Clinical telerehabilitation: applications for physiatrists

Transitioning to a virtual post-intensive care rehabilitation service in response to the COVID-19 pandemic: results of multidisciplinary focus-groups

Background

Telehealth has vastly expanded since the SARS-CoV-2 (COVID-19) pandemic and has been widely implemented as an efficient, cost-effective and accepted means of health care delivery, including rehabilitation. Although telerehabilitation is recommended across national guidelines, there is a lack of practical guidance to support clinicians with virtual adaptations.

Aims

This study aimed to describe the key components of a safe and effective virtual post-intensive-care rehabilitation service, through qualitative exploration.

Methods

This is a qualitative study using a focus-group design based upon grounded theory. This study is nested within a service development project, taking place during the COVID-19 pandemic. Focus groups were held after the first wave of the COVID-19 pandemic with key stakeholders from the physiotherapy and critical care departments of a large tertiary hospital in the United Kingdom. Semi-structured questions were used to guide discussions, led by a facilitator and scribe. Transcripts were thematically analysed using an exploratory inductive approach by two researchers then crosschecked.

Findings

Three focus groups were attended by 12 multidisciplinary stakeholders, including six physiotherapists, two administration staff members, two critical-care follow-up nurses and two critical care consultants. Thematic analysis identified seven critical elements for virtual adaptations: (1) safety and risk assessment, (2) assessment and outcome measures, (3) virtual platform, (4) resources and equipment, (5) exercise programme adaptation, (6) exercise monitoring and safety, and (7) privacy and information governance.

Conclusion

Our findings provide practical recommendations for virtual rehabilitation service development and delivery.

Effectiveness of telerehabilitation-based structured exercise program in individuals with unilateral transtibial amputation: a randomized controlled study

PURPOSE

The study aimed to compare the effects of home exercise alone and telerehabilitation combined with home exercise in individuals with transtibial amputation.

MATERIALS AND METHODS

The telerehabilitation group (n = 24) received telerehabilitation combined with home exercise, while the control group (n = 24) received home exercise alone. Outcomes included the timed up-and-go (TUG) test and the 30-second chair-stand test (30CST), the Activities-specific Balance Confidence (ABC) Scale, the Trinity Amputation and Prosthesis Experience Scales (TAPES), the Amputee Body Image Scale (ABIS), and the Nottingham Health Profile (NHP). The analysis used a 2 × 2 mixed repeated measures ANOVA.

RESULTS

The group-by-time interactions were significant for TUG (p = 0.002, F[1;41] = 10.74) and 30CST (p = 0.001, F[1;41] = 11.48). The mean difference (6th week-baseline) was -0.49 for TUG and 0.95 for 30CST in the telerehabilitation group and -0.14 for TUG and 0.13 for 30CST in the control group. There were statistically meaningful group-by-time interactions on the ABC (p = 0.0004, F[1;41] = 14.47), the TAPES-activity restriction (p = 0.0001, F[1;41] = 28.96), TAPES-prosthesis satisfaction (p = 0.004, F[1;41] = 9.19), and the NHP (p = 0.0002, F[1;41] = 16.07) favoring the telerehabilitation group.

CONCLUSIONS

Telerehabilitation combined with home exercise can offer greater benefits in improving gait, muscle strength, balance confidence, activity restriction, prosthesis satisfaction, and quality of life compared to home exercise alone for individuals with transtibial amputation.Implications for rehabilitationExercise helps individuals with lower limb amputation overcome their physical limitations and enables them to use their prostheses effectively.Physiotherapy and rehabilitation after amputation are not at the desired level, and individuals with lower limb amputation encounter various difficulties in accessing physiotherapy.Telerehabilitation has great potential to facilitate access to physiotherapy for individuals with amputation and reduce resource utilization.In a relatively small sample of amputees, this study shows that telerehabilitation-based exercise improves physical health and quality of life.

