A Home-Based Telerehabilitation Program for Patients With Stroke

Abstract

Background: Although rehabilitation therapy is commonly provided after stroke, many patients do not derive maximal benefit because of access, cost, and compliance. A telerehabilitation-based program may overcome these barriers. We designed, then evaluated a home-based telerehabilitation system in patients with chronic hemiparetic stroke.

Methods: Patients were 3 to 24 months poststroke with stable arm motor deficits. Each received 28 days of telerehabilitation using a system delivered to their home. Each day consisted of 1 structured hour focused on individualized exercises and games, stroke education, and an hour of free play.

Results: Enrollees (n = 12) had baseline Fugl-Meyer (FM) scores of 39 ± 12 (mean ± SD). Compliance was excellent: participants engaged in therapy on 329/336 (97.9%) assigned days. Arm repetitions across the 28 days averaged 24,607 ± 9934 per participant. Arm motor status showed significant gains (FM change 4.8 ± 3.8 points, P = .0015), with half of the participants exceeding the minimal clinically important difference. Although scores on tests of computer literacy declined with age ( r = -0.92; P < .0001), neither the motor gains nor the amount of system use varied with computer literacy. Daily stroke education via the telerehabilitation system was associated with a 39% increase in stroke prevention knowledge ( P = .0007). Depression scores obtained in person correlated with scores obtained via the telerehabilitation system 16 days later ( r = 0.88; P = .0001). In-person blood pressure values closely matched those obtained via this system ( r = 0.99; P < .0001).

Conclusions: This home-based system was effective in providing telerehabilitation, education, and secondary stroke prevention to participants. Use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.

Keywords: games; motor; rehabilitation; stroke; telehealth.

Figure 1

[A] Hardware for the telerehabilitation system included a standard table, chair, laptop with keyboard covered, Verizon wireless modem, mat used for game play and moving through the day’s itinerary (via the buttons and arrows), standard rehabilitation equipment, and multiple USB-based input devices to drive game play. [B] Carnival shooting, a game in which the patient performed supination/pronation movements to move the red cursor then squeezed a trigger using a lateral pinch movement to shoot at the yellow, but not red, ducks. [C] Slot machine, a game in which the patient had to perform shoulder extension movements to stop each of the three reels from spinning at the correct time to match all three symbols. [D] Shoulder abduction/adduction, one of the 67 available exercises.

Figure 2

Mean±SEM scores on the bopping game, during which subjects had to use a cylinder held in the stroke-affected hand to bop the tabletop mat target that was indicated on the computer screen. Scores increased significantly across the 28 days of therapy (r=0.65, p=0.0002); note that this increase in scores over time remained significant if values from the first three days were removed.

Figure 3

[A] Arm motor deficits (mean±SEM) were moderate-severe at baseline and increased 1-month post-therapy by 4.8 points (p=0.0015), with gains in 6/12 subjects exceeding the minimal clinically important difference. FM=Fugl-Meyer. [B] Stroke education using the home-based telerehabilitation system improved scores on tests of stroke prevention knowledge. White bars: For the 40 questions that were practiced as part of 28 days of daily stroke education, correct answers increased 39%, from 22.8 to 31.7 (p=0.0007). Gray bars: As a control, 40 questions were not practiced but were also serially tested, and these scores did not change significantly (p=0.17). [C] Computer literacy was inversely related to age (r = −0.92, p<0.0001, left panel) but not system usage (average amount of time subjects spent each day using the telerehabilitation system, p>0.5, right panel). [D] Depression score in the lab at Visit 1 using the Geriatric Depression Scale (GDS) correlated significantly (r=0.88, p=0.0001) with the depression score obtained an average of 16 days later in the home on the telerehabilitation system using the Patient Health Questionnaire (PHQ)-2.