and accessible rehabilitation programs. Research is underway to trial whether information and communication technologies can be used to aid recovery and rehabilitation efforts in low- and middle-income countries as a way of offering services at low cost to a large group of stroke survivors. For example, a smartphone-enabled, carer-supported educational intervention for stroke survivors is currently being tested in India. Even in countries that are considered high income, the concept of improving care outcomes for a large group of stroke survivors using low-cost approaches is appealing. In the iVERVE trial, researchers are testing whether personalized electronic self-management support (sent via personalized text messages or emails) can better support the person to achieve their goals. Outcomes of this study are not yet known.
Incorporating Family and Caregiver Support
Upon discharge from hospital or inpatient rehabilitation, the patient’s family will ultimately become more involved in care (and may experience increased carer burden). Family may also be involved in encouraging and supporting the person to complete their rehabilitation therapies. Caregiver-mediated training (in which the patient and carer are educated about which activities are appropriate and the carer supports and supervises the person to perform their rehabilitation with e-health support) has been identified as a promising way of augmenting therapy with beneficial outcomes for the stroke survivor. The CARE4STROKE intervention consists of an 8-week program, executed with a caregiver, and use of an e-health application that presents prescribed and tailored exercise programs. Between sessions, the person and caregiver are encouraged to make contact with the therapist via the phone, videoconferencing, or email. Trials of the CARE4STROKE intervention have had mixed results. A trial involving 63 stroke survivors in Australia found that those who received CARE4STROKE had improved extended activities of daily living (ADL) and fewer readmissions over 12 months, whereas a trial involving 66 people after stroke in the Netherlands did not find that those involved in the intervention had significantly better outcomes on mobility or function compared with those in the usual care group.
Using Combinations of Innovative Technologies Including Gaming and Wearable Sensors
Various telerehabilitation applications have incorporated virtual reality programs to increase the level of innovation for people participating in home-based rehabilitation programs. These telerehabilitation programs assume that the person with stroke will enjoy using the virtual reality program and therefore be more likely to participate in home-based therapy. While there is some research that suggests that virtual reality can be enjoyable, this may not always be the case and may not apply to all individuals. The therapist can monitor the person’s performance and how much time they spend in the program from a distance. The AMOUNT trial used a pragmatic approach and tested whether the tailored prescription of affordable digital technologies results in better outcomes for people admitted to aged care and neurological rehabilitation units. They used a suite of devices including commercial exergaming applications, activity monitors, and specialized rehabilitation programs and commenced intervention in the hospital and continued upon discharge home with remote support from trial staff.
Practice
In practice, the key principles of telerehabilitation remain.
Use of Telerehabilitation for Initial Consultation Purposes
Initial consultations in rehabilitation include multidisciplinary assessment and goal setting, all of which can take place using telerehabilitation technologies.
Swallowing, Speech, and Communication Assessment
Clinical swallowing examinations can be conducted remotely using telehealth. A study in Australia used a trained assistant who assisted the client. The speech pathologist was able to remotely screen for dysphagia risk and review client progress; however, having the correct software and hardware was important (including good lighting, free standing speakers, lapel microphones, and web cameras). A separate study involved the Teleswallowing approach that was developed in the United Kingdom and also uses a trained assistant who assists the person being assessed. This person could be a nurse, care worker, or therapy assistant. A number of studies have demonstrated that assessment of aphasia can successfully be conducted remotely. Furthermore, studies that compared remote versus in-person assessment reported that there were no significant differences between the results obtained in each setting.
Physical Assessment
Uptake of mobility and balance assessments conducted via telehealth appears variable, with clinicians possibly reluctant to do this because assessment can be “hands on” and may present risk of falls. Many specialist mobility and gait assessment clinics have used trained assistants to be present with the client to help and ensure safety. However, this may not always be required and studies have shown that in other health conditions it is possible to conduct a remote assessment of lower limb function and mobility where the patient can safely follow instructions. Multiple specific assessment tools have been tested via remote administration including the Tinetti Performance-Oriented Mobility Assessment, Six Meter Walk Test, Timed Up and Go, Sit to Stand, and Forward Reach Test. Venkataraman and colleagues used standard videoconferencing equipment (desktop computers) and showed that teleassessment of mobility (assessed using the Tinetti Assessment) was feasible, valid, and reliable. It is also possible that a carer or family member could assist the person where they are able to do so and the person is at risk of falls or that the environment could be structured for safety (e.g., exercises while standing at the kitchen bench). As previously mentioned, the eHAB system includes features such as a goniometer that may assist with remote assessment of physical function.
Upper Limb and Hand Assessment
Worboys and colleagues compared telehealth hand function assessment (using standard videoconferencing equipment) with traditional clinical model assessment and found that agreement between the two methods of assessment was high and that clinical decisions made using telehealth were comparable to those made in traditional clinic settings.
Home Assessment
Home assessments conducted by occupational therapists can be time-consuming, require a vehicle, and may involve extensive travel. In a review of the use of information and communication technology within occupational therapy home assessments, we found that therapists are both developing new technologies to facilitate assessments and using simple and accessible equipment to conduct home assessments. Studies to date have shown feasibility of assessing the home remotely. However, traditional in-home assessment appears to be more sensitive in identifying hazards. Whether or not this makes a difference to patient outcomes is unknown. Implementation of this approach in practice has been shown to lead to increased capacity of occupational therapists to conduct home assessments for more people.