Personalized robots for long-term telerehabilitation after stroke: a perspective on technological readiness and clinical translation

Stroke rehabilitation, which demands consistent, intensive, and adaptable intervention in the long term, faced significant challenges due to the COVID-19 pandemic. During this time, telerehabilitation emerged as a noteworthy complement to traditional rehabilitation services, offering the convenience of at-home care delivery and overcoming geographical and resource limitations. Self-help rehabilitation robots deliver repetitive and intensive physical assistance, thereby alleviating the labor burden. However, robots have rarely demonstrated long-term readiness for poststroke telerehabilitation services. The transition from research trials to general clinical services presents several challenges that may undermine the rehabilitative gains observed in these studies. This perspective discusses the technological readiness of personal use robots in the context of telerehabilitation and identifies the potential challenges for their clinical translation. The goal is to leverage technology to seamlessly integrate it into standard clinical workflows, ultimately enhancing the outcomes of stroke rehabilitation.

Telerehabilitation for a Non-specific Low Back Pain: A Case Report

One of the most common conditions that affect activities of daily living and make them significantly more difficult to perform is low back pain (LBP). As a result, it is essential to treat LBP at an early stage. Particularly in geographically remote areas where there is a shortage of medical professionals and a lack of rehabilitation services, telerehabilitation is considered a potential alternative. Hence, this case report represents the impact of telerehabilitation on LBP in a 32-year-old female corporate worker who presented to the out-patient department of physiotherapy with the chief complaints of LBP for the last three months with difficulty in performing activities, and being unable to sit for prolonged period of time. The physiotherapeutic rehabilitation was virtually administered through online sessions through the cloud-based application as the patient was not able to visit the outpatient department on a regular basis. Post-intervention results demonstrated increased range of motion and flexibility, reduced pain, increased muscle strength, reduced disability and kinesiophobia, and improved quality of life. Hence, it can be concluded that telerehabilitation offers a novel solution to increase access to rehabilitation services.

Telemedicine Use Among Physiatrists During the Early Phase of the COVID-19 Pandemic and Potential for Future Use

Introduction: With the coronavirus disease 2019 (COVID-19) pandemic causing the need for social distancing, telemedicine saw a significant increase in use to provide routine medical care. As a field, physiatry had already been implementing telemedicine prior to the pandemic. In this study, we characterized the use of telemedicine among physiatrists during the early phase of the COVID-19 pandemic to understand the barriers and facilitators to implementing telemedicine use in the field of physiatry in the future. Methods: Online survey of a cross-sectional sample of physiatrists. Analysis was conducted using logistic regression. Results: One hundred seventy one (n = 171) participants completed the survey. Before the pandemic, only 17.5% of respondents used telemedicine. In the logistic regression, physicians who used a hospital-provided platform were more likely to use telemedicine in the future compared with those who used their own secure platform, conducted a phone visit, and used a non-secure platform or other platforms. The three most popular barriers identified were "inability to complete the physical examination," "patients lack of access to technology," and "patients lack of familiarity with the technology." Discussion: Focus on education on telemedicine functional examination strategies and technology strategies for patients and providers (including addressing the digital divide and hospital-provided secure platforms) are potential targets of implementation strategies for greater telemedicine uptake for physiatrists in the future.

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

The neurogenic dysphagia management via telemedicine: a systematic review

INTRODUCTION

Telerehabilitation is the provision of rehabilitation remotely through Information and Communication Technologies (ICT). Recently, there has been an increase of interest in its application thanks to increasing a new technology. The aim of this systematic review was to examine the evidence of the literature regarding the management of neurogenic dysphagia via telerehabilitation, compared to face-to-face rehabilitation treatment. The secondary aim was to create recommendations on telerehabilitation sessions for patients diagnosed with neurogenic dysphagia.

EVIDENCE ACQUISITION

The databases were: Medline, Embase, CINAHL, Scopus. A total of 235 records emerged from bibliographic research, manual search of full text and from gray literature, published until January 2021. Two blinded authors carried out titles and abstract screening and followed by full-text analysis. Sixteen articles were included in the systematic review and assessed through critical appraisal tools.

