Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial: protocol of a randomized clinical trial on tele-rehabilitation for stroke patients

Research hotspots and trends of the tele-rehabilitation for stroke survivors based on CiteSpace: A review

Our first goal is to understand the research status and popularity of telerehabilitation research for stroke survivors since 2012; the second goal is to analyze the research trends and frontiers in this field, and provide a scientific basis for the future application of telerehabilitation technology in patients with poststroke functional defects. We searched the Web of Science Core Collection (WoSCC) for literature on telerehabilitation for stroke survivors published from 2012 to 2022. The included articles were visually analyzed using CiteSpace6.1.6R (64-bit). In total, 968 eligible articles were included in this study. In the past 10 years, the number of papers published on telerehabilitation after stroke has been increasing annually, with the largest number of papers published in the United States and Australia, with 101 papers published by Chinese scholars. Some subsets of cooperative networks have been formed among major research institutions and their authors, but the scale remains small, and academic exchanges and cooperation need to be strengthened further. Research on virtual reality (VR) technology and rehabilitation robot technology is popular, and the choice of time and intensity of rehabilitation exercises, patients' participation in rehabilitation exercises, and care are also worth attention. In the last 10 years, research on telerehabilitation technology in the field of rehabilitation for stroke survivors has steadily developed, and is characterized by multidisciplinary joint development. Countries around the world can combine their own characteristics and advantages, strengthen academic exchanges and cooperation with mature research institutions or authors, and explore suitable poststroke remote rehabilitation technologies and service models in different environments.

Telerrehabilitación en tiempos de COVID: una encuesta de satisfacción a cuidadores y pacientes con daño cerebral

Objetivo

Material y métodos

Resultados

Conclusión

Physical exercise intervention via telerehabilitation in patients with neurological disorders: a narrative literature review

Background

In recent years, telerehabilitation applications have increased with the rapid development of mobile technology. Remote rehabilitation services have utmost importance in chronic neurological disorders. The aim of this narrative literature review was to discuss the physical exercise interventions via telerehabilitation in patients with neurological disorders. The literature search was conducted via PubMed using the neurological pathology terms in the MeSH (Medical Subject Headings) database. Physical exercise-based studies within the scope of neurological rehabilitation were included in the study. The contents of the studies were discussed with narrative synthesis.

Results

A total of 329 studies were obtained in the initial search. Twelve studies including cases of multiple sclerosis (MS), stroke, parkinson's disease, intracranial tumors, spinal-cord injury were interpreted. A vast majority of studies (50%) was conducted with stroke cases. On the other hand, half of the studies addressed the specific results of balance or balance-falling. The results of the studies were discussed comprehensively.

Conclusion

Physical exercise with telerehabilitation provides productive results to improve quality of life, muscle strength-endurance, hand function, balance, aerobic capacity in neurologic rehabilitation.

The Application of Technological Intervention for Stroke Rehabilitation in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Background

The technological intervention is considered as an adjunct to the conventional therapies applied in the rehabilitation session. In most high-income countries, technology has been widely used in assisting stroke survivors to undergo their treatments. However, technology use is still lacking in Southeast Asia, especially in middle- and low-income countries. This scoping review identifies and summarizes the technologies and related gaps available in Southeast Asia pertaining to stroke rehabilitation.

Methods

The JBI manual for evidence synthesis was used to conduct a scoping study. Until September 2021, an electronic search was performed using four databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only the studies that were carried out in Southeast Asia were chosen.

Results

Forty-one articles were chosen in the final review from 6,873 articles found during the initial search. Most of the studies reported the implementation of technological intervention combined with conventional therapies in stroke rehabilitation. Advanced and simple technologies were found such as robotics, virtual reality, telerehabilitation, motion capture, assistive devices, and mobility training from Singapore, Thailand, Malaysia, and Indonesia. The majority of the studies show that technological interventions can enhance the recovery period of stroke survivors. The consultation session suggested that the technological interventions should facilitate the needs of the survivors, caregivers, and practitioners during the rehabilitation.

Conclusions

The integration of technology into conventional therapies has shown a positive outcome and show significant improvement during stroke recovery. Future studies are recommended to investigate the potential of home-based technological intervention and lower extremities.

[The impact of educational level on cognitive assessments in young patients admitted to rehabilitation after ischaemic stroke]

INTRODUCTION AND OBJECTIVE

We propose to assess the impact of educational level on cognitive tests at admission and discharge after a period of cognitive rehabilitation in young patients after ischaemic stroke.

MATERIALS AND METHODS

We considered secondary and higher education (group A) and less than 6 years of formal education (group B). We compared A and B using χ² and Kruskal-Wallis. We studied A and B as predictors of verbal and working memory at discharge. Verbal and working memories were assessed at admission and discharge using Rey Auditory Verbal Learning Test (RAVLT) and DIGITS of the Barcelona Test respectively.

