To compare participation and subjective experience of participants in both home-based multi-user VR therapy and home-based single-user VR therapy.
Background: Exergames have the potential to provide an accessible, remote approach for post stroke upper extremity (UE) rehabilitation. However, the use of exergames without any follow-up by a health professional could lead to compensatory movements during the exercises, inadequate choice of difficulty level, exercises not being completed and lack of motivation to pursue exercise program, thereby decreasing their benefits. Combining telerehabilitation with exergames could allow continuous adjustment of the exercises and monitoring of the participant completion and adherence. Currently, there is limited evidence regarding the feasibility or efficacy of combining telerehabilitation and exergames for stroke rehabilitation.
Objective: 1) To determine the preliminary efficacy of using telerehabilitation combined with exergames on UE motor recovery, function, quality of life and motivation, in participants with chronic stroke, compared with conventional therapy (the graded repetitive arm supplementary program) 2) To examine the feasibility of using the technology with stroke participants at home 3) To identify the obstacles and facilitators for its use by stroke participants and therapists and understand the shared decision-making process.
Methods: A mixed-methods study protocol is proposed, including a randomized, blinded feasibility trial with an embedded multiple case study. The intervention consists of the provision of a remote rehabilitation program, during which participants will use the Jintronix exergame for UE training and the Reacts Application to conduct video conferenced sessions with the therapists (physical or occupational therapists). We plan to recruit 52 stroke participants, randomly assigned to a control group (n=26, 2 months on-paper home exercise program: the graded repetitive arm supplementary program with no supervision) and an experimental group (n=26, 2 months home program using the technology). A blinded trained evaluator will be responsible for the face to face administration of the outcome measures. The primary outcome is the Fugl-Meyer UE Assessment, a performance-based measure of UE impairment. The secondary outcomes are self-reported questionnaires and include the Motor Activity Log-28 (quality and frequency of use of the UE in 28 everyday tasks), Stroke Impact Scale-16 (impact on quality of life) and Treatment Self-Regulation Questionnaire (motivation). Feasibility data include process (recruitment and retention rates), resources (exercise adherence, time spent with therapist,), management (technical problems)and scientific (safety, simple size) outcomes. Qualitative data will be collected by interviews with both participants and therapists.
Results: We expect to: A) Collect preliminary efficacy data of this technology on the functional and motor recovery of the UE, following a stroke B) collect feasibility data with users at home (adherence, safety, technical difficulties, etc.) and C) identify the obstacles and facilitators for the technology use and understand the shared decision-making process.
Conclusions: This paper describes the protocol underlying the study of a telerehabilitation-exergame technology to contribute to understanding its feasibility and preliminary efficacy for UE stroke rehabilitation.
Comparison of Kinect2Scratch Game-Based Training and Therapist-Based Training for the Improvement of Upper Extremity Functions of Patients With Chronic Stroke: A Randomized Controlled Single-Blinded Trial
Background: Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face or when added to usual care.
Objectives: To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation or usual care. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self-care and domestic life and improved mobility, balance, health-related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions.
Search methods: We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists.
Selection criteria: Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation.
Data collection and analysis: Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings.
Main results: We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies. Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post-hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post-stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke.
Primary outcome: we found moderate-quality evidence that there was no difference in activities of daily living between people who received a post-hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) -0.00, 95% confidence interval (CI) -0.15 to 0.15)). We found low-quality evidence of no difference in effects on activities of daily living between telerehabilitation and in-person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI -0.43 to 0.48).
Secondary outcomes: we found a low quality of evidence that there was no difference between telerehabilitation and in-person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI -0.30 to 0.46). Pooling of three studies with 569 participants showed moderate-quality evidence that there was no difference between those who received post-discharge support interventions and those who received usual care on health-related quality of life (SMD 0.03, 95% CI -0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate-quality evidence that there was no difference in depressive symptoms when comparing post-discharge tele-support programs with usual care (SMD -0.04, 95% CI -0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI -2.17 to 4.64, low-quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in-person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial-related adverse events were reported.
Authors’ conclusions: While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate-level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short-term post-hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in-person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost-effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.
