Jon A. Sanford

Effects of Telerehabilitation on Physical Function and Disability for Stroke Patients: A Randomized, Controlled Trial

Background and Purpose— To determine the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on physical function, and secondarily on disability, in veterans poststroke. Methods— We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans with stroke from 3 Veterans Affairs medical centers. Veterans with a stroke in the preceding 24 months were randomized to the STeleR intervention or usual care. The STeleR intervention consisted of 3 home visits, 5 telephone calls, and an in-home messaging device provided over 3 months to instruct patients in functionally based exercises and adaptive strategies. Usual care participants received routine rehabilitation care as prescribed by their physicians. The primary outcome measures were improvement in function at 6 months, measured by both the motor subscale of the Telephone Version of Functional Independence Measure and by the function scales of the Late-Life Function and Disability Instrument. Results— The 2 complementary primary outcomes (Late-Life Function and Disability Instrument Function and Telephone Version of Functional Independence Measure) improved at 6 months for the STeleR group and declined for the usual care group, but the differences were not statistically significant (P=0.25, Late-Life Function and Disability Instrument; P=0.316). Several of secondary outcomes were statistically significant. At 6 months, compared with the usual care group, the STeleR group showed statistically significant improvements in 4 of the 5 Late-Life Function and Disability Instrument disability component subscales (P<0.05), and approached significance in 1 of the 3 Function component subscales (P=0.06). Conclusions— The STeleR intervention significantly improved physical function, with improvements persisting up to 3 months after completing the intervention. STeleR could be a useful supplement to traditional poststroke rehabilitation given the limited resources available for in-home rehabilitation for stroke survivors. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00384748.

Development of a teletechnology protocol for in-home rehabilitation.

Our ability to provide in-home rehabilitation is limited by distance and available personnel. We may be able to meet some rehabilitation needs with videoconferencing technology. This article describes the feasibility of teletechnology for delivering multifactorial, in-home rehabilitation interventions to community-dwelling adults recently prescribed a mobility aid. We used standard telephone lines to provide two-way video and audio interaction. The interventions included prescription of and/or training in functionally based exercises, home-hazard assessment, assistive technology, environmental modifications, and adaptive strategies. Patients were evaluated in three transfer and three mobility tasks, and appropriate treatment was provided over the course of four visits. To date, 13 of the 14 subjects enrolled in the rehabilitation study have completed all four visits (56 visits total). Equipment-related problems were most common early in the study, particularly on the initial visit to a subjects house. We identified (mean +/- standard deviation [SD]) 13.1 +/- 7.9 mobility/self-care problems per subject and made 12.5 +/- 8.3 recommendations per subject to address those problems. At 6-week follow-up, 60.1 percent of our recommendations had been implemented. The greatest number of problems was identified for tub transfers (mean +/- SD = 3.4 +/- 1.4), the greatest number of recommendations was made for toilet transfers (mean +/- SD = 3.1 +/- 3.4), and the most frequently implemented recommendations were for transition between locations. Overall, our results show promise that both the telerehabilitation technology and intervention procedures are feasible.

Using telerehabilitation to identify home modification needs.

Teleconferencing technology has great potential for providing cost-effective in-home assessment for home modification services from anywhere to anyone in need. Despite its enormous potential, the use of this technology as a means to deliver these specific services had not been investigated. This project investigated the use of televideo technology to provide remote home assessment services to patients prior to discharge so that they could function as independently as possible in their own homes after being discharged from a specialty clinic. Specifically, an assessment protocol that could be implemented using video-conferencing technology was developed and feasibility of the remote assessment process was determined by validating it against the standard of practice, an in-home assessment by a home modifications specialist. Independent in-home and remote home assessments were completed by two occupational therapists who specialize in home modifications. The results were compared for agreement in identification of specific accessibility problems in and quantitative measurements of the home. The remote assessment correctly identified a total of 51 of the 59 problems (86.4%) identified by the in-home assessment and only identified five problems (8.9%) that were not identified by the on-site assessment. In addition, 54 of 60 (90%) of the quantitative measurements from the remote assessment matched those from the in-home assessment. Findings suggest that remote telerehabilitation assessments have the potential to enable specialists to diagnose potential accessibility problems in home environments and prescribe appropriate modifications regardless of the location of the client, home, or specialist.

Study protocol: home-based telehealth stroke care: a randomized trial for veterans

BackgroundStroke is one of the most disabling and costly impairments of adulthood in the United States. Stroke patients clearly benefit from intensive inpatient care, but due to the high cost, there is considerable interest in implementing interventions to reduce hospital lengths of stay. Early discharge rehabilitation programs require coordinated, well-organized home-based rehabilitation, yet lack of sufficient information about the home setting impedes successful rehabilitation. This trial examines a multifaceted telerehabilitation (TR) intervention that uses telehealth technology to simultaneously evaluate the home environment, assess the patients mobility skills, initiate rehabilitative treatment, prescribe exercises tailored for stroke patients and provide periodic goal oriented reassessment, feedback and encouragement.MethodsWe describe an ongoing Phase II, 2-arm, 3-site randomized controlled trial (RCT) that determines primarily the effect of TR on physical function and secondarily the effect on disability, falls-related self-efficacy, and patient satisfaction. Fifty participants with a diagnosis of ischemic or hemorrhagic stroke will be randomly assigned to one of two groups: (a) TR; or (b) Usual Care. The TR intervention uses a combination of three videotaped visits and five telephone calls, an in-home messaging device, and additional telephonic contact as needed over a 3-month study period, to provide a progressive rehabilitative intervention with a treatment goal of safe functional mobility of the individual within an accessible home environment. Dependent variables will be measured at baseline, 3-, and 6-months and analyzed with a linear mixed-effects model across all time points.DiscussionFor patients recovering from stroke, the use of TR to provide home assessments and follow-up training in prescribed equipment has the potential to effectively supplement existing home health services, assist transition to home and increase efficiency. This may be particularly relevant when patients live in remote locations, as is the case for many veterans.Trial RegistrationClinical Trials.gov Identifier: NCT00384748

