The Future of Rehab May Be at Home

How telerehab is showing great promise for stroke survivors



Telerehab — delivering rehab services through the internet — may change everything according to Steven C. Cramer, MD, MMSc, FAAN, FAHA, professor of neurology at the University of California, Irvine School of Medicine.

In his study, presented at the International Stroke Conference this year, 124 stroke survivors underwent six weeks of intensive arm motor therapy. Half of them received traditional supervised in-clinic therapy. The other half underwent an in-home rehabilitation program supervised via a video-conferenced telemedicine system.

Study participants averaged 61 years of age, were four and a half months post-stroke and had moderate arm motor deficits. When examined 30 days after the end of therapy, the Fugl-Meyer scale was used. It is a measure of arm motor status and ranges from 0 to 66, with higher numbers being better. Subjects in the in-clinic group improved by 8.4 points. Subjects in the telerehab group improved by 7.9 points. These levels of improvement on a 66-point scale are practically the same.

In addition to this study, Cramer is working on other studies involving telerehab.

Telerehab is seen as having many inherent benefits for stroke survivors and their families.

Benefit #1 — Convenience

Survivors and caregivers know that 50 minutes of outpatient rehab generally requires a much larger expenditure of time and effort. Cramer outlined the challenges involved for people who have had a stroke, especially a recent stroke. Oftentimes, the spouse (or other family caregiver) has to:

  • take time out of their workday
  • drive to the survivor’s home
  • pack whatever is necessary — pills, meal replacement, walker — in the car
  • get the survivor to and into the car
  • drive to the rehab facility (not a small task in big city traffic or in many parts of the country where therapists are not nearby)
  • then walk from the parking lot to the therapist’s reception area. “For someone who’s had a recent stroke and maybe has a new ambulation assistive device, that could be five minutes, that could be 35 minutes, depending on where the parking garage is and maybe the snow or ice,” Cramer said.
Dr. Steven Cramer

Dr. Steven Cramer

That’s just getting there. Once there, a significant amount of time is taken up with non-therapy activity. Waiting is often involved. The therapist may have to take a history or review the chart, come up with a plan, explain the plan (maybe write it down) and wait for equipment to become available. “Good therapists doing a good job have so many activities to cover in that 50-minute session that often there isn’t a lot of time for a large dose of rehab therapy,” Cramer said. “Studies show that on average there are just 32 arm repetitions in a rehab therapy session.”

After their session, the survivor and caregiver have to reverse the process to return home. Navigate back to the house, unpack themselves and their stuff and maybe collapse in a heap from all the energy they’ve expended. (Energy that, for the survivor, might be better spent actually performing more therapy repetitions.) In total, this process can easily amount to half a day, which can be a big deal for a caregiver who is still working or taking care of children or has health challenges of their own. “I had a patient explain it to me this way, ‘Dr. Cramer, if I could get to rehab, I wouldn’t need rehab.’”

Benefit #2 — More repetition

In the study, survivors were limited to 70 minutes per day on the system, but that was because the purpose of the trial was to compare a specific dose of rehab therapy in the home with the exact same dose in the clinic. “Telerehab offers the potential for the survivor to do massive amounts of practice once the template for therapy is set up by the therapist,” Cramer said. “They can do it when it’s convenient for them. They can take a bathroom break or run an errand and come back and do more, and we know that large doses of therapy are associated with superior outcomes. In the telerehab trial, persons doing home-based rehab, using the telehealth system we provided, performed an average of 1,031 arm movement repetitions per day [in 70 minutes per day].”

Cramer emphasized this point: “Home-based telerehabilitation is not a tool that competes with therapists,” he said. “It is a tool that extends what therapists and physicians and nurses can do. We would never say to a patient, ‘Just grab a system and get busy.’ It starts with a live exam by a licensed therapist who then prescribes a therapy regimen in the language of the system, with the games and exercises of the system. While telerehab saves the patient a lot of time and trouble by not having to do that schlep all the way to the clinic and back three times a week for six weeks, we do think it’s important that the patient visit that therapist at least once or twice at the beginning. That’s how the trial was designed.”

Benefit #3 — It’s fun!

Wall plaque: Home is where the rehab isThe telerehab therapy that Cramer and his team devised is largely delivered through games. “If you want to rewire the brain, the task that you practice can have a bigger or lesser effect depending on some principles of learning,” Cramer said. For example, a task that is challenging and varied will produce more learning than a task that is simple, not challenging and the same every time. “We can adjust the challenge level and add variety to our games. We provide feedback. We try to make it motivating and goal-oriented. We try to make it interesting and fun. Plus, to an increasing extent, we’re trying to make some of the games directly relevant to real-life activities that people want to get good at, like a driving game or some kitchen tasks.”