Loss of arm function occurs in up to 85% of stroke survivors. Home-based telerehabilitation is a viable approach for upper limb training post-stroke when rehabilitation services are not available. Method: A costing analysis of a telerehabilitation program was conducted under several scenarios, alongside a single-blind two-arm randomized controlled trial with participants randomly allocated to control (N=25) or intervention group (N=26). Detailed analysis of the cost for two different scenarios for providing telerehabilitation were conducted. The fixed costs of the telerehabilitation are an important determinant of the total costs of the program. The detailed breakdown of the costs allows for costs of future proposed telerehabilitation programs to be easily estimated. The costs analysis found that a program supplying all required technology costs between CAD$475 per patient and CAD$482 per patient, while a program supplying only a camera would have total costs between CAD$242 per patient and $245 per patient. The findings of this study support the potential implementation of telerehabilitation for stroke survivors for improving accessibility to rehabilitation services. This cost-analysis study will facilitate the implementation and future research on cost-effectiveness of such interventions.
Post-stroke cognitive disorders can affect different domains, depending on typology of stroke and lesion localization, onset time, age and diagnostic tools used. In recent years, telerehabilitation using virtual reality has been used to reduce the healthcare costs encouraging continuity of care.
The aim of our study is to evaluate the efficacy of a virtual reality rehabilitation system in improving cognitive function in stroke survivors. Forty patients affected by stroke were enrolled in this study and randomized into either the control or the experimental groups in order of recruitment.
The study lasted 6 months, and included two phases: (1) during the first phase the experimental group underwent cognitive rehabilitation training using the Virtual Reality Rehabilitation System-Evo, whereas the control group was submitted to standard cognitive training; (2) in the second phase (after discharge), the experimental group was treated by means of virtual reality rehabilitation system Home Tablet (three sessions a week, each session lasting about 50 minutes), and the control group continued the traditional training, with the same amount of treatment. The patients underwent a neuropsychological evaluation before and at the end of the treatment. Linear mixed-effects analysis results showed that the scores of Montreal overall cognitive assessment, attentive matrices, Trail Making Test B, Phonemic Fluency, Semantic Fluency, Rey Auditory Verbal Learning Test I, Hamilton Rating Scale-Anxiety and Hamilton Rating Scale-Depression were affected by the type of the rehabilitative treatment.
Our data show the effectiveness of telerehabilitation for the treatment of cognitive disorders following stroke.
Objective: This article describes the findings of a study examining the ability of persons with strokes to use home virtual rehabilitation system (HoVRS), a home-based rehabilitation system, and the impact of motivational enhancement techniques on subjects’ motivation, adherence, and motor function improvements subsequent to a 3-month training program.
Materials and Methods: HoVRS integrates a Leap Motion controller, a passive arm support, and a suite of custom-designed hand rehabilitation simulations. For this study, we developed a library of three simulations, which include activities such as flexing and extending fingers to move a car, flying a plane with wrist movement, and controlling an avatar running in a maze using reaching movements. Two groups of subjects, the enhanced motivation (EM) group and the unenhanced control (UC) group, used the system for 12 weeks in their homes. The EM group trained using three simulations that provided 8–12 levels of difficulty and complexity. Graphics and scoring opportunities increased at each new level. The UC group performed the same simulations, but difficulty was increased utilizing an algorithm that increased difficulty incrementally, making adjustments imperceptible.
Results: Adherence to both the EM and UC protocols exceeded adherence to home exercise programs described in the stroke rehabilitation literature. Both groups demonstrated improvements in upper extremity function. Intrinsic motivation levels were better for the EM group and motivation levels were maintained for the 12-week protocol.
Conclusion: A 12-week home-based training program using HoVRS was feasible. Motivational enhancement may have a positive impact on motivation, adherence, and motor outcome.
To compare participation and subjective experience of participants in both home-based multi-user VR therapy and home-based single-user VR therapy.
Crossover, randomized trial
Initial training and evaluations occurred in a rehabilitation hospital; the interventions took place in participants’ homes
Stroke survivors with chronic upper extremity impairment (n=20)
4 weeks of in-home treatment using a custom, multi-user virtual reality system (VERGE): two weeks of both multi-user (MU) and single-user (SU) versions of VERGE. The order of presentation of SU and MU versions was randomized such that participants were divided into two groups, first multi-user (FMU) and first single-user (FSU).