RESULTS

We analysed n=277 patients (55% belonging to A, mean age of 51 years) admitted to a specialised centre in Spain between 2009 and 2019. We found significant differences (P<.05) at admission, all in favour of A in the assessments of attention, inhibition, visuoperception, visuoconstruction, verbal fluency and comprehension. In DIGITS and RAVLT-learning we found differences at admission. In Digits and RAVLT-recognition we found differences at discharge, all in favour of A. We found no differences in age, severity, time at admission, or length of stay in hospital. Nor did we find differences in cognitive gains or treatment efficiency in memory tests. The groups A and B did not predict RAVLT (R²=.53) or DIGITS (R²=.48).

CONCLUSIONS

A scores better in 63% of tests at admission and in 75% of tests at discharge, A and B are similar in gains and efficiency on memory tests.

Integrating Tactile Feedback Technologies Into Home-Based Telerehabilitation: Opportunities and Challenges in Light of COVID-19 Pandemic

The COVID-19 pandemic has highlighted the need for advancing the development and implementation of novel means for home-based telerehabilitation in order to enable remote assessment and training for individuals with disabling conditions in need of therapy. While somatosensory input is essential for motor function, to date, most telerehabilitation therapies and technologies focus on assessing and training motor impairments, while the somatosensorial aspect is largely neglected. The integration of tactile devices into home-based rehabilitation practice has the potential to enhance the recovery of sensorimotor impairments and to promote functional gains through practice in an enriched environment with augmented tactile feedback and haptic interactions. In the current review, we outline the clinical approaches for stimulating somatosensation in home-based telerehabilitation and review the existing technologies for conveying mechanical tactile feedback (i.e., vibration, stretch, pressure, and mid-air stimulations). We focus on tactile feedback technologies that can be integrated into home-based practice due to their relatively low cost, compact size, and lightweight. The advantages and opportunities, as well as the long-term challenges and gaps with regards to implementing these technologies into home-based telerehabilitation, are discussed.

A Mobile Health App for the Collection of Functional Outcomes After Inpatient Stroke Rehabilitation: Pilot Randomized Controlled Trial

BACKGROUND

Monitoring the functional status of poststroke patients after they transition home is significant for rehabilitation. Mobile health (mHealth) technologies may provide an opportunity to reach and follow patients post discharge. However, the feasibility and validity of functional assessments administered by mHealth technologies are unknown.

OBJECTIVE

This study aimed to evaluate the feasibility, validity, and reliability of functional assessments administered through the videoconference function of a mobile phone-based app compared with administration through the telephone function in poststroke patients after rehabilitation hospitalization.

METHODS

A randomized controlled trial was conducted in a rehabilitation hospital in Southeast China. Participants were randomly assigned to either a videoconference follow-up (n=60) or a telephone follow-up (n=60) group. We measured the functional status of participants in each group at 2-week and 3-month follow-up periods. Half the participants in each group were followed by face-to-face home visit assessments as the gold standard. Validity was assessed by comparing any score differences between videoconference follow-up and home visit assessments, as well as telephone follow-up and home visit assessments. Reliability was assessed by computing agreements between videoconference follow-up and home visit assessments, as well as telephone follow-up and home visit assessments. Feasibility was evaluated by the levels of completion, satisfaction, comfort, and confidence in the 2 groups.

RESULTS

Scores obtained from the videoconference follow-up were similar to those of the home visit assessment. However, most scores collected from telephone administration were higher than those of the home visit assessment. The agreement between videoconference follow-up and home visit assessments was higher than that between telephone follow-up and home visit assessments at all follow-up periods. In the telephone follow-up group, completion rates were 95% and 82% at 2-week and 3-month follow-up points, respectively. In the videoconference follow-up group, completion rates were 95% and 80% at 2-week and 3-month follow-up points, respectively. There were no differences in the completion rates between the 2 groups at all follow-up periods (X²₁=1.6, P=.21 for 2-week follow-up; X²₁=1.9, P=.17 for 3-month follow-up). Patients in the videoconference follow-up group perceived higher confidence than those in the telephone follow-up group at both 2-week and 3-month follow-up periods (X²₃=6.7, P=.04 for 2-week follow-up; X²₃=8.0, P=.04 for 3-month follow-up). The videoconference follow-up group demonstrated higher satisfaction than the telephone follow-up group at 3-month follow-up (X²₃=13.9; P=.03).

