Telerehabilitation: Has Its Time Come?

Pamela W. Duncan, PT, PhD; Julie Bernhardt, PhD

Disclosures

Stroke. 2021;52(8):2694-2696. 

Telemedicine is commonly defined as the use of electronic information and communication technologies to provide and support health care when distance separates the participants.[1] Early adopters of telemedicine included prison systems, rural health care systems, and the radiology profession. Telerehabilitation appears to have begun in the mid-late 1990s; a 1997 US telemedicine survey identified 3 rehabilitation counselling programs, with ≈12 teleconsultations per program.[1] This advances article provides an overview of current stroke telerehabilitation research and practice. We pose the question: has the time finally come for telerehabilitation to be a mainstream part of stroke rehabilitation care?

Telerehabilitation can deliver stroke rehabilitation services to manage functional recovery, motor recovery, communication, depression, and stroke risk factors (eg, exercise, diet to reduce blood pressure).[2] Telerehabilitation is a blanket term applied to approaches that employ an ever-expanding range of technologies. Even limiting our review to approaches that deliver or support specific training or therapy (not just consult or advise patients), the number of alternative approaches is still vast. Telerehabilitation can be synchronous (connecting patient and therapist in real time via any device), asynchronous (computer-based interventions are remotely monitored and adapted offline by a therapist), or a combination of both.[3] Some core principles to govern provision of telerehabilitation should include (1) professional and health care standards must not be lowered by delivering rehabilitation via telehealth methods, including patient confidentiality, (2) access to telerehabilitation must be inclusive of diverse groups and rural populations, and (3) we must have a strong commitment to research and ongoing development of the telerehabilitation evidence base.

Telerehabilitation randomized trials have demonstrated low to moderate evidence that telerehabilitation services are not inferior to in-person care.[4,5] Telerehabilitation interventions can improve stroke survivor's impairments, disability, and quality of life and help reduce depression and improve quality of life in their caregivers.[4] Telehealth participants identify the need for technical support, availability of a care giver, and a good physical environment to implement telerehabilitation.[6]

Recently, Cramer et al [7] compared the effectiveness of home-based arm motor function rehabilitation (36 therapy sessions; 70 minutes each) using telemedicine (62 patients) to that of in-clinic rehabilitation (62 patients). Both therapy groups displayed significant improvements in arm motor function, again confirming that telerehabilitation appears as effective as in-clinic rehabilitation.[7] Yet, broad uptake of these interventions has been slow.[2]

As the 2020 coronavirus disease 2019 (COVID-19) pandemic unfolded, health systems were quickly reorganized to cope. Stroke care was impacted, including in-person rehabilitation services which were radically reduced or ceased altogether for a time.[8] Telerehabilitation services for stroke rapidly expanded into routine practice throughout the world as an alternative to inpatient care.[9] This led in many countries to rapid development and dissemination of how to telehealth resource guides and information (eg, National Stroke Foundation Australia,https://informme.org.au/News/2020/03/26/COVID-19-Telehealth-resources),[10] webinars, and development of telehealth communities of practice to support uptake.

While it is too early for many published reports of rapidly implemented telerehabilitation stroke services to emerge, some examples exist. Yang et al [11] rapidly implemented the virtual Graded Repetitive Arm Supplementary Program, delivered and evaluated via videoconferencing. In a small sample, they demonstrated feasibility of Graded Repetitive Arm Supplementary Program delivery via teleconferencing, that geographic reach was greater, with higher attendance of telerehabilitation sessions than in person sessions. In the United Kingdom, outcomes from the first 22 patients to attend a telehealth-delivered, synchronous, guided upper limb rehabilitation program were recently reported. This rapidly implemented telerehabilitation program aimed to replicate, as much as possible, a previously delivered intensive training programme.[12] In total, patients engaged in 83 hours of active upper limb therapy over 4 weeks. These early results suggest that selected patients with chronic stroke can make significant improvements in impairment, function, and quality of life. However, not all patients are suitable, and ongoing work to optimize service delivery is required.[13]

In Canada, COVID-19 also prompted update of the Canadian Stroke Best Practice Recommendations Telestroke Implementation Toolkit to help clinicians and patients effectively engage in virtual health care services, including stroke rehabilitation. The toolkit provides best evidence guidance for assessment, diagnosis, and management of people with stroke when direct in-person care is not available.[14] Within the toolkit are checklists for the provider (therapist or clinician) and the individual, family and caregivers, to help guide telerehabilitation appointments, telerehabilitation skills and capacity, technical aspects including data security, etc, and suggested performance measures for telehealth service evaluation. Importantly, the need for coordinated and sustainable funding and reimbursement is clearly acknowledged as essential to effective telehealth service delivery.

Almost overnight, major reorganization of health care delivery occurred in the United States and other countries to accommodate physical distancing. Expanded policy coverage permitted health systems and hospitals to broaden telehealth services, deepen infrastructure, and increase telehealth and telerehabililtation use. This rapid expansion of telehealth has overcome substantial challenges in providing care during this unprecedented period and has introduced unique challenges, as well as potential barriers and disparities in care delivery. For example, older individuals, men, and Black individuals are less likely to engage in telehealth visits.[15]

With widespread adoption of telerehabilitation catalyzed by the COVID-19 pandemic, there is great potential for improve care equity, addressing geographic, demographic, and socioeconomic barriers.[16] However, this new care model is likely to reveal new disparities encountered by patients. The reliance on technology is central to the delivery of telehealth and creative ways to overcome this barrier maybe needed.[2] Future studies will be needed to explore ways to overcome these challenges. Prvu Bettger and Resnik [3] recommend we consider the COVID-19 pandemic, and the rapid shift to telerehabilitation, as an opportunity to take a Learning Health System research approach to evaluate telerehabilitation. Taking a learning health system iterative research approach would require acquisition and integration of evidence from real-world telerehabilitation experiences (clinical practice) across different clinical domains, settings, and patient populations to identify best practices that should be scaled up in the future. To harness this opportunity requires mobilization and coordination of interested groups to agree and implement the stroke telerehabilitation research and practice agenda.

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