We measured arm displacement during each session (meters) as the primary outcome measure. Secondary outcome measures include: time participants spent using each MU and SU VERGE, and Intrinsic Motivation Inventory (IMI) scores. Fugl-Meyer Upper-Extremity (FMUE) score and compliance with prescribed training were also evaluated. Measures were recorded before, midway, and after the treatment. Activity and movement were measured during each training session.
Arm displacement during a session was significantly affected the mode of therapy (MU: 414.6m, SU: 327.0m, p=0.019). Compliance was very high (99% compliance for MU mode and 89% for SU mode). Within a given session, participants spent significantly more time training in the MU mode than in the SU mode (p=0.04). FMUE score improved significantly across all participants (Δ3.2, p=0.001).
Multi-user VR exercises may provide an effective means of extending clinical therapy into the home.
Telerehabilitation is defined as delivery of rehabilitation services over telecommunication networks and the internet, which comprise of clinical assessment (the patient’s functional abilities in his or her environment) and clinical therapy.This new area of medical advancement, using state of the art technology is developing at a great speed and is definitely going to be the next milestone in health care revolution.The objective of this study was to explore the awareness, knowledge and perception of the patients for using telerehabilitation as a medium to provide physiotherapy services as a part of home healthcare services. A pretest-post test design was used where the home healthcare patients (n = 90) aged between 50 -75 years were asked to express views by given a validated modified TUQ questionnaire followed by an indepth interviewing to develop a key understanding regarding the themes. Interviews were transcribed and a qualitative thematic analysis was conducted. The awareness level regarding the telerehabilitation changed significantly from 57% to 96% post session(p<0.05). Similarly, the knowledge of the participants regarding online consultation, followup and online therapy changed significantly from 50%, 47% and 57% to 96%, 76% and 96% respectively post session of rehabilitation(p<0.05). The perception level regarding the key benefits including its usage in emergency(83%), convenience of no travel(84%), ease of getting treated at home(97%) and availability of specialist consultation (84%) were the prime ideas for excellent rating among 95% participants (p<0.05) post session. Findings are helpful to health practitioners in designing their intervention programs across the kingdom. However the actual impact could be only derived from future studies which has to conducted based on different clinical conditions.
Telerehabilitation is defined as the provision and delivery of rehabilitation health services at a distance using information and communication technologies and tools (Tan 2005; Russell 2007). Throughout the world, the health care practices is going through major transformation as it is driven through sea change because of the increased use of technology. The kingdom of Saudi Arabia too is witnessing a massive change with significant restructuring of healthcare systems with some major high-end technology driven development solutions. The increased demand is created on account of rapidly increasing saudi population including the growing elderly community, changing disease patterns, global climatic changes and financial inequity (Mahmood 2018). According to a United nations report the elderly population of Saudi Arabia those aged 60 and above is projected to increase from 3% in 2010 to 9.5% and 18.4% in 2035 and 2050, respectively (UN Report, 2018).
Similarly, comparing this phenomenon to an average life expectancy of the population in Saudi Arabia, the latest WHO data published in 2018, suggests that Saudi male and female have an average of 73.5 and female 76.5 life years with an average life expectancy of 74.8 years as against an average world life expectancy of 84 years.The increased demand in kingdom also raised because of immense economic pressure with steep fall in global oil prices in 2015-16 affecting the GDP significantly thereby been one of the key stimulus for the government to take timely corrective actions and diversify the economy from heavily oil dependent to develop other verticals for revenue generation (MoH Report, 2018).
Brian child of Crown Prince HH Mohammad Bin Salman, Vision 2030 was adopted in April 2016 and has identified its priorities across all economic sectors and serves as a roadmap for the economic development of the KSA with development of health services been one of the most important key themes. Therefore, as a part of realization of this vision the government strongly supports the partnership of private and public sectors and been seen as a strong indication of the Government’s commitment for making healthcare accessible to its citizens irrespective of the disparities available in the Saudi society (Vision 2030 Report, 2016). Access to healthcare generally relates to people’s ability to use health services when and where they are needed. Determinants of healthcare access are the types and quality of services, including the costs, time, distance (ease of travel) as well as regular interface between service users and healthcare providers. Saudi Arabia is the largest and fastest growing health care market in the region and is estimated to reach $40 billion by 2020 (NTP 2020 Report, 2016).