CONCLUSIONS

The videoconference follow-up assessment of functional status demonstrates higher validity and reliability, as well as higher confidence and satisfaction perceived by patients, than the telephone assessment. The videoconference assessment provides an efficient means of assessing functional outcomes of patients after hospital discharge. This method provides a novel solution for clinical trials requiring longitudinal assessments.

TRIAL REGISTRATION

chictr.org.cn: ChiCTR1900027626; http://www.chictr.org.cn/edit.aspx?pid=44831&htm=4.

Home-based telerehabilitation software systems for remote supervising: a systematic review

OBJECTIVES

In the past decade, with the ever-increasing growth of information and communication technologies, telerehabilitation, especially home-based rehabilitation (HBR), has been widely considered by researchers. Many software systems are developed to address HBR programs, which includes various functionalities. The aim of this study is to review the functional features of these systems designed for remote supervising of HBR programs.

METHODS

Scopus, PubMed, EMBASE, ISI Web of Science, Cochrane Library, IEEE Xplore Digital Library, and ProQuest databases were searched for English-language articles published between January 2008 and February 2018 to retrieve studies reported an home-based telerehabilitation software system aiming to remotely supervise HBR program.

RESULTS

A total of fifty studies that reported twenty-two unique systems met the inclusion criteria. Various functional features were identified including but not limited to exercise plan management, report/statistics generating, patient education, and task scheduling. Disorders or diseases addressed by these systems could mainly be grouped into five categories: musculoskeletal, neurological, respiratory, cardiovascular, and other health-related problems. Usability and acceptability, and clinical/patient outcomes were the most reported outcomes and data analysis was used by the majority of included studies to measure the outcomes.

CONCLUSIONS

Systems developed for supervising of HBR program are diverse. However, preliminary results of this review revealed that these systems share more or less common functionalities. However, further research is needed to determine the requirements, structure, and effectiveness of these systems in real-life settings.

Telerehabilitation services for stroke

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.

Telerehabilitation System in Nursing Post Stroke - A Systematic Review

Background: Stroke is currently the main cause of disability worldwide. Telerehabilitation is a rehabilitation approach that can be used to repair the damage to motor, sensory and cognitive functions. This can also substantially reduce the travel time for the health workers and therefore increase the number of patients who are consulted in a day.Method: A search using specific keywords was done in both the journal articles and in the database. In total, 119 articles were from Scopus, 45 articles were from PubMed, 87 articles were from Science Direct, 52 articles were from EBSCO and 97 articles were from Proquest. There were 15 articles that matched the inclusion criteria. Most of the available literature only refers to short-term results and most of the research is of low quality.Result: Evidence of the relative effectiveness was found in the types of videos, VR, cellphones and computer use. The location of the network support and technological progress are still obstacles that must be addressed immediately. Based on the current scientific evidence, only a few telerehabilitation methods can be recommended for wider use.Conclusion: The telerehabilitation system can provide long-term therapy, meet the patient needs and save the health resources needed to minimize the severity of the patients’ condition. The application of telerehabilitation is used by the nurses to optimize their role in improving patient health and telerehabilitation will answer the problem of penetrating the distance dimension.

Activity Performance, Participation, and Quality of Life Among Adults in the Chronic Stage After Acquired Brain Injury-The Feasibility of an Occupation-Based Telerehabilitation Intervention

Objective: Acquired brain injury (ABI) is a leading cause of long-term disability. This calls for effective and accessible interventions to support participation in the community over time. One promising avenue to answer this need is telerehabilitation. Prior to conducting a larger trial, the main objective of this pilot study is to explore the feasibility, acceptability, and preliminary efficacy of a metacognitive occupation-based intervention in a telerehabilitation format with adults and older adults in the chronic phase after ABI.

Methods: Five community dwelling participants (ages 65–72), 6–10 months post-ABI, with scores 2–4 on the modified Rankin scale and without dementia, completed the teleintervention. The intervention included ~10 weekly videoconferencing sessions administered by an occupational therapist using the Cognitive Orientation to Daily Occupational Performance approach. Each participant defined five functional goals and three were trained and two were not trained during the intervention. Evaluations were conducted at pre, post, and 3-month follow-up. The primary outcome measures included activity performance (The Canadian Occupational Performance Measure; COPM), participation (the Mayo-Portland Adaptability Inventory-4 Participation Index; MPAI-4-P), and quality of life (QoL) (stroke impact scale; SIS). Other measures included a feedback interview, satisfaction questionnaire, field notes, and a treatment fidelity checklist.