EVIDENCE SYNTHESIS

The research shows that the majority of the studies on neurogenic dysphagia involved the Clinical Swallow Examination via telerehabilitation, compared with the in-person modality. Significant levels of agreement and high satisfaction from clinicians and patients are reported to support the use of telerehabilitation. Based on the results of this systematic review and qualitative analysis, the authors developed practical recommendations for the management of telerehabilitation sessions for patients with neurogenic dysphagia.

CONCLUSIONS

Despite the presence of barriers, telerehabilitation allowed healthcare provision and increasing access to care and services with specialized professionals, remote rehabilitation can be a valid resource during the health emergency due to COVID-19.

Design, development, and testing of a virtual reality device for upper limb training in people with multiple sclerosis: a feasibility study (Preprint)

Background

Multiple sclerosis (MS) is a common nontraumatic, neurological, disabling disease that often presents with upper limb dysfunction. Exercise training has resulted in improvement for patients; however, there can be a lack of compliance due to access because of location and lack of MS experts. Virtual reality (VR) is a promising technology that can offer exercise therapy/rehabilitation at a distance. This type of remote training can be motivational and effective for patients with MS and can improve range of motion and muscle strength for those with upper limb dysfunction.

Objective

The aim of this study is to evaluate the safety and feasibility of the XRHealth software and the Oculus Rift Station for patients with MS with upper limb motor dysfunction.

Methods

A single-center, prospective, feasibility study was conducted with patients with MS who had upper limb motor dysfunction. Patients participated in a single 45-minute digital environment session with VR and completed a questionnaire about the quality of the training and fatigability. The clinician also completed a questionnaire to evaluate the suitability and safety of the training.

Results

Overall, 30 patients were enrolled between the ages of 20 and 81 years. Patients reported that the training sessions within the digital environment were helpful, challenging, fun, and simple to understand, and that they would be willing to repeat the sessions again. The physical therapist that oversaw the patients reported that the training was suitable for 87% (n=26) of the patients. Anticipated adverse events were fatigue, temporary dizziness, and temporary nausea. The operator complications included that the cable of the head-mounted display interrupted the training (n=2, 7%) and fatigue that caused cessation of the VR training session (n=2, 7%). No serious adverse events were reported.

Conclusions

These preliminary results demonstrated that the use of the XRHealth software and Oculus Rift Station platform is feasible, safe, and engaging for patients, and has the potential to improve the functionality of the upper limbs in patients with MS. This study provides support for future studies of implementing a series of training sessions with virtual reality in a home-based environment.

Effectiveness of Telerehabilitation on Motor Impairments, Non-motor Symptoms and Compliance in Patients With Parkinson's Disease: A Systematic Review

Introduction: Parkinson's disease (PD) is a chronic neurodegenerative disease involving a progressive alteration of the motor and non-motor function. PD influences the patient's daily living and reduces participation and quality of life in all phases of the disease. Early physical exercise can mitigate the effects of symptoms but access to specialist care is difficult. With current technological progress, telemedicine, and telerehabilitation is now a viable option for managing patients, although few studies have investigated the use of telerehabilitation in PD. In this systematic review, was investigated whether telerehabilitation leads to improvements in global or specific motor tasks (gait and balance, hand function) and non-motor dysfunction (motor speech disorder, dysphagia). The impact of TR on quality of life and patient satisfaction, were also assessed. The usage of telerehabilitation technologies in the management of cognitive impairment was not addressed.

Method: An electronic database search was performed using the following databases: PubMed/MEDLINE, COCHRANE Library, PEDro, and SCOPUS for data published between January 2005 and December 2019 on the effects of telerehabilitation systems in managing motor and non-motor symptoms. This systematic review was conducted in accordance with the PRISMA guideline and was registered in the PROSPERO database (CRD42020141300).

Results: A total of 15 articles involving 421 patients affected by PD were analyzed. The articles were divided into two categories based on their topic of interest or outcome. The first category consisted of the effects of telerehabilitation on gait and balance (3), dexterity of the upper limbs (3), and bradykinesia (0); the second category regarded non-motor symptoms such as speech disorders (8) and dysphagia (0). Quality of life (7) and patient satisfaction (8) following telerehabilitation programs were also analyzed, as well as feasibility and costs.