Moreover, the steep increase in the number of hospitals across all major cities of KSA are run by both government and private organizations which use corporate business strategies and technology driven specializations, which aim to create demand as well as attract high number patients as the facilities in majority of these hospitals are world class.Among the various strategies listed in the NTP Report 2020, one of the key components of making healthcare accessible across the kingdom is the enhanced use of telemedicine (NTP 2020 Report, 2016). In the last one decade the health services across the kingdom have taken gigantic leap jumps with private healthcare taking lead and using innovations in delivering healthcare. One of such innovations is using Home Healthcare for delivering physiotherapy and other rehabilitation based services for the patients at home (Pulse Report 2018).
Rehabilitation is a very important component in medical care and helps in propelling patient to preinjury level. It is a well known fact that in all long term cases which requires follow-ups such as in surgical cases and other debilitating disorders including Stroke, Cancer, Multiple Sclerosios, rehabilitation is time consuming and financially constraining. To add to this, patients travelling long distances for treatment, it is not only physically challenging but emotionally draining too and especially in case of geriatric patients.Therefore home tele rehabilitation programs, are winding up progressively as an elective method of service delivery. In the western countries, quite a number of research studies has been proved that the Telerehabilitation for the delivery of health services is quite effective, however the scope of using such services in the kingdom is still novice and requires a detailed study, (Hailey et al., 2010, Johansson and Wild 2011, Chang et al 2019 ).
There are scant studies to prove its efficacy in the developing countries as its successful will depends on a number of factors (Clemens et al 2018) . However, among all the variables, the two most important are the technological component and second been its implementation in real terms (Jackson and McClean 2012, Clemens et al 2018). Accordingly, these both are of extreme critical importance from the patient satisfaction point of view. The perceptions of the stakeholders, i.e. the patient and the members of the Rehabilitation team are of utmost importance for its use and wide spread application.The home healthcare services in Saudi Arabia is still in infancy stages with few delivery partners across the kingdom. The usage of telerehabilitation is even more nascent, as the perception of patients in using such a technology for delivering healthcare would be quite critical and important to understand the phenomenon which would be quite useful in framing the guidelines for its applications at a mass level, (Alaboudi et al 2016).
Therefore, this study is an attempt to study the awareness, knowledge and perceptions of the home healthcare patients in using physiotherapy services delivered via cloud based telerehabilitation. This study, to our knowledge is the first of its kind in the kingdom especially from the perspective of home healthcare patients. It aims to explore the key ideas which might work in favour or against the successful implementation of telerehabilitation used for the home healthcare delivery.
Materials and Methods
The pretest-post test study design was conducted on home healthcare patients so as to obtain an in-depth understanding of the patients’ perception about telerehabilitation services which they will receive as a part of home health services. While a few studies conducted earlier emphasized about telemedicine to be a key part in delivery of health services, however none of the studies emphasized on perception of patients to implement telerehabilitation as part of home healthcare (Clemens et al 2018, Khalil et al 2018).
Due necessary approval were taken from the ethical clearance committee of the respective organization, which is a reputed home healthcare organization based in Riyadh. In order to recruit participants for the study, sample population were selected from a pool of home healthcare patients who were undergoing treatment under one of the most prominent home healthcare organizations in the kingdom, which incidentally was the only first licensed stand-alone home healthcare services company in Riyadh province.
The study was conducted from Jan 15 to May 30, 2019. In this context, non-probability sampling method was used. Out of 113 home healthcare patients who underwent treatment for different ailments, 90 were randomly selected who also gave their consent to participate in the study out of which 57 were males and 33 were females. Those patients who suffered from orthopedic problems such as Knee pain, low back ache, disc prolapse etc. or underwent orthopedic surgeries such as knee replacement or meniscectomy etc. participated in the study. The study mainly included common geriatric patients for the study who were willing to participate but excluded the pediatric and the critical care, neurological and cardiac patients as they underwent major surgeries such as for stroke or CABG and also were unable to respond directly to answer the questions. The patients who were able respond in English or Arabic were recruited for the study.