Results: The teleintervention was found to be feasible and the participants expressed a high degree of satisfaction with the intervention and the technology use. A Wilcoxon Signed-Ranks test indicated statistically significant improvements post intervention in COPM performance (z = −2.023, p = 0.043) and satisfaction (z = −2.023, p = 0.043) ratings. Additionally, clinically significant improvements (≥2 points) in both performance and satisfaction with performance were found for each participant in at least three of their five defined functional goals. Trends toward significant improvement were found in MPAI-4-P ratings post intervention (z = −1.826, p = 0.068). Furthermore, clinically significant improvements (≥15 points) post intervention were found for each participant in some subscales of the SIS. Results were partially maintained at 3-month follow-up.

Conclusions: This pilot study demonstrated the feasibility of a metacognitive occupation-based telerehabilitation intervention and its potential benefits in activity performance, participation, and QoL for older adults coping with long-term disability following ABI.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708.

[Use of smartphone apps in secondary stroke prevention]

Modifiable risk factors such as hypertension, obesity or smoking have been reported to explain up to 90% of risk for ischemic stroke. Treatment of these risk factors is known to decrease the risk of recurrent stroke events. We performed a computer-based literature research from June to August 2018 using the electronic database PubMed to investigate the effect of smartphone apps on risk factor control for secondary stroke prevention as well as feasibility and patient satisfaction with mobile health. Studies evaluating interventions by smartphone or tablet devices in stroke patients and reported results regarding risk factors, feasibility or patient satisfaction were considered (n = 10). Identified data showed significant improvement regarding the control of risk factors hypertension and diabetes as well as significant improvements of the lifestyle risk factors physical inactivity and obesity. Stroke patients perceive smartphone apps mostly as useful and are open-minded regarding mHealth, provided that these complement rather than replace personal medical care.

Feasibility and Utility of Tele-Neurorehabilitation Service in India: Experience from a Quaternary Center

Background:

Neurological rehabilitation service in developing countries like India is a great challenge in view of limited resources and manpower. Currently, neurological rehabilitation with a multidisciplinary team is limited to a few major cities in the country. Tele-neurorehabilitation (TNR) is considered as an alternative and innovative approach in health care. It connects the needy patients with the health-care providers with minimum inconvenience and yields cost-effective health care.

Aim:

The aim of this study was to study the socioclinical parameters, feasibility, and utility of TNR services in India.

Methodology:

A retrospective file review of TNR consultations provided through Telemedicine Center at a quaternary hospital-based research center in south India between August 2012 and January 2016.

Results:

A total of 37 consultations were provided to the patients belonging to four districts of Karnataka. The mean age of the patients was 34.7 (±19.5) years, 23 (62.1%) were aged between 19 and 60 years, and 31 (83.8%) were male. Thirty-one patients (83.8%) had central nervous system-related disorders such as stroke, cerebral palsy, and tubercular meningitis with sequelae or neuromuscular disorders such as Guillain–Barre Syndrome and Duchenne muscular dystrophy. Twelve patients (32.4%) were advised to consult higher centers in the vicinity, and the rest was referred to the district hospital.

Conclusion:

The findings suggest that TNR services are feasible, effective, and less resource intensive in delivering quality telemedicine care in India. More clinical studies are required to elucidate its full utility at different levels and in different parts of the country.

In-Home Video Telehealth for Dementia Management: Implications for Rehabilitation

PURPOSE OF REVIEW

The progressive nature of dementia requires ongoing care delivered by multidisciplinary teams, including rehabilitation professionals, that is individualized to patient and caregiver needs at various points on the disease trajectory. Video telehealth is a rapidly expanding model of care with the potential to expand dementia best practices by increasing the reach of dementia providers to flexible locations, including patients' homes. We review recent evidence for in-home video telehealth for patients with dementia and their caregivers with emphasis on implications for rehabilitation professionals.

RECENT FINDINGS

Eleven studies were identified that involved video visits into the home targeting patients with dementia and/or their family caregivers. The majority describe protocolized interventions targeting caregivers in a group format over a finite, pre-determined period. For most, the discipline of the interventionist was unclear, though two studies included rehabilitation interventions. While descriptions of utilized technology were often lacking, many reported that devices were issued to participants when needed, and that technical support was provided by study teams. Positive caregiver outcomes were noted but evidence for patient-level outcomes and cost data are mostly lacking.

SUMMARY

More research is needed to demonstrate implementation of dementia best care practices through in-home video telehealth. Though interventions delivered using in-home video telehealth appear to be effective at addressing caregivers' psychosocial concerns, the impact on patients and the implications for rehabilitation remain unclear. Larger, more systematic inquiries comparing in-home video telehealth to traditional visit formats are needed to better define best practices.

Home-based tele-rehabilitation presents comparable positive impact on self-reported functional outcomes as usual care: The Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) randomised controlled trial

INTRODUCTION

The aim of this research was to evaluate the impact of a novel tele-rehabilitation system on self-reported functional outcomes compared to usual care during the first three months after stroke.

