Recent trends in telerehabilitation of stroke patients: A narrative review

Cognitive telerehabilitation: an expert consensus paper on current evidence and future perspective

The progressive improvement of the living conditions and medical care of the population in industrialized countries has led to improvement in healthcare interventions, including rehabilitation. From this perspective, Telerehabilitation (TR) plays an important role. TR consists of the application of telemedicine to rehabilitation to offer remote rehabilitation services to the population unable to reach healthcare. TR integrates therapy-recovery-assistance, with continuity of treatments, aimed at neurological and psychological recovery, involving the patient in a family environment, with an active role also of the caregivers. This leads to reduced healthcare costs and improves the continuity of specialist care, as well as showing efficacy for the treatment of cognitive disorders, and leading to advantages for patients and their families, such as avoiding travel, reducing associated costs, improving the frequency, continuity, and comfort of performing the rehabilitation in its own spaces, times and arrangements. The aim of this consensus paper is to investigate the current evidence on the use and effectiveness of TR in the cognitive field, trying to also suggest some recommendations and future perspectives. To the best of our knowledge, this is the first consensus paper among multiple expert researchers that comprehensively examines TR in different neurological diseases. Our results supported the efficacy and feasibility of TR with good adherence and no adverse events among patients. Our consensus summarizes the current evidence for the application of cognitive TR in neurological populations, highlighting the potential of this tool, but also the limitations that need to be explored further.

Telerehabilitation for Neurological Motor Impairment: A Systematic Review and Meta-Analysis on Quality of Life, Satisfaction, and Acceptance in Stroke, Multiple Sclerosis, and Parkinson's Disease

Telerehabilitation (TR) seems to be a viable and feasible solution to face the rehabilitative challenges posed by neurological impairments and to improve patients' quality of life (QoL). This review aims to synthesize and analyze the evidence on the impact of physiotherapy intervention through TR on QoL in patients with stroke, Parkinson's disease (PD), and multiple sclerosis (MS), together with an evaluation of their satisfaction and technology acceptance levels. Through a systematic search of the literature and a screening process, treatment effects were assessed with meta-analyses using the standardized mean difference, setting the confidence interval at 95%. We included 28 studies in the review, which were analyzed for methodological quality, whereas 16 studies were included in the meta-analyses. The results suggest a significant improvement in QoL in patients who underwent TR. We were unable to perform analyses for satisfaction and technology acceptance outcomes due to insufficient data. Overall, motor TR has a positive impact on the QoL of patients with neurological diseases, especially in stroke patients; although caution is needed in the interpretation of the results due to the high heterogeneity found. For PD and MS, TR seems to yield comparable results to in-person treatment.

Three-Dimensional Magnetic Rehabilitation, Robot-Enhanced Hand-Motor Recovery after Subacute Stroke: A Randomized Controlled Trial

We developed an end-effector-type rehabilitation robot that can uses electro- and permanent magnets to generate a three-way magnetic field to assist hand movements and perform rehabilitation therapy. This study aimed to investigate the therapeutic effect of a rehabilitation program using a three-dimensional (3D) magnetic force-based hand rehabilitation robot on the motor function recovery of the paralyzed hands of patients with stroke. This was a double-blind randomized controlled trial in which 36 patients with subacute stroke were assigned to intervention and control groups of 18 patients each. The intervention group received 30 min of rehabilitation therapy per day for a month using a 3D magnetic force-driven hand rehabilitation robot, whereas the control group received 30 min of conventional occupational therapy to restore upper-limb function. The patients underwent three behavioral assessments at three time points: before starting treatment (T0), after 1 month of treatment (T1), and at the follow-up 1-month after treatment completion (T2). The primary outcome measure was the Wolf Motor Function Test (WMFT), and secondary outcome measures included the Fugl-Meyer Assessment of the Upper Limb (FMA_U), Modified Barthel Index (MBI), and European Quality of Life Five Dimensions (EQ-5D) questionnaire. No participant safety issues were reported during the intervention. Analysis using repeated measures analysis of variance showed significant interaction effects between time and group for both the WMFT score (p = 0.012) and time (p = 0.010). In post hoc analysis, the WMFT scores and time improved significantly more in the patients who received robotic rehabilitation at T1 than in the controls (p = 0.018 and p = 0.012). At T2, we also consistently found improvements in both the WMFT scores and times for the intervention group that were superior to those in the control group (p = 0.024 and p = 0.018, respectively). Similar results were observed for FMA_U, MBI, and EQ-5D. Rehabilitation using the 3D hand-rehabilitation robot effectively restored hand function in the patients with subacute stroke, contributing to improvement in daily independence and quality of life.