Based on literature review and discussion with key stakeholders, a questionnaire and an the interview guide was prepared, modified from Telehealth Usability Questionnaire (TUQ) based on key themes of perceived usefulness, ease of use and learnability, Interaction quality, Reliability and Satisfaction and future use (Langbecker et al 2017) . The questionnaire was converted to Arabic version adapted from the original English version and pilot tested for the home healthcare patients using both forward and backward translation methods and achieved very acceptable score of confirmatory factor analysis of 0.78 using SPSS. It was also pilot tested for the members of the rehabilitation team. The questionnaires as given in Appendix 1 were responded by the patients and the members of the rehabilitation team followed by a semi structured individual interview from the patient as well as from the team members involved in providing home health services. The interviews were audio recorded and transcribed verbatim using Text Analysis Markup System (TAMS) Analyzer as suggested by Yin (Yin 2013).
The Tele-rehabilitation Technological solutions were a part of home health services which were delivered by the company. As a part of cloud based HIPAA compliant network, the telemedicine unit consists of a portal to track health metrics and rehabilitation treatment plan and progress by the PT specialists as well as the Case Managers. The system included case briefing, consultation by specialists as well as providing physiotherapy sessions both by Home health therapists or via health workers such as PTAs within the vicinity of home environment at patient’s ease as schematically represented in Fig. no.1.
The participants were given a pre and post session modified TUQ and asked to reflect on their entire rehabilitation experience using the Telerehabilitation platform so as to get relevant information about telemedicine services including key events such as finding out they would receive services at home by videoconference, having the internet and videoconferencing equipment installed at home and receiving services by videoconference including dealing with technical issues. Following the same detailed interview was taken using the TAMS so as to identify key ideas which can affect usage of telerehabilitation. . Statistical tests was conducted using SPSS for Pre-post differences evaluation. using paired t-tests to assess factors associated with awareness, knowledge and perception. Significance was set a priori at p < 0.05. […]
Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues.
To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education.
In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population.
Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups.
Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy.
A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately.
Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale.
Background: Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.
Objective: Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.
Methods: We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.
Results: The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.
Conclusions: We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.
Stroke has become a global problem . One new case is reported every 2 seconds, and the number of stroke patients is predicted to increase by 59% over the next 20 years [ ]. In the United Kingdom alone, more than 100,000 stroke cases are reported annually [ ], with impairment or disability affecting two-thirds of the 1.2 million stroke survivors [ ]. In the United Kingdom, only 77% of stroke survivors are taken directly to the stroke unit. Due to the high number of patients, in England, for example, the social care costs are almost £1.7 billion per annum. The social care cost varies with the age of the patient: the older the patient, the higher the cost. The cost for a person who has had a stroke was reported in 2017 to be around £22,000 per annum. Thus, cost is one of the main drives for service delivery practices. In that respect, early discharge units have been used due to better outcomes and greater success on rehabilitation. Early discharge units consist of specialized personnel who offer an intensive rehabilitation program to the patient. However, after this intensive program of relatively short duration, the patient is discharged and continues the rehabilitation at home. This is expected to reduce costs by £1600 over 5 years for every patient, according to a 2017 report [ ].
Due to increasing pressure to discharge patients early from hospital , they rely increasingly on home rehabilitation to improve their condition after discharge. As a result, the need has been increasing for home rehabilitation systems that are not dependent on specialist or clinician operators [ , , ] while providing service similar to a clinical environment. Technological advances in home rehabilitation have been mainly focused on motor control impairments due to their prevalence in the patient population (85% worldwide [ ]).
Rehabilitation in a home environment can prove more efficient than that in a clinical environment, as the home environment supports patient empowerment through self-efficacy [, ]. The presence of supportive family members and a familiarity with the space are significant contributors to motivation. Additionally, rehabilitation in cooperation or in competition with family members demonstrates higher level of engagement [ ].
