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
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!
The 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.”
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.
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