In essence, the games are tailored to each patient. A panel of two physical therapists and two occupational therapists determines the movements each survivor needs to work on. For instance, lifting the hand off a desk, rotating the hand at the wrist and at the elbow, flexing the elbow and extending it. That’s step one

“Then we ask, ‘What is a commercially available transducer that measures this?’” Cramer said. “So, if you’re rotating palm up, palm down, then an accelerometer for $10 or so that is plugged into a computer shows you whether the palm is up or down. If you’re taking a hand on the desk and lifting up 2 feet and then setting it down again, a PlayStation Move [motion controller] held in the hand will capture the hand going up and going down. So, these are the types of transducers of movement for which the signal can be fed into a computer. That’s step two out of three.”

Step three is devising a game that uses that signal to drive game play, in a way that allows the difficulty to be adjusted. “That’s the fun part,” Cramer said.

Benefit #4 — Holistic approach

Another advantage of the telehealth revolution that is taking shape is the possibility of a holistic approach. In all telerehab studies that Cramer has performed to date, stroke education is included. “People with stroke, on average, often have limited insight into their disease,” he said. “That’s not surprising since they don’t have neurology training. Risk factor control after stroke is often not great. Helping people get a better grip on that is just low-hanging fruit. So, consistent with the telehealth school of thinking that emphasizes a holistic approach, we do that for home-based telerehab post-stroke. In our latest trial, we included stroke education. For the telerehab group, we used a Jeopardy-game format, which is established as being effective for teaching. It’s not just games for rehab.

“A holistic approach extends to videoconferences to talk with the therapist. One day, it could be videoconferences to talk with your doctor and your nurse and your occupational therapist and then your speech therapist. It’s also prevention, checking the blood pressure. In one pilot study, we had people taking a pill every day and taking a picture of it — so, medication compliance. In another study, patients donned a blood pressure cuff each day, and the telehealth system recorded their blood pressure. It’s a very holistic approach that we take in the big study and across the other studies.”

Benefit #5 — Flexibility and control

“Another thing about this that is important is it gives patients more control,” Cramer said. “The games or exercise typically run two or three minutes each, so in between, the patient can run to the bathroom, go on a quick errand or what have you. Survivors can take a break and then pick it right back up — just hit the GO button to continue. That gives the patient more control. They can start whenever they want and pause as often as they like.”

Benefit #6 — It’s simple to use

Ease of use is another point Cramer emphasized. Despite the fact that telehealth services rely on advanced technology, telerehab does not require the survivor to be computer literate. “We actually tested that. We found a computer literacy scale and found that computer literacy was not related to system usage or degree of benefit,” he said. “All you have to do is hit a big GO button to get started, and there’s a thing on the screen that prompts you to do so, saying, ‘Hit the button to get started.’ We’re keeping it really simple. Our instructions are large font accompanied by pictures because vision and language can be a problem for some older survivors. In fact, about a third of the people enrolled in our recent big trial had some degree of aphasia, and they did just as well as the people who did not have aphasia.”

The study Cramer presented at the ISC investigated upper body rehab. He’ll soon publish results of a lower extremity study funded by a research grant from the American Stroke Association. He also sees great potential for telerehab in working with speech therapy. He is seeking funding and speech-language pathologists (SLPs) as partners for that study.

What won’t work

We asked if there were some stroke deficits for which telerehab may not be as effective. “I’m pretty optimistic, but I confess that some types of therapy are probably harder than others to effectively practice using a telerehab method,” he said. “Swallowing would be difficult as would bladder control. But I think anything can be helped with a home-based telehealth rehabilitation approach as long as it can be gamified and a transducer can be found to measure it.”

Cramer stressed that though the therapist is not in the room with the survivor, the therapist must be involved. “It’s important to maintain a relationship with the therapist,” he said. “It’s not ‘Hello, here’s your device. Good luck.’ It’s just like now, whereby a therapist sees a patient, gives them equipment and sends them home to do some practice. This just maybe reduces the transportation, not the amount of therapist involvement. Or, it makes the therapist hours that are paid for more efficiently used. Videoconferences are essential.”

Stumbling blocks

Cramer identifies one of the biggest stumbling blocks to wide adoption of telerehab: There is as yet no mechanism to be reimbursed for doing it. “In other areas of medicine, Congress has acted effectively to directly boost clinician payments for telehealth services,” he said. “As an example, sometimes I do acute stroke telehealth where we help distant hospitals evaluate patients with suspected acute stroke in the ER. That’s readily reimbursed. There are effective reimbursement approaches in place for dermatology and psychiatry and for many, many other areas. But to my knowledge, telerehabilitation is not yet clearly on that list. That means that when people want to work with a therapist or physician though a telerehabilitation system, it’s a harder decision because currently insurance companies often do not cover these services as they do for other aspects of health care.”

Another stumbling block is getting funding for more studies. “That’s number one, two, three, four and five,” he said. “I need to get more grants in order to improve the system and put them in more people’s hands and pay therapists to do the studies. On the research front, the short answer is getting more grants. There’s another answer, too, which is that the University of California — that’s my boss — has licensed this technology to a private company (TeleRehabCare, www.trcare.net) who is working on creating a commercial product.”

Cramer is excited about the future of telerehab. “We really think that we’re on to something here. We hope we’ll come up with something that lots of people can access before too long, and that this will improve lots of people’s lives.”