Though rehabilitation in the comfort of a patient’s home seems an attractive option, home environments have limitations that can affect the use of clinical devices. The most prevalent limitations are related to space and the lack of qualified personnel to operate devices. The number of occupants; the patient’s mobility, individual personality, and mood disorders following stroke; and sound insulation, home modification requirements, and cost [, ] also contribute to limitations of home rehabilitation. Finally, different age groups react differently to technology and devices; for example, elderly survivors often do not engage with wearable devices or video games [ ]. As a result, stroke rehabilitation requires a person-centric approach that is suitable for the home environment and that does not require infrastructure change in the home.
The success of stroke rehabilitation depends heavily on personal commitment and effort. Recent studies, for example, on applied psychology in behavior change theories for stroke rehabilitation [– ], do support that the self-esteem of the patient is limited after stroke. In addition, there is an extended sedentary period due to disability and, thus, different programs of activities are set to motivate the patients. Thus, the patient’s motivation and engagement have a critical impact on the success of any routine that is to be encouraged [ ]. This is especially critical for devices used at home, since patients are usually interacting with them alone without frequent checks. Indeed, if a device does not provide a high level of engagement or motivation enhancement, it is more likely to be abandoned within 90 days [ ]. Motivation levels depend on the individual, their achievements, and their needs at each given point in time. For example, once the patients achieve their physiotherapy exercise targets, they lose motivation for further practice. There are 3 main approaches to enhancing patients’ motivation: (1) goal-setting theory, (2) self-efficacy improvement theory, and (3) possible selves theory.
This approach has been proved effective for stroke survivors. According to the goal-setting theory, the patient’s motivation can be increased through setting small goals or targets. These need to be realistic, manageable, and well defined for the individual patient. However, they also need to be sufficiently challenging for the patient to be engaged [, – ]. presents the main components contributing to motivation enhancement based on the goal-setting theory.
Telerehabilitation was not inferior to in-clinic rehabilitation therapy in helping to improve arm function after stroke but could substantially increase access to therapy for those who are unable to access a rehabilitation clinic, researchers opine.
“Few patients fully recover from arm weakness after a stroke. The remainder demonstrate persistent arm impairments that are directly linked to activity limitations, participation restrictions, reduced quality of life, and decreased well-being,” Steven C. Cramer, MD, from the department of neurology at the University of California, Irvine, and colleagues write, in a study published in JAMA Neurology.
“Some rehabilitation therapies can improve these deficits, with higher doses associated with better outcomes. However, many patients do not receive high doses of rehabilitation therapy, for reasons that include cost, difficulty traveling to the location where therapy is provided, shortage of regional rehabilitation care, and poor adherence with assignments,” they continue, in a media release from Healio.
Cramer and colleagues conducted a randomized, assessor-blinded, noninferiority clinical trial to compare telerehabilitation and in-clinic rehabilitation therapy outcomes for patients who had a stroke that resulted in arm motor deficit.
Patients were enrolled in the study at 4 to 36 weeks after experiencing an ischemic stroke or intracerebral hemorrhage that resulted in arm weakness. After enrollment, participants were randomly assigned to receive intensive arm motor therapy in a rehabilitation clinic or in their home using telerehabilitation delivery services with a computer connected to the internet. Scores on the Fugl-Myer arm motor scale were measured at the baseline and after treatment to determine changes in arm motor function.
All patients received 36 treatment sessions (70 minutes) in a 6- to 8-week period, which included 18 supervised and 18 unsupervised sessions. The content of therapy was carefully matched, with each group using the same exercises and standard exercise equipment.
A total of 124 participants were included in the study. Participants had a mean age of 61 years, a mean baseline Fugl-Meyer score of 43 points and were enrolled for a mean 18.7 weeks following stroke, the release explains.
Patients in the in-clinic group were adherent to 33.6 of 36 therapy sessions (93.3%), and those who received telerehabilitation at home were adherent to 35.4 of 36 therapy sessions (98.3%).
Both groups experienced significant changes in Fugl-Meyer scores from the baseline period to 30 days after treatment, with a mean change of 8.36 points in patients who received in-clinic therapy and 7.86 points in those who received telerehabilitation therapy.
The noninferiority margin was 2.47 and fell outside the 95% confidence interval, suggesting that telerehabilitation was not inferior to in-clinic therapy.
“Our study found that a 6-week course of daily home-based [telerehabilitation] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic,” Cramer and colleagues conclude, in the release.
[Source: Healio Primary Care]