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Monday October 1, 2012

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Telemedicine has gained recognition for improving outcomes when people present with a stroke, and now researchers are investigating the technology for use in stroke rehabilitation.

"Some of the advantages of telemedicine are to serve individuals who live in rural areas or quite a distance from their local hospital who are underserved by physical therapy," said Dorian Rose, PT, PhD, research assistant professor at the University of Florida Department of Physical Therapy in Gainesville. "And itís more cost effective with therapistsí time."

Rose developed the home-exercise intervention and the assessment protocol — checking patientsí balance, mobility and ability to navigate their homes — for a U.S. Department of Veterans Affairs-supported stroke telerehabilitation program, called STeleR, led by Neale Chumbler, PhD, a research scientist at the Richard L. Roudebush VA Medical Center in Indianapolis. The study involving 52 veterans began in November 2008, was completed in June 2011 and reported in the May 24 online issue of the journal Stroke.

Patients in the intervention and control arms were similar at baseline — no more than two years post-stroke. A research assistant recorded video during three home visits and sent it to a physical therapist to review. The STeleR team found patients experienced improved lower-body physical function, which lasted as long as three months after completing the program.

The intervention group targeted safe functional mobility, exercises to address the underlying stroke-related impairment and adaptive strategies to help compensate for disabilities. The control group received usual care from the VA.

"This was an effective intervention for individuals to be monitored more peripherally, from a distance using technology, rather than having the provider in person," Rose said. "Another take-home message from this study is individuals further out post-onset from their stroke can benefit."

Constraint-induced movement teletherapy

Researchers at the University of Alabama at Birmingham, with support from the National Institutes of Health, are conducting a randomized clinical trial using constraint-induced movement therapy, an approach developed at UAB, in the home, with patients more than one year post-stroke and with mild to moderate impairment. CI Movement therapy is a behavioral approach to physical rehabilitation that includes intense training of the more affected arm for several hours daily for multiple consecutive days, restraint of the less affected arm during training hours and afterward during the treatment period, and techniques designed to transfer gains from the treatment setting to daily life.

The study began in June 2010 and is expected to be completed in March 2014. Researchers plan to enroll 58 participants.

A telerehabilitation automated constraint-induced therapy extender device, known as Tele-AutoCITE, measures movement as patients complete 3.5 hours of training daily for at least 10 consecutive weekdays, but offers no power assistance to those movements.

"Itís a therapy with strong evidence of efficacy, and the purpose of this trial is to see if we can find ways the therapy can be disseminated on a more widespread basis by reducing barriers for patients to access treatment," said primary investigator Gitendra Uswatte, PhD, associate professor of psychology at UAB.

Telerobotics

Steven L. Wolf, PT, PhD, a professor in the Department of Rehabilitation Medicine at Emory University School of Medicine in Atlanta, and Jay Alberts, PhD, at the Cleveland Clinic Lerner Research Institute in Ohio, are conducting the Rehabilitation of the Stroke Hand at Home randomized clinical trial, funded by the American Recovery and Reinvestment Act of 2009. The study began in June 2010 and is scheduled for completion in May 2013. Researchers plan to enroll 96 people.

The intervention combines five to six weeks using the Hand Mentor robotic-assist device by Kinetic Muscles Inc. and broadband teletechnology with stroke patients within six months of the start of rehabilitation. Alberts said he expects patients in underserved areas, or those without insurance or whose coverage has run out to benefit the most.

"In stroke rehab, we are not able to provide the quantity of therapy that is thought optimal to drive neuroplasticity and improvements in motor function," said Susan Linder, PT, DPT, NCS, a clinical specialist at Lerner. "Put in the home environment, patients can do it on their own, without the one-on-one work of a therapist, which insurance and the medical model doesnít allow for. It provides for a more intensive practice we are not able to provide well in a traditional environment."

PTs assess patientsí eligibility, which includes the ability to understand how to use the equipment, and obtain baseline information. A PT visits each patientís home to teach a home exercise program to both cohorts, plus use of the Hand Mentor device to the intervention group. Those using the device play games for three hours daily. The games require wrist or hand movement as the participant tries to avoid hitting an object crossing the screen, plays tennis against the computer or helps a cartoon character lift weights. The games can become harder as the user progresses.

A therapist can see each repetition of movement and how much time patients spend on each game. During weekly telephone calls, Linder assesses the patientsí movements and helps translate those improvements into functional tasks.

"If the outcomes are favorable, it will support the emerging use of telerehabilitation and inform federal agencies that the home environment is ripe for further rehabilitation that potentially could be cost effective," Wolf said. "In that context, we need to educate more clinicians about the value of telehealth and the need for more telerehabiliation specialists."

Stroke telerehabilitation offers an opportunity for patients to continue working toward better outcomes and may allow PTs to provide care to a greater number of patients, Wolf said. "But there is going to come a time where the question about the cost-benefit must be addressed." •

Debra Wood is a freelance writer.


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Monday October 1, 2012
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