Use of Telerehabilitation in Disease Management, Secondary Stroke Prevention, and Self-Management Programs
There are a few examples of applications being used to promote healthy lifestyle, reduce risk of subsequent stroke, and assist with self-management; however, they have reported limited success to date and are therefore not in a position to be widely implemented yet. Adie and James evaluated whether four telephone calls (over 4 months) could help with risk factor management and resulted in changes in blood pressure, statin use, and cholesterol. The intervention was based on social cognitive theory and used a motivational interviewing approach; however, they found no difference in outcomes between groups at 6 months. Gillham and Endacott similarly found that secondary prevention support delivered in part via the telephone did not significantly alter the person’s readiness to change behavior after TIA or minor stroke. Chronic disease self-management programs have not been rigorously tested in people with stroke via telerehabilitation although studies to date suggest that this is possible, can feasibly include group activities, and may have positive outcomes on self-efficacy and lifestyle in people after stroke.
Use of Telerehabilitation for Therapy Purposes
Rehabilitation therapies including physiotherapy, occupational therapy, cognitive and communication therapies, and psychosocial interventions have all been tested through telerehabilitation and in randomized controlled trials. In most cases, the usual therapeutic approach is simply adapted by the therapist for remote delivery. This involves a less hands-on approach and structuring the environment and communication methods to develop rapport. Therapies may involve screen sharing or sending and receiving information to complete some therapy tasks. Only in some cases does the intervention involve more sophisticated technologies such as virtual reality.
When Compared With In-Person Rehabilitation
Metaanalyses of randomized trials show that to date there have been no significant differences in outcomes between groups where one group received telerehabilitation therapy and the other group received in-person therapy. This applies for outcomes of independence in ADL, balance, and upper limb function. However, the grade of evidence is considered low as there are few studies, and the studies that do exist feature some characteristics that place them at risk of bias. Overall, the implication for practice is that telerehabilitation can be used in place of in-person therapy in cases where this seems feasible. This assumes that the person can use the technology (or has someone who can help) and the intervention can be delivered remotely without placing the person at risk of harm (e.g., falls).
When Compared With Usual Care
The evidence for using telerehabilitation as an additional therapy to improve the quality of care is less positive. Metaanalyses have shown that the addition of a telerehabilitation to usual care has not resulted in improved ADL function or upper limb function and has not reduced depressive symptoms or improved quality of life. The grade of evidence for these outcomes is also low to moderate as there are few studies and those studies that do exist are at risk of bias. The implication for practice is that considerable thought should be given before health service managers develop and implement new telerehabilitation programs as an add-on service with the goal of improving care. As there are few studies it is important to conduct more research in the area as it is quite possible that the mode of therapy (e.g., telephone rather than videoconference) and low dose of therapy could play a strong role in the failure of these studies to date.
Special Considerations
Some extra telerehabilitation considerations are required for stroke survivors as they are usually older, may be less technologically literate, may have visual impairment, and may have cognitive or communication impairments.
For clients with communication issues, including people with aphasia , it may be useful to have supported conversation tools on hand (i.e., maps, rating scales, pictures). Consider sending materials in advance so that the person has them with them. Stick with simple technology and ensure rapport through chatting informally at the start. Be aware of what is required to help the person understand and use gesturing, written key words, and diagrams. Monitor the speed of your own speech and allow time for processing. Consider fatigue levels and minimize background noise which will make the person work harder.
For clients with cognitive issues , it is important to minimize distractions. Check in regularly to monitor fatigue and seek support from family members when required. Take advantage of the person being in their own environment and the ability to perform contextually relevant activities. Use notes or a follow-up email to reiterate key information shared.
For clients with visual issues , it is important to determine whether they can see you and you can see all of them, as visual field deficits and neglect can be a barrier to communication. Ensure that the lighting is appropriate for the client and there is no background clutter.
When the client needs “hands-on” help , check whether there is a carer or helper who can be present. Can the person be instructed in using their own hands to test or guide? Can the environment be set up to support the person (e.g., standing at a bench for balance support)?
Control and scheduling . Multidisciplinary rehabilitation programs often involve multiple therapy sessions per day. Patient-centered care models place the person (and possibly their family) centrally in planning therapy and working in collaboration. Therapists and physicians must consider that telerehabilitation sessions should be properly scheduled in advance as if the professional was planning to visit the person in their own home. This ensures that both the professional and the patient are properly prepared and the person with stroke can have control over their day and fit in other important roles such as spending time with friends or leisure activities. Some telerehabilitation programs include features to assist with scheduling although this is not common. For example, the program may contain a calendar that shares the person’s availability for treatment sessions, displays when they are seeing other health professionals, enables the clinician to book the appointment, and provides the person with reminders. A review of features of telerehabilitation devices found that only approximately one-third of devices contained this feature. Morris tested a scheduling app (Anna Cares) within a clinical service. An avatar (named Anna) communicates with the person about their schedule and provides reminders about who is providing therapy and for what purpose (e.g., speech therapy). Evaluation found that while therapists could see the benefit of the app for patients, there were challenges in using the app particularly when their work schedule was unpredictable, or they needed to frequently cancel and reschedule. They also felt that benefits were most apparent when the whole team and patient were using the app and in that case, it could be quite effective.
A summary of important considerations when establishing telerehabilitation is presented in Box 4.1 .