ABOUT OUR EXPERT: Dr. Cramer runs the Neural Repair Lab at the University of California-Irvine, which is focused on central nervous system repair. If you’re interested in participating in a telerehab study, Dr. Cramer would like to hear from you.

This information is provided as a resource to our readers. The tips, products or resources listed or linked to have not been reviewed or endorsed by the American Stroke Association.

- Advertisement -

This link is provided for convenience only and is not an endorsement or recommendation of either the linked-to entity or any product or service.

AD. Is upper limb spasticity tying you down? Learn more. The Juniper study is now enrolling participants experiencing spasticity in the arms (also upper limb spasticity or ULS). Logo: Revance, remarkable science, enduring performance. Logo: Juniper:


AD. American Heart Association logo. Know your blood pressure numbers. And what they mean. Gain Control.  Learn more.


 

Stroke Connection. Get the app for free.


 

Edit ModuleShow Tags

Stroke Rehabilitation

Making the Best Decisions at Discharge After Stroke

The type of rehabilitation and support systems a survivor receives at discharge can strongly influence health outcomes and recovery. In this, the first part of a two-part series on stroke rehab, we offer guidance for the decision-making process required when it’s time to leave the hospital.

What to Expect from Outpatient Rehab

After stroke, about two-thirds of survivors receive some type of rehabilitation. Outpatient therapy may consist of Several types of therapy. Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required.

What to Expect in Stroke Rehab

Following a stroke, about two-thirds of survivors receive some type rehabilitation. In this second of our two-part series, we want to alleviate some of the mystery, fear and anxiety around the inpatient rehab part of the stroke recovery journey.
Edit ModuleShow Tags Edit ModuleShow Tags

AHA-ASA Resources

The Support Network

When faced with challenges recovering from heart disease or stroke, it’s important to have emotional support. That is why we created a network to connect patients and loved ones with others during their journey.

Caregiver Guide to Stroke

The Caregiver Guide to Stroke is meant to help caregivers better navigate the recovery process and the financial and social implications of a stroke.

Stroke Support Group Finder

To find a group near you, simply enter your ZIP code and a mile radius. If your initial search does not pull up any groups, try

Tips for Daily Living Library

This volunteer-powered library gathers tips and ideas from stroke survivors, caregivers and healthcare professionals all over the country who’ve created or discovered adaptive and often innovative ways to get things done!

Stroke Family Warmline

The Warmline connects stroke survivors and their families with an ASA team member who can provide support, helpful information or just a listening ear.

Let's Talk About Stroke Patient Information Sheets

Let's Talk About Stroke is a series of downloadable patient information sheets, created by the American Stroke Association, that presents information in a question-and-answer format that's brief, easy to follow and easy to read.

Request Free Stroke Information Packets

Fill out this online form to request free information about a variety of post-stroke topics.
Edit ModuleShow Tags

Stroke & Parts of the Brain

When Stroke Affects the Cerebellum

The cerebellum contains 80 percent of our neurons. Its job seems to be to make things better. We talked with neuroscientist Jeremy Schmahmann about how stroke affects the “little brain.”

When Stroke Affects the Parietal Lobe

The parietal lobe helps us make sense of sensory information, like where our bodies and body parts are in space, our sense of touch, and the part of our vision that deals with the location of objects.

When Stroke Affects the Frontal Lobe

Of the four lobes that make up the cerebral cortex, the frontal lobe is the largest. It plays a huge role in many of the functions that make us human — memory, language, movement, judgment, abstract thinking.

When Stroke Affects the Temporal Lobe

The temporal lobe has several functions, mainly involved with memory, perception and language.

When Stroke Affects the Brain Stem

The brain stem serves as a bridge in the nervous system. It sits at the top of the spinal column in the center of the brain. When a stroke happens there, it can cause a few different deficits and, in the most severe cases, can lead to locked-in syndrome.

When Stroke Affects the Thalamus

The thalamus can be thought of as a "relay station," receiving signals from the brain’s outer regions (cerebral cortex), interpreting them, then sending them to other areas of the brain to complete their job.
Edit ModuleShow Tags

Departments

Stroke Notes

Stroke-related news you can use about new scientific findings, public policy, programs and resources.

Readers Room

Articles, poems and art submitted by stroke survivors and their loved ones.

Life Is Why

Everyone has a reason to live a longer, healthier life. These stroke survivors, caregivers and others share their 'whys'. We'd love for you to share yours, too!

Everyday Survival

Practical tips and advice for day-to day living after stroke.

Life At The Curb

A unique perspective on survival by comedian and stroke survivor John Kawie.

Simple Cooking

Cooking at home can be a daunting task, but a rewarding one for your diet and lifestyle (and your wallet). Making small changes in your diet is important to your heart health. Here are simple, healthy and affordable recipes and cooking tips.

Helping Others Understand

Stroke affects people differently and many of the effects of stroke can be complicated. Helping friends and family understand how a stroke is affecting a survivor can help everyone involved.

Support Showcase

Our new department highlighting the good work being done by stroke support groups from around the nation. If you are part of a successful support group we should consider featuring, let us know!