Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic

A year ago the World Stroke Organisation (WSO) highlighted the enormous global impact of the COVID-19 pandemic on stroke care. In this review, we consider a year later where we are now, what the future holds, and what the long-term effects of the pandemic will be on stroke. Stroke occurs in about 1.4% of patients hospitalized with COVID-19 infection, who show an excess of large vessel occlusion and increased mortality. Despite this association, stroke presentations fell dramatically during the pandemic, although emerging data suggest that total stroke mortality may have risen with increased stroke deaths at home and in care homes. Strategies and guidelines have been developed to adapt stroke services worldwide, and protect healthcare workers. Adaptations include increasing use of telemedicine for all aspects of stroke care. The pandemic is exacerbating already marked global inequalities in stroke incidence and mortality. Lastly, the pandemic has had a major impact on stroke research and funding, although it has also emphasized the importance of large scale collaborative research initiatives.

https://journals.sagepub.com/doi/pdf/10.1177/17474930211006435

COVID-19 and stroke-Understanding the relationship and adapting services. A global World Stroke Organisation perspective.

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Telestroke Across the Continuum of Care: Lessons from the COVID-19 Pandemic.

Exercise training is an essential component in the treatment or rehabilitation of various diseases and conditions. However, barriers to exercise such as the burdens of travel or time may hinder individuals' ability to participate in such training programs. Advancements in technology have allowed for remote, home-based exercise training to be utilized as a supplement or replacement to conventional exercise training programs. Individuals in these home-based exercise programs are able to do so under varying levels of supervision from trained professionals, with some programs having direct supervision, and others having little to no supervision at all. The purpose of this review is to examine the use of home-based, tele-exercise training programs for the treatment of different disease states and conditions, and how these programs compare to conventional clinic-based exercise training programs.

https://www.frontiersin.org/articles/10.3389/fresc.2022.811465/pdf

Home-Based Tele-Exercise in Musculoskeletal Conditions and Chronic Disease: A Literature Review

Stroke remains the second leading cause of global disability with 87% of stroke-related disability occurring in low- and middle-income countries. In low- and middle-income countries, access to acute stroke interventions is often limited, making effective poststroke rehabilitation potentially the best available intervention to promote poststroke recovery. Here, we build on our experience as an illustrative example of barriers individuals with stroke face in accessing rehabilitation services and review the literature to summarize challenges to providing effective rehabilitation in low- and middle-income countries. First, we focus on barriers individuals with stroke face in accessing rehabilitation in low- and middle-income countries, including health system barriers, such as lack of national guidelines, low prioritization of rehabilitation services, and inadequate numbers of skilled rehabilitation specialists, as well as patient factors, including limited health literacy, financial constraints, and transportation limitations. Next, we highlight consequences of this lack of rehabilitation access, including higher mortality, poorer functional outcomes, financial burden, caregiver stress, and loss of gross domestic product at a national level. Finally, we review possible strategies that could improve access and quality of rehabilitation services in low- and middle-income countries, including creation of inpatient stroke units, increased training opportunities for rehabilitation specialists, task shifting to available healthcare workers or caregivers, telerehabilitation, and community-based rehabilitation services. 

Stroke Rehabilitation in Low- and Middle-Income Countries

Objective: To determine the effects of a 12-week home-based motor training telerehabilitation program in subcortical stroke patients by combing of motor function assessments and multimodality MRI analysis methods. Methods: Fifty-two stroke patients with hemiplegia were randomly assigned to either a home-based motor training telerehabilitation (TR) group or a conventional rehabilitation (CR) group for 12 weeks. The Fugl-Meyer assessment (FMA) for upper and lower extremities and the modified Barthel index (MBI) were used as primary outcomes. The secondary outcomes included resting-state functional connectivity (rsFC) between the bilateral M1 areas, gray matter volumes of the primary motor cortex (M1) areas and white matter integrity of the corticospinal tract (CST). Analysis of covariance was applied to examine the effects of the home-based motor training TR program on neural function recovery and brain plasticity. Results: Compared with the CR group, the TR group showed significant improvement in the FMA (P = 0.011) and significantly increased M1-M1 rsFC (P = 0.031) at the end of the rehabilitation. The M1-M1 rsFC change was significantly positively correlated with the FMA change in the TR group (P = 0.018). Conclusion: This study showed a beneficial effect of the home-based motor training telerehabilitation program on motor function in stroke patients, which was accompanied by enhanced interhemispheric functional connectivity of the M1 areas. We inferred that it is feasible, safe and efficacious for stroke patients to receive professional rehabilitation training at home. Additionally, the combined use of imaging biomarkers should be encouraged in motor training clinical studies in stroke patients. Classification of Evidence: This study provides Class II evidence that for stroke patients with hemiplegia, home-based telerehabilitation compared to conventional rehabilitation significantly improves some motor function tests.

Effects of home-based telerehabilitation in patients with stroke: A randomized controlled trial.

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Effects of home-based telerehabilitation in patients with stroke: A randomized controlled trial.