Patricia C. Griffiths

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.