METHODS

A parallel, two-arm, evaluator-blinded, randomised controlled trial was conducted. Adults aged ≥40 years who had suffered a stroke within four weeks of the start of the study were recruited from the general community. The intervention group received access to a novel tele-rehabilitation system and programme for three months. The primary outcome measures utilised were the frequency and limitation total scores of the Late-Life Function and Disability Instrument (LLFDI) at three months.

RESULTS

A total of 124 individuals were recruited. The mean differences in the LLDFI frequency and limitation total scores at three months comparing the intervention and control groups were -3.30 (95% confidence interval (CI) -7.81 to 1.21) and -6.90 (95% CI -15.02 to 1.22), respectively. Adjusting for the respective baseline covariates and baseline Barthel Index also showed no significant difference between interventions in the LLFDI outcomes.

DISCUSSION

The intervention and control groups self-reported similar improvements in functional outcomes. Tele-rehabilitation may be a viable option to provide post-stroke rehabilitation services in Singapore while reducing barriers to continue rehabilitation conventionally after discharge from hospital and encouraging more participation.

MicroRNA‑22 alleviates inflammation in ischemic stroke via p38 MAPK pathways

The present study aimed to ascertain the potential roles and mechanisms of action of micro (mi)RNA-22 in ischemic stroke. The results indicated that miRNA-22 expression was downregulated in ischemic stroke rats model, compared with a control group. The downregulation of miRNA-22 upregulated the expression of inflammatory factors [including tumor necrosis factor-α, interleukin (IL)-1β, IL-6 and IL-18]. It could also induce the expression of macrophage inflammatory protein (MIP-2), prostaglandin E2 (PGE2), cyclooxygenase-2 (COX-2) and inducible NO synthase (iNOS) in the in vitro model. By contrast, the overexpression of miRNA-22 downregulated the expression of inflammatory factors, and suppressed the expression of MIP-2, PGE2, COX-2 and iNOS in the in vitro model. The downregulation of miRNA-22 induced the protein expression of nuclear factor (NF)-κB and phosphorylated-p38 (p-p38) mitogen-activated protein kinase (MAPK) in the in vitro model. By comparison, the overexpression of miRNA-22 suppressed the protein expression of NF-κB and p-p38 in the in vitro model. Typically, LY2228820, the p38 inhibitor (3 nM) would mitigate the pro-inflammatory effects of anti-miRNA-22 in the in vitro model. These results suggested that miRNA-22 can alleviate ischemic stroke-induced inflammation in rats model or vitro model through p38 MAPK/NF-κB pathway suppression.

Telerehabilitation in individuals with severe acquired brain injury: Rationale, study design, and methodology

BACKGROUND

Severe acquired brain injury (SABI) rehabilitation should be as intensive and long as to allow the patients get the best independence and quality of life (QoL), but facing with the rehabilitation socioeconomic burden. Telerehabilitation (TR) could supply frail subjects requiring long-term rehabilitation.

METHODS

A multicenter, prospective, parallel design, single-blind trial will be conducted at the IRCCS Neurolesi Bonino Pulejo (Messina, Italy) and IRCCS Hospital San Camillo (Venice, Italy) involving patients suffering from SABI and requiring home motor and cognitive rehabilitation. We will investigate the use of TR, based on advanced Information and Communication Technology (ICT) solutions, taking into account that the supervision of rehabilitation at home will be enriched with the counseling and vital parameters monitoring. The enrolled patients will be balanced for pathology, and randomized in 2 groups, performing TR (G1) or standard rehabilitation training (G2), respectively, according to a pc-generated random assignment. TR will be delivered by means of an advanced video-conferencing system, whereas the patient will be provided with low-cost monitoring devices, able to collect data about his/her health status and QoL. In both the groups each treatment (either cognitive or motor, or both as per patient functional status) will last about 1 hour a day, 5 days/week, for 12 weeks. Two structured telephone interviews will be administered to the patients (when possible) and/or their caregivers, and to all the healthcare professionals involved in the patient management, 1 week after the beginning and at the end of the TR. All the patients will undergo a complete neurological and cognitive examination performed by skilled physicians and psychologists, blindly. Clinical evaluations will be administered blindly, before and after the treatments.

RESULTS

the data of this study should demonstrate that TR is at least non-inferior in comparison with the same amount of usual territorial rehabilitative physical treatments, taking into account patients' functional recovery, psychological well-being, caregiver burden, and healthcare costs.

CONCLUSION

data coming from this study could demonstrate the usefulness of TR in facing the rehabilitation socioeconomic burden of managing patients with SABI, so to allow the patients get the best independence and quality of life (QoL).

A systematic review of measures of adherence to physical exercise recommendations in people with stroke

OBJECTIVE:

To review methods for measuring adherence to exercise or physical activity practice recommendations in the stroke population and evaluate measurement properties of identified tools.

DATA SOURCES:

Two systematic searches were conducted in eight databases (MEDLINE, CINAHL, PsycINFO, Cochrane Library of Systematic Reviews, Sports Discus, PEDro, PubMed and EMBASE). Phase 1 was conducted to identify measures. Phase 2 was conducted to identify studies investigating properties of these measures.

REVIEW METHODS:

Phase 1 articles were selected if they were published in English, included participants with stroke, quantified adherence to exercise or physical activity recommendations, were patient or clinician reported, were defined and reproducible measures and included patients >18 years old. In phase 2, articles were included if they explored psychometric properties of the identified tools. Included articles were screened based on title/abstract and full-text review by two independent reviewers.

RESULTS:

In phase 1, seven methods of adherence measurement were identified, including logbooks ( n = 16), diaries ( n = 18), 'record of practice' ( n = 3), journals ( n = 1), surveys ( n = 2) and questionnaires ( n = 4). One measurement tool was identified, the Physical Activity Scale for Individuals with Physical Disabilities ( n = 4). In phase 2, no eligible studies were identified.

CONCLUSION:

There is not a consistent measure of adherence that is currently utilized. Diaries and logbooks are the most frequently utilized tools.

Development of a 3D, networked multi-user virtual reality environment for home therapy after stroke

BACKGROUND

Impairment of upper extremity function is a common outcome following stroke, to the detriment of lifestyle and employment opportunities. Yet, access to treatment may be limited due to geographical and transportation constraints, especially for those living in rural areas. While stroke rates are higher in these areas, stroke survivors in these regions of the country have substantially less access to clinical therapy. Home therapy could offer an important alternative to clinical treatment, but the inherent isolation and the monotony of self-directed training can greatly reduce compliance.

METHODS

We developed a 3D, networked multi-user Virtual Environment for Rehabilitative Gaming Exercises (VERGE) system for home therapy. Within this environment, stroke survivors can interact with therapists and/or fellow stroke survivors in the same virtual space even though they may be physically remote. Each user's own movement controls an avatar through kinematic measurements made with a low-cost, Kinect™ device. The system was explicitly designed to train movements important to rehabilitation and to provide real-time feedback of performance to users and clinicians. To obtain user feedback about the system, 15 stroke survivors with chronic upper extremity hemiparesis participated in a multisession pilot evaluation study, consisting of a three-week intervention in a laboratory setting. For each week, the participant performed three one-hour training sessions with one of three modalities: 1) VERGE system, 2) an existing virtual reality environment based on Alice in Wonderland (AWVR), or 3) a home exercise program (HEP).

RESULTS

Over 85% of the subjects found the VERGE system to be an effective means of promoting repetitive practice of arm movement. Arm displacement averaged 350 m for each VERGE training session. Arm displacement was not significantly less when using VERGE than when using AWVR or HEP. Participants were split on preference for VERGE, AWVR or HEP. Importantly, almost all subjects indicated a willingness to perform the training for at least 2-3 days per week at home.

CONCLUSIONS

Multi-user VR environments hold promise for home therapy, although the importance of reducing complexity of operation for the user in the VR system must be emphasized. A modified version of the VERGE system is currently being used in a home therapy study.

Activity monitors for increasing physical activity in adult stroke survivors

BACKGROUND

Stroke is the third leading cause of disability worldwide. Physical activity is important for secondary stroke prevention and for promoting functional recovery. However, people with stroke are more inactive than healthy age-matched controls. Therefore, interventions to increase activity after stroke are vital to reduce stroke-related disability.

OBJECTIVES

To summarise the available evidence regarding the effectiveness of commercially available, wearable activity monitors and smartphone applications for increasing physical activity levels in people with stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, and the following clinical trial registers: WHO International Clinical Trials Registry Platform, Clinical Trials, EU Clinical Trial Register, ISRCTN Registry, Australian and New Zealand Clinical Trial Registry, and Stroke Trials Registry to 3 March 2018. We also searched reference lists, Web of Science forward tracking, and Google Scholar, and contacted trial authors to obtain further data if required. We did not restrict the search on language or publication status.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and randomised cross-over trials that included use of activity monitors versus no intervention, another type of intervention, or other activity monitor. Participants were aged 18 years or older with a diagnosis of stroke, in hospital or living in the community. Primary outcome measures were steps per day and time in moderate-to-vigorous intensity activity. Secondary outcomes were sedentary time, time spent in light intensity physical activity, walking duration, fatigue, mood, quality of life, community participation and adverse events. We excluded upper limb monitors that only measured upper limb activity.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology to analyse and interpret the data. At least two authors independently screened titles and abstracts for inclusion. We resolved disagreements by consulting a third review author. We extracted the following data from included studies into a standardised template: type of study, participant population, study setting, intervention and co-interventions, time-frame, and outcomes. We graded levels of bias as high, low, or unclear, and assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We retrieved 28,098 references, from which we identified 29 potential articles. Four RCTs (in 11 reports) met the inclusion criteria.The sample sizes ranged from 27 to 135 (total 245 participants). Time poststroke varied from less than one week (n = 1), to one to three months (n = 2), or a median of 51 months (n = 1). Stroke severity ranged from a median of one to six on the National Institutes of Health Stroke Scale (NIHSS). Three studies were conducted in inpatient rehabilitation, and one was in a university laboratory. All studies compared use of activity monitor plus another intervention (e.g. a walking retraining programme or an inpatient rehabilitation programme) versus the other intervention alone. Three studies reported on the primary outcome of daily step counts.There was no clear effect for the use of activity monitors in conjunction with other interventions on step count in a community setting (mean difference (MD) -1930 steps, 95% confidence interval (CI) -4410 to 550; 1 RCT, 27 participants; very low-quality evidence), or in an inpatient rehabilitation setting (MD 1400 steps, 95% CI -40 to 2840; 2 RCTs, 83 participants; very low-quality evidence). No studies reported the primary outcome moderate-to-vigorous physical activity, but one did report time spent in moderate and vigorous intensity activity separately: this study reported that an activity monitor in addition to usual inpatient rehabilitation increased the time spent on moderate intensity physical activity by 4.4 minutes per day (95% CI 0.28 to 8.52; 1 RCT, 48 participants; low-quality evidence) compared with usual rehabilitation alone, but there was no clear effect for the use of an activity monitor plus usual rehabilitation for increasing time spent in vigorous intensity physical activity compared to usual rehabilitation (MD 2.6 minutes per day, 95% CI -0.8 to 6; 1 RCT, 48 participants; low-quality evidence). The overall risk of bias was low, apart from high-risk for blinding of participants and study personnel. None of the included studies reported any information relating to adverse effects.

AUTHORS' CONCLUSIONS

Only four small RCTs with 274 participants (three in inpatient rehabilitation and one in the community) have examined the efficacy of activity monitors for increasing physical activity after stroke. Although these studies showed activity monitors could be incorporated into practice, there is currently not enough evidence to support the use of activity monitors to increase physical activity after stroke.

Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges

There have been many advances in management of cerebrovascular diseases. However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This review summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation units, and types of rehabilitation resources and services available in Singapore. We also present the challenges faced by the elderly stroke survivors in the local setting and propose strategies to overcome the barriers to rehabilitation in this aging population.

Digital technologies for social inclusion of individuals with disabilities

Information technology can be an important facilitator of social inclusion for people with disabilities into society. However, the goals specified in this area by organizations such as the European Commission have not yet been achieved in their totality. The aim of this paper is to explore which types of information communication technology-based applications and/or digital services have been suggested to facilitate the social integration of people who suffer from different types of disabilities. We performed a literature review that included studies published during a period of 6 years (2010–2016). The results show that, in the data we have had access to, no concrete patterns can be identified regarding the type of technology or technological trends that can be used to support the social integration of individuals with disabilities. This literature review is of relevance to the identification of further research areas and to the identification of issues which have to be considered in the context of the development and implementation of technological innovations that are aimed at promoting or facilitating social inclusion of individuals with disabilities.

Acceptance of Tele-Rehabilitation by Stroke Patients: Perceived Barriers and Facilitators

OBJECTIVE

To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting.

DESIGN

Qualitative study involving semi-structured in-depth interviews and focus group discussions.

SETTING

General community.

PARTICIPANTS

Participants (N=37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling.

INTERVENTIONS

Singapore Tele-technology Aided Rehabilitation in Stroke trial.

MAIN OUTCOME MEASURES

Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists.

RESULTS

Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled hypertension. Barriers identified by patients were equipment setup-related difficulties and limited scope of exercises; barriers identified by tele-therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation.

CONCLUSIONS

Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment methods suitable for virtual platforms.

Telehealth in Physical Medicine and Rehabilitation: A Narrative Review

Telehealth refers to health care interactions that leverage telecommunication devices to provide medical care outside the traditional face-to-face, in-person medical encounter. Technology advances and research have expanded use of telehealth in health care delivery. Physical medicine and rehabilitation providers may use telehealth to deliver care to populations with neurologic and musculoskeletal conditions, commonly treated in both acute care and outpatient settings. Patients with impaired mobility and those living in locations with reduced access to care may particularly benefit. Video-teleconferencing has been shown to be effective for management of burn patients during acute rehabilitation, including reduced health care use expenses and less disruptions to care. Telehealth can facilitate developing interprofessional care plans. Patients with neurologic conditions including stroke, spinal cord injury, traumatic brain injury, and amyotrophic lateral sclerosis may use telehealth to monitor symptoms and response to treatment. Telehealth also may facilitate occupational and physical therapy programs as well as improve weight management and skin care in patients with chronic conditions. Other applications include imaging review in sports medicine, symptom management and counseling in concussion, traumatic brain injury, and pain management programs. Limitations of telehealth include barriers in establishing relationship between medical provider and patient, ability to perform limited physical examination, and differences in payment models and liability coverage. The expansion of telehealth services is expected to grow and has potential to improve patient satisfaction by delivering high quality and value of care.

Apps and intensive care medicine

Technological advances have played a key role over the last century in the development of humankind. Critical Care Medicine is one of the greatest examples of this revolution. Smartphones with multiple sensors constitute another step forward, and have led to the development of apps for use by both professionals and patients. We discuss their main medical applications in the field of Critical Care Medicine.

A Rehabilitation-Internet-of-Things in the Home to Augment Motor Skills and Exercise Training

Although motor learning theory has led to evidence-based practices, few trials have revealed the superiority of one theory-based therapy over another after stroke. Nor have improvements in skills been as clinically robust as one might hope. We review some possible explanations, then potential technology-enabled solutions. Over the Internet, the type, quantity, and quality of practice and exercise in the home and community can be monitored remotely and feedback provided to optimize training frequency, intensity, and progression at home. A theory-driven foundation of synergistic interventions for walking, reaching and grasping, strengthening, and fitness could be provided by a bundle of home-based Rehabilitation Internet-of-Things (RIoT) devices. A RIoT might include wearable, activity-recognition sensors and instrumented rehabilitation devices with radio transmission to a smartphone or tablet to continuously measure repetitions, speed, accuracy, forces, and temporal spatial features of movement. Using telerehabilitation resources, a therapist would interpret the data and provide behavioral training for self-management via goal setting and instruction to increase compliance and long-term carryover. On top of this user-friendly, safe, and conceptually sound foundation to support more opportunity for practice, experimental interventions could be tested or additions and replacements made, perhaps drawing from virtual reality and gaming programs or robots. RIoT devices continuously measure the actual amount of quality practice; improvements and plateaus over time in strength, fitness, and skills; and activity and participation in home and community settings. Investigators may gain more control over some of the confounders of their trials and patients will have access to inexpensive therapies.

iPad Use in Stroke Neuro-Rehabilitation

Neuro-rehabilitation services are essential in reducing post-stroke impairments, enhancing independence, and improving recovery in hospital and post-discharge. However these services are therapist-dependent and resource intensive. Patients’ disengagement and boredom in stroke units are common which adversely affect functional and psychological outcomes. Novel techniques such as use of iPads™ are increasingly researched to overcome such challenges. The aim of this review is to determine the feasibility, effectiveness, acceptability, and barriers to the use of iPads™ in stroke neuro-rehabilitation. Four databases and manual literature search were used to identify published studies using the terms “iPad”, “Stroke”, and “neuro-rehabilitation”. Studies were included in accordance with the review selection criteria. A total of 16 articles were included in the review. The majority of the studies focused on iPads use in speech and language therapy. Although of small scale, the studies highlighted that iPads are feasible, have the potential to improve rehabilitation outcomes, and can improve patient’s social isolation. Patients’ stroke severity and financial limitations are some of the barriers highlighted in this review. This review presents preliminary data supportive for the use of iPad technology in stroke neuro-rehabilitation. However, further research is needed to determine impact on rehabilitation goals acquisition, clinical efficacy, and cost-efficiency.

Caregiver-mediated exercises for improving outcomes after stroke

BACKGROUND

Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES

To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, Issue 10), MEDLINE (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS

We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention.We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; P = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; P = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; P = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; P = 0.45; low-quality evidence).Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; P = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; P = 0.37; very low-quality evidence).At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; P = 0.002; low-quality evidence) and quality of life (1 study; physical functioning: MD 12.40, 95% CI 1.67 to 23.13; P = 0.02; mobility: MD 18.20, 95% CI 7.54 to 28.86; P = 0.0008; general recovery: MD 15.10, 95% CI 8.44 to 21.76; P < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; P = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; P < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (i.e.

PATIENT

motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life).In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; P = 0.01; moderate-quality evidence).The methodological quality of the included trials and variability in interventions (e.g. content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS' CONCLUSIONS

There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.