Personalized Technology to Support Older Adults With and Without Cognitive Impairment Living at Home

Although persons with dementia (PWD) and their family caregivers need in-home support for common neuropsychiatric symptoms (NPS), few if any assistive technologies are available to help manage NPS. This implementation study tested the feasibility and adoption of a touch screen technology, the Companion, which delivers psychosocial, nondrug interventions to PWD in their home to address individual NPS and needs. Interventions were personalized and delivered in home for a minimum of 3 weeks. Postintervention measures indicated the technology was easy to use, significantly facilitated meaningful and positive engagement, and simplified caregivers’ daily lives. Although intervention goals were met, caregivers had high expectations of their loved one’s ability to regain independence. Care recipients used the system independently but were limited by cognitive and physical impairments. We conclude the Companion can help manage NPS and offer caregiver respite at home. These data provide important guidance for design and deployment of care technology for the home.

Development of a Comprehensive Assessment for Delivery of Home Modifications

Modifying ones home is an important strategy to manage chronic health conditions, increase independence, and ensure safety of frail older adults. However, in many areas of the country home modifications are difficult to obtain due to either a lack of specialists or a comprehensive assessment tool that would enable specialists to diagnose problems and prescribe solutions without having to perform an on-site evaluation. The purpose of this project was to develop and validate an assessment protocol that provides sufficient information about an individual, his/her occupational performance, and environment such that specialists can prescribe appropriate modifications without having to perform an on-site assessment.

Home and Community Environmental Features, Activity Performance, and Community Participation among Older Adults with Functional Limitations.

This paper describes relationships among home and community environmental features, activity performance in the home, and community participation potential to support aging in place. A subset of data on older adults with functional limitations (N = 122), sixty three (63) with mobility and 59 with other limitations, were utilized in this study from a larger projects subject pool. Results showed significant and positive correlations between environmental barriers, activity dependence and difficulty at home, and less community participation in the mobility limitation group. While kitchen and bathroom features were most limiting to home performance, bathtub or shower was the only home feature, and destination social environment was the only community feature, that explained community participation. Compared to environmental features, home performance explained much more community participation. Study results provide detailed information about environmental features as well as types of home activities that can be prioritized as interventions for aging in place.

A randomized controlled trial on Stroke telerehabilitation: The effects on falls self-efficacy and satisfaction with care

Summary We determined the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on falls-related self-efficacy and satisfaction with care. We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans from three Veterans Affairs Medical Centers. Participants who experienced a stroke in the past 24 months were randomized to the STeleR intervention or usual care. Participants in the intervention arm were administered an exit interview to gather specific patient satisfaction data three months after their final outcome measure. The STeleR intervention consisted of three home visits, five telephone calls, and an in-home messaging device provided over three months to instruct patients in functionally based exercises and adaptive strategies. The outcome measures included Falls Efficacy Scale to measure fall-related self-efficacy and a Stroke-Specific Patient Satisfaction with Care (SSPSC) scale, a measure separated into two subscales (satisfaction with home care and satisfaction with hospital care) was employed to measure the participants’ satisfaction. At six months, compared with the usual care group, the STeleR group showed statistically significant improvements in one of the two SSPSC scales (satisfaction with hospital care, p = .029) and approached significance in the second SSPSC scale (satisfaction with home care, p = .077). There were no improvements in fall-related self-efficacy. Core concepts identified were: (a) beneficial impact of the trained assistant; (b) exercises helpful; (c) home use of technology. The STeleR intervention improved satisfaction with care, especially as it relates to care following their experience from the hospital. With the limited resources available for in-home rehabilitation for stroke survivors, STeleR (and especially its exercise components) can be a useful complement to traditional post-stroke rehabilitation.

Implementing Telerehabilitation Research For Stroke Rehabilitation With Community Dwelling Veterans: Lessons Learned

Telerehabilitation (TR) is the use of telehealth technologies to provide distant support, rehabilitation services, and information exchange between people with disabilities and their clinical providers. This article discusses the barriers experienced when implementing a TR multi-site randomized controlled trial for stroke patients in their homes, and the lessons learned. The barriers are divided into two sections: those specific to TR and those pertinent to the conduct of tele-research. The TR specific barriers included the rapidly changing telecommunications and health care environment and inconsistent equipment functionality. The barriers applicable to tele-research included the need to meet regulations in diverse departments and rapidly changing research regulations. Lessons learned included the need for: telehealth equipment options to allow for functionality within a diverse telecommunications infrastructure; rigorous pilot testing of all equipment in authentic situations; and on-call and on-site biomedical engineering and/or IT staff.

A Comparison of Televideo and Traditional In-Home Rehabilitation in Mobility Impaired Older Adults

This paper reports on a randomized controlled trial to evaluate the effectiveness of using interactive video conferencing technology to diagnose problems, prescribe interventions, and implement solutions for six mobility and transfer tasks in comparison with traditional home visits. Thirty-two community-dwelling adults with new mobility devices were randomized into either traditional in-home (n = 16) or telerehab (n = 16) intervention group. Each group received weekly, one-hour therapy sessions for four consecutive weeks. There were no significant differences in the number of problems identified, recommendations made, or number of recommendations implemented for five of the six tasks. The only task for which there were significant differences, moving from room to room, is likely attributable to the nature of the protocol which did not accommodate an inherent limitation in the technology, rather than a fatal flaw in the technology itself.