Conclusion: Telerehabilitation is feasible in people affected by PD. Our analysis of the available data highlighted that telerehabilitation systems are effective in maintaining and/or improving some clinical and non-clinical aspects of PD (balance and gait, speech and voice, quality of life, patient satisfaction).

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier: CRD42020141300.

Telemedicine in the Coronavirus Disease 2019 Pandemic: A Pediatric Rehabilitation Perspective

ABSTRACT

In the spring of 2020, coronavirus disease 2019 evolved into a worldwide pandemic, forcing traditional face-to-face healthcare to a standstill. Telemedicine was quickly adopted as a major tool for pediatric rehabilitation services. This article describes the national legislative response of the United States to the coronavirus disease 2019 pandemic and the opportunities and challenges of implementing telemedicine in pediatric rehabilitation outpatient settings, consultations, as well as physician and patient education. The feasibility of performing a remote pediatric musculoskeletal and neurological tele-evaluation is also discussed. Although challenges exist, telemedicine has demonstrated its potential and has proven to be a practical system. Future developments in technology and accessibility, in addition to support from government and third-party payers, have the potential to make telemedicine an effective and vital platform in a coordinated healthcare system.

Telehealth in Pediatric Rehabilitation

Pediatric rehabilitation focuses on optimizing function and quality of life of children through a holistic and transdisciplinary patient-centered team approach. This article describes the incorporation of telehealth in pediatric rehabilitation and its growth over the past decade. It also reviews the experience of practitioners using telehealth by necessity during the 2020 COVID-19 pandemic. Evidence suggests many applications where telehealth can appropriately substitute for traditional in-person visits, and there are many potential applications of telehealth to be explored as a means to enhance connectivity of the interdisciplinary rehabilitation team and the outreach to patients in remote and underserved areas.

Telerehabilitation Guidelines in Saudi Arabia

Rehabilitation needs are increasing globally due to population growth, aging population, high survival rates for people with disability, and severe health conditions. In the past few years, new telecommunication-based practices, including various forms of e-rehabilitation have gained attention all over the world, including the Kingdom of Saudi Arabia (KSA). Telerehabilitation is an alternative way of delivering rehabilitation services in which information and communication technologies are used to expedite communication between the health care professional and the patient at a distant location. It can be beneficial to people in rural areas, especially individuals in isolated communities. At present, the COVID-19 pandemic has forced speedy adoption of telerehabilitation due to restricted traditional in-person visits all over the world, including KSA; however, no telerehabilitation guidelines are available in the country. Since specialized rehabilitation services are limited to main cities of the country, the provision of care by reaching out the underserved areas using telemedicine technology is deemed important. These guidelines were established collaboratively by panel of various rehabilitation experts with input from other practitioners in the field and strategic stakeholders. It will facilitate rehabilitation clinicians practicing in KSA providing consultation, counseling, education, assessment, monitoring, therapy, or follow-up to a patient remotely using telemedicine communication technologies. This document includes administrative, clinical, and technical guidelines, which are aimed to standardize telerehabilitation practice across the country. The core principles are based on standards set forth by American Telemedicine Association and are guided by telemedicine policy in KSA. Additionally, ethical considerations of telerehabilitation practice pertinent to Saudi culture and health care system are elaborated as well. This document serves as a general guide for the provision of telerehabilitation services and do not describe a specialty-specific clinical practice guideline.

Practical Considerations for Implementing Virtual Care in Physical Medicine and Rehabilitation: For the Pandemic and Beyond

This article outlines a practical approach to quickly implementing virtual care for physiatrists. This skill is relevant not only during times of a pandemic, when face to face care is impossible, but is also valuable when caring for patients who have physical, financial, logistic, or other challenges to on-site care. Key themes covered in this article include selecting appropriate virtual care platforms, consenting patients for virtual care and conducting successful virtual visits. It also reviews strategies for performing virtual physical examinations and engaging learners in virtual care.