Evaluating Feasibility of a Secondary Stroke Prevention Program

Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information (referrals, uptake, participant demographics and costs), and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre-post scores on standardized clinical tests (e.g., waist circumference and 6-Minute Walk (6MWT)). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for 'relevance' (100%), 'felt safe to exercise' (96%) and 'intend to continue' (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors (diet, exercise, smoking and alcohol). Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m, p < 0.001) and waist circumference (MD -2.1 cm, 95%CI -3.9 cm to -1.4 cm, p < 0.001). The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention.

ICTs and interventions in telerehabilitation and their effects on stroke recovery

Telerehabilitation (TR) is a new model to provide rehabilitation services to stroke survivors. It is a promising approach to deliver mainstream interventions for movement, cognitive, speech and language, and other disorders. TR has two major components: information and communication technologies (ICTs) and stroke interventions. ICTs provide a platform on which interventions are delivered and subsequently result in stroke recovery. In this mini-review, we went over features of ICTs that facilitate TR, as well as stroke interventions that can be delivered via TR platforms. Then, we reviewed the effects of TR on various stroke disorders. In most studies, TR is a feasible and effective solution in delivering interventions to patients. It is not inferior to usual care and in-clinic therapy with matching dose and intensity. With new technologies, TR may result in better outcomes than usual care for some disorders. One the other hand, TR also have many limitations that could lead to worse outcomes than traditional rehabilitation. In the end, we discussed major concerns and possible solutions related to TR, and also discussed potential directions for TR development.

Digital Therapeutics for the Egocentric and Allocentric Neglects in Patients with Brain Injury: A Mini Review

Various therapeutic approaches have been developed for neglect. Many studies have demonstrated the effect of digital therapeutics (DTx) on neglect. However, few studies have reported the effects of DTx on egocentric and allocentric neglect. The differentiation of types of neglect and separate interventions is crucial in the rehabilitation process. In this article, seven studies on DTx on egocentric and allocentric neglect were reviewed. DTx, which was employed in these studies, could be classified as follows: (1) software adaptation in traditional treatment, (2) VR game using the head-mount display as treatment, and (3) the development of a new digital program like ReMoVES. In addition, more studies and more effective results were reported for egocentric neglect than for allocentric neglect. In future studies, each effect on egocentric and allocentric neglect should be identified in detail with the appropriate use of differential evaluation and long-term application of independent DTx.

Telerehabilitation in the Finnish Outpatient Rehabilitation Setting from the Perspective of the Socio-Technical Systems Theory

BACKGROUND

In the development of effective telerehabilitation (TR) interventions, understanding the various characteristics affecting its practice is essential. Remote connection creates a new technically shaped environment for therapy and, therefore, previous therapy methods do not work the same way as before.

OBJECTIVE

The objective of this survey was to describe the practice of TR through the socio-technical theory approach.

METHODS

The 629 respondents to the online questionnaire included music therapists, occupational therapists, speech and language therapists, physiotherapists, and neuropsychologists. The materials consisted of five open-ended questions. The analysis combined data-based and theory-based analysis.

RESULTS

In the data-based content analysis, we identified three main categories and eight generic categories, whereas in the theory-based, we categorised the main results according to the Fit Between Individuals, Tasks, Technology, and Environment (FITTE) framework dimensions. TR is everyday-life based, it requires shared participation, and the approach has to include coaching and collaboration with the client and their close associates. The everyday-life environment is one of the main dimensions that affect all the other dimensions.

CONCLUSIONS

TR can be seen as technology-mediated home-based rehabilitation, as it can integrate rehabilitation into the client's everyday life. In TR, therapy becomes multilateral and it creates a new kind of shared partnership into outpatient therapy.

Empirical Myoelectric Feature Extraction and Pattern Recognition in Hemiplegic Distal Movement Decoding

In myoelectrical pattern recognition (PR), the feature extraction methods for stroke-oriented applications are challenging and remain discordant due to a lack of hemiplegic data and limited knowledge of skeletomuscular function. Additionally, technical and clinical barriers create the need for robust, subject-independent feature generation while using supervised learning (SL). To the best of our knowledge, we are the first study to investigate the brute-force analysis of individual and combinational feature vectors for acute stroke gesture recognition using surface electromyography (EMG) of 19 patients. Moreover, post-brute-force singular vectors were concatenated via a Fibonacci-like spiral net ranking as a novel, broadly applicable concept for feature selection. This semi-brute-force navigated amalgamation in linkage (SNAiL) of EMG features revealed an explicit classification rate performance advantage of 10-17% compared to canonical feature sets, which can drastically extend PR capabilities in biosignal processing.

Measures to ensure safety during telerehabilitation of people with stroke: A scoping review

BACKGROUND

Measures used to prevent adverse events during the implementation of exercise sessions delivered via telerehabilitation can be varied, ranging from simple telephone monitoring to synchronous therapist-led sessions. However, this information is scattered in the literature, as evidence synthesis studies have only addressed the safety, satisfaction, and effectiveness aspects of exercise delivered via telerehabilitation.

AIMS

This scoping review aims to describe that measures are used to ensure safety during exercise sessions delivered to people with stroke through telerehabilitation, as reported by authors of primary studies. Secondarily, it describes the designs most frequently used to notify the effects of telerehabilitation and evidence level, the characteristics of the participants and type of stroke, and the characteristics of telerehabilitation.

SUMMARY OF REVIEW

A scoping review was conducted according to the Joana Briggs Institute (JBI) recommendations. A systematic search of MEDLINE (Ovid), Embase (Ovid), CENTRAL, and CINHAL was conducted from inception to August 2022, and a review of systematic review references on the topic. We included primary studies that enrolled adults with stroke who underwent exercise delivered via telerehabilitation. Two independent reviewers performed study selection and data extraction, and disagreements were resolved by consensus or a third reviewer. A qualitative analysis of the information was performed. One hundred seven primary studies (3991 participants) published between 2002 and 2022 were included. Most studies were case series (43%) and rated with an Oxford level of evidence of "4" (55.3%). Regarding randomized clinical trials, half included 53 or more participants (IQR 26.75 to 81). Most studies applied the exercises via asynchronous telerehabilitation (55.1%), of which only ten reported measures to avoid adverse events. Some of the measures included assessing the location where exercises are to be performed, only using a seated position, and using live warning systems that prevent or stop exercises when they are risky.

CONCLUSIONS

Reporting of measures implemented to prevent adverse events during exercise delivery via asynchronous telerehabilitation is scarce. Future primary studies should always consider reporting adverse events related to exercise delivery via telerehabilitation and strategies implemented to decrease the incidence of these unwanted safety events.

REGISTRATION NUMBER

INPLASY202290104.

Rehabilitation of motor function after stroke: A bibliometric analysis of global research from 2004 to 2022

BACKGROUND AND AIMS

The mortality rate of stroke has been increasing worldwide. Poststroke somatic dysfunctions are common. Motor function rehabilitation of patients with such somatic dysfunctions enhances the quality of life and has long been the primary practice to achieve functional recovery. In this regard, we aimed to delineate the new trends and frontiers in stroke motor function rehabilitation literature published from 2004 to 2022 using a bibliometric software.

METHODS

All documents related to stroke rehabilitation and published from 2004 to 2022 were retrieved from the Web of Science Core Collection. Publication output, research categories, countries/institutions, authors/cocited authors, journals/cocited journals, cocited references, and keywords were assessed using VOSviewer v.1.6.15.0 and CiteSpace version 5.8. The cocitation map was plotted according to the analysis results to intuitively observe the research hotspots.

RESULTS

Overall, 3,302 articles were retrieved from 78 countries or regions and 564 institutions. Over time, the publication outputs increased annually. In terms of national contribution, the United States published the most papers, followed by China, Japan, South Korea, and Canada. Yeungnam University had the most articles among all institutions, followed by Emory University, Fudan University, and National Taiwan University. Jang Sung Ho and Wolf S.L. were the most productive (56 published articles) and influential (cited 1,121 times) authors, respectively. "Effect of constraint-induced movement therapy on upper extremity function 3-9 months after stroke: the Extremity Constraint Induced Therapy Evaluation randomized clinical trial" was the most frequently cited reference. Analysis of keywords showed that upper limbs, Fugl-Meyer assessment, electromyography, virtual reality, telerehabilitation, exoskeleton, and brain-computer interface were the research development trends and focus areas for this topic.

CONCLUSION

Publications regarding motor function rehabilitation following stroke are likely to continuously increase. Research on virtual reality, telemedicine, electroacupuncture, the brain-computer interface, and rehabilitation robots has attracted increasing attention, with these topics becoming the hotspots of present research and the trends of future research.

A feasibility study to assess the effectiveness of Muvity: A telerehabilitation system for chronic post-stroke subjects

OBJECTIVES

To assess the feasibility of a telerehabilitation system for chronic post-stroke subjects compared to a conventional treatment.

METHODS

A feasibility cross-over analysis was conducted in ten chronic post-stroke subjects. Two randomized groups followed two eight-weeks treatments, one with the telerehabilitation system Muvity and the other following conventional therapy (in random order). Before and after each treatment, physical evaluations were performed assessing functional independence, the perceived level of pain, balance control and self-reported health status. After the study, the participants answered a short questionnaire to measure the usability of the system.

RESULTS

Four out of six subjects demonstrated better performance in ADLs (equal or higher FIM scores) and five out of six reported lower pain (VAS score) after the treatment with Muvity when compared to the treatment without. There were no clear trends in terms of balance control (Berg scale) or self-reported health status (PCS score within SF-36).

CONCLUSIONS

The results suggest that the proposed telerehabilitation system aids users to overall maintain or improve their ability to perform ADLs without increasing pain, when compared to conventional therapy. Most subjects found the use of Muvity more motivating than the conventional rehabilitation treatment. This provides initial evidence that Muvity might be an appropriate complement for the telerehabilitation of patients with physical disabilities. However, the differences observed between both treatments were not statistically significant. A clinical study with a larger sample size will be necessary to obtain more robust results.

Common Neuroanatomical Substrate of Cholinergic Pathways and Language-Related Brain Regions as an Explanatory Framework for Evaluating the Efficacy of Cholinergic Pharmacotherapy in Post-Stroke Aphasia: A Review

Despite the relative scarcity of studies focusing on pharmacotherapy in aphasia, there is evidence in the literature indicating that remediation of language disorders via pharmaceutical agents could be a promising aphasia treatment option. Among the various agents used to treat chronic aphasic deficits, cholinergic drugs have provided meaningful results. In the current review, we focused on published reports investigating the impact of acetylcholine on language and other cognitive disturbances. It has been suggested that acetylcholine plays an important role in neuroplasticity and is related to several aspects of cognition, such as memory and attention. Moreover, cholinergic input is diffused to a wide network of cortical areas, which have been associated with language sub-processes. This could be a possible explanation for the positive reported outcomes of cholinergic drugs in aphasia recovery, and specifically in distinct language processes, such as naming and comprehension, as well as overall communication competence. However, evidence with regard to functional alterations in specific brain areas after pharmacotherapy is rather limited. Finally, despite the positive results derived from the relevant studies, cholinergic pharmacotherapy treatment in post-stroke aphasia has not been widely implemented. The present review aims to provide an overview of the existing literature in the common neuroanatomical substrate of cholinergic pathways and language related brain areas as a framework for interpreting the efficacy of cholinergic pharmacotherapy interventions in post-stroke aphasia, following an integrated approach by converging evidence from neuroanatomy, neurophysiology, and neuropsychology.