Pediatric telerehabilitation medicine: Making your virtual visits efficient, effective and fun

The COVID-19 pandemic has accelerated many changes in medicine including the transition from providing care in person to providing care via technology enabled telemedicine. The benefits of telemedicine visits with a Pediatric Rehabilitation Medicine (PRM) provider, also known as telerehabilitation medicine visits, are numerous. Telerehabilitation medicine provides an opportunity to deliver timely, patient and family-centric rehabilitation care while maintaining physical distance and reducing potential COVID-19 exposure for our patients, their caregivers and medical providers. Telerehabilitation medicine also allows for access to PRM care in rural areas or areas without medical specialty, virtual in-home equipment evaluation, and reduced travel burden. Because of these and many other benefits, telerehabilitation medicine will likely become part of our ongoing model of care if barriers to telemedicine continue to be lowered or removed. This paper is intended to establish a foundation for pediatric telerehabilitation medicine visit efficiency and effectiveness in our current environment and into the future.

Digital Analysis of Sit-to-Stand in Masters Athletes, Healthy Old People, and Young Adults Using a Depth Sensor

The aim of this study was to compare the performance between young adults (n = 15), healthy old people (n = 10), and masters athletes (n = 15) using a depth sensor and automated digital assessment framework. Participants were asked to complete a clinically validated assessment of the sit-to-stand technique (five repetitions), which was recorded using a depth sensor. A feature encoding and evaluation framework to assess balance, core, and limb performance using time- and speed-related measurements was applied to markerless motion capture data. The associations between the measurements and participant groups were examined and used to evaluate the assessment framework suitability. The proposed framework could identify phases of sit-to-stand, stability, transition style, and performance between participant groups with a high degree of accuracy. In summary, we found that a depth sensor coupled with the proposed framework could identify performance subtleties between groups.

Quantification and visualization of coordination during non-cyclic upper extremity motion

There are many design challenges in creating at-home tele-monitoring systems that enable quantification and visualization of complex biomechanical behavior. One such challenge is robustly quantifying joint coordination in a way that is intuitive and supports clinical decision-making. This work defines a new measure of coordination called the relative coordination metric (RCM) and its accompanying normalization schemes. RCM enables quantification of coordination during non-constrained discrete motions. Here RCM is applied to a grasping task. Fifteen healthy participants performed a reach, grasp, transport, and release task with a cup and a pen. The measured joint angles were then time-normalized and the RCM time-series were calculated between the shoulder-elbow, shoulder-wrist, and elbow-wrist. RCM was normalized using four differing criteria: the selected joint degree of freedom, angular velocity, angular magnitude, and range of motion. Percent time spent in specified RCM ranges was used asa composite metric and was evaluated for each trial. RCM was found to vary based on: (1) chosen normalization scheme, (2) the stage within the task, (3) the object grasped, and (4) the trajectory of the motion. The RCM addresses some of the limitations of current measures of coordination because it is applicable to discrete motions, does not rely on cyclic repetition, and uses velocity-based measures. Future work will explore clinically relevant differences in the RCM as it is expanded to evaluate different tasks and patient populations.

Bilateral Control of Functional Electrical Stimulation and Robotics-based Telerehabilitation

Currently a telerehabilitation system includes a therapist and a patient where the therapist interacts with the patient, typically via a verbal and visual communication, for assessment and supervision of rehabilitation interventions. This mechanism often fails to provide physical assistance, which is a modus operandi during physical therapy or occupational therapy. Incorporating an actuation modality such as functional electrical stimulation (FES) or a robot at the patient's end that can be controlled by a therapist remotely, to provide therapy or to assess and measure rehabilitation outcomes can significantly transform current telerehabilitation technology. In this paper, a position-synchronization controller is derived for FES-based telerehabilitation to provide physical assistance that can be controlled remotely. The newly derived controller synchronizes an FES-driven human limb with a remote physical therapist's robotic manipulator despite constant bilateral communication delays. The control design overcomes a major stability analysis challenge: the unknown and unstructured nonlinearities in the FES-driven musculoskeletal dynamics. To address this challenge, the nonlinear muscle model was estimated through two neural networks functions that approximated unstructured nonlinearities and an adaptive control law for structured nonlinearities with online update laws. A Lyapunov-based stability analysis was used to prove the globally uniformly ultimately bounded tracking performance. The performance of the state synchronization controller was validated through experiments on an able-bodied subject. Specifically, we demonstrated bilateral control of FES-elicited leg extension and a human operated robotic manipulator. The controller was shown to effectively synchronize the system despite unknown and different delays in the forward and backward channels.

A Commentary on Telerehabilitation Services in Pakistan: Current Trends and Future Possibilities

A 2014 World Health Organization (WHO) study reported that almost 27 million people with disability live in Pakistan with fewer than one allied rehabilitation professional per 10,000 people. The current study sought to determine the attitudes toward telerehabilitation via a survey administered to 329 Pakistani rehabilitation professionals. Study results indicate that rehabilitation professionals in Pakistan are knowledgeable about telerehabilitation and Information and Communication Technology (ICT), and are receptive to employing telerehabilitation programs and applications. Therefore, we can infer that the future of telerehabilitation can be bright in Pakistan but requires the attention of policy makers and non-government organizations to launch an appropriate program nationwide. The authors suggest that a range of telerehabilitation services (e.g., consultation, assessment, and therapy) could alleviate the shortage of rehabilitation personnel in Pakistan.

Telestroke—the promise and the challenge. Part two—expansion and horizons

Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the second of a two part review, and is focused on the challenges telestroke faces for wider adoption. It further details the anticipated evolution of this novel therapeutic platform, and the potential roles it holds in stroke prevention, ambulance based care, rehabilitation, and research.

Caregiver-mediated exercises with e-health support for early supported discharge after stroke (CARE4STROKE): study protocol for a randomized controlled trial

BACKGROUND

Several systematic reviews have shown that additional exercise therapy has a positive effect on functional outcome after stroke. However, there is an urgent need for resource-efficient methods to augment rehabilitation services without increasing health care costs. Asking informal caregivers to do exercises with their loved ones, combined with e-health services may be a cost-effective method to promote early supported discharge with increased functional outcome. The primary aim of the CARE4STROKE study is to evaluate the effects and cost-effectiveness of a caregiver-mediated exercises program combined with e-health services after stroke in terms of self-reported mobility and length of stay.

METHODS

An observer-blinded randomized controlled trial, in which 66 stroke-patients admitted to a hospital stroke unit, rehabilitation center or nursing home are randomly assigned to either 8 weeks of the CARE4STROKE program in addition to usual care (i.e., experimental group) or 8 weeks of usual care alone (i.e., control group). The CARE4STROKE program is compiled in consultation with a trained physical therapist. A tablet computer is used to present video-based exercises for gait and gait-related activities in which a caregiver acts as an exercise coach. Primary outcomes are the mobility domain of the Stroke Impact Scale and length of stay. Secondary outcomes are the other domains of the Stroke Impact Scale, motor impairment, strength, walking ability, balance, mobility, (Extended) Activities of Daily Living, psychosocial functioning, self-efficacy, fatigue, health-related quality of life of the patient as well as the experienced strain, psychosocial functioning and quality of life of the caregiver. An economic evaluation will be conducted from the societal and health care perspective.

DISCUSSION

The main aspects of the CARE4STROKE program are 1) increasing intensity of training by doing exercises with a caregiver in addition to usual care and 2) e-health support. We hypothesize this program leads to better functional outcome and early supported discharge, resulting in reduced costs.

TRIAL REGISTRATION

The study is registered in the Dutch trial register as NTR4300, registered 2 December 2013.

Advances in rehabilitation medicine

Rehabilitation medicine is the medical specialty that integrates rehabilitation as its core therapeutic modality in disability management. More than a billion people worldwide are disabled, and the World Health Organization has developed the International Classification of Functioning, Disability and Health as a framework through which disability is addressed. Herein, we explore paradigm shifts in neurorehabilitation, with a focus on restoration, and provide overviews on developments in neuropharmacology, rehabilitation robotics, virtual reality, constraint-induced therapy and brain stimulation. We also discuss important issues in rehabilitation systems of care, including integrated care pathways, very early rehabilitation, early supported discharge and telerehabilitation. Finally, we highlight major new fields of rehabilitation such as spasticity management, frailty and geriatric rehabilitation, intensive care and cancer rehabilitation.

Wearable accelerometry-based technology capable of assessing functional activities in neurological populations in community settings: a systematic review

BACKGROUND

Integrating rehabilitation services through wearable systems has the potential to accurately assess the type, intensity, duration, and quality of movement necessary for procuring key outcome measures.

OBJECTIVES

This review aims to explore wearable accelerometry-based technology (ABT) capable of assessing mobility-related functional activities intended for rehabilitation purposes in community settings for neurological populations. In this review, we focus on the accuracy of ABT-based methods, types of outcome measures, and the implementation of ABT in non-clinical settings for rehabilitation purposes.

DATA SOURCES

Cochrane, PubMed, Web of Knowledge, EMBASE, and IEEE Xplore. The search strategy covered three main areas, namely wearable technology, rehabilitation, and setting.

STUDY SELECTION

Potentially relevant studies were categorized as systems either evaluating methods or outcome parameters.

METHODS

Methodological qualities of studies were assessed by two customized checklists, depending on their categorization and rated independently by three blinded reviewers.

RESULTS

Twelve studies involving ABT met the eligibility criteria, of which three studies were identified as having implemented ABT for rehabilitation purposes in non-clinical settings. From the twelve studies, seven studies achieved high methodological quality scores. These studies were not only capable of assessing the type, quantity, and quality measures of functional activities, but could also distinguish healthy from non-healthy subjects and/or address disease severity levels.

CONCLUSION

While many studies support ABT's potential for telerehabilitation, few actually utilized it to assess mobility-related functional activities outside laboratory settings. To generate more appropriate outcome measures, there is a clear need to translate research findings and novel methods into practice.

Systematic review of telestroke for post-stroke care and rehabilitation

Telemedicine for acute stroke care is supported by a literature base. It remains unclear whether or not the use of telemedicine for other phases of stroke care is beneficial. The authors conducted a systematic review of the published literature on telemedicine for the purposes of providing post-stroke care. Studies were included if the title or abstract expressed use of two-way audio/video communication for post-stroke care. From an initial yield of 1,405 potentially eligible hits, two reviewers ultimately identified 24 unique manuscripts to undergo functionality, application, technology, and evaluative (F.A.T.E.) scoring. Each article was classified using a scoring rubric to assess the functionality, application, technology, and evaluative stage. It was found that most post-stroke telemedicine studies evaluated rehabilitation of adults. All primary data manuscripts were small and preliminary in scope and evaluative phase, and median F.A.T.E. score for primary data was 2. The use of telemedicine for post-stroke care is nascent and is primarily focused on post-stroke rehabilitation.

A telerehabilitation program improves postural control in multiple sclerosis patients: a Spanish preliminary study

Postural control disorders are among the most frequent motor disorder symptoms associated with multiple sclerosis. This study aims to demonstrate the potential improvements in postural control among patients with multiple sclerosis who complete a telerehabilitation program that represents a feasible alternative to physical therapy for situations in which conventional treatment is not available. Fifty patients were recruited. Control group (n = 25) received physiotherapy treatment twice a week (40 min per session). Experimental group (n = 25) received monitored telerehabilitation treatment via videoconference using the Xbox 360^® and Kinect console. Experimental group attended 40 sessions, four sessions per week (20 min per session).The treatment schedule lasted 10 weeks for both groups. A computerized dynamic posturography (Sensory Organization Test) was used to evaluate all patients at baseline and at the end of the treatment protocol. Results showed an improvement over general balance in both groups. Visual preference and the contribution of vestibular information yielded significant differences in the experimental group. Our results demonstrated that a telerehabilitation program based on a virtual reality system allows one to optimize the sensory information processing and integration systems necessary to maintain the balance and postural control of people with multiple sclerosis. We suggest that our virtual reality program enables anticipatory PC and response mechanisms and might serve as a successful therapeutic alternative in situations in which conventional therapy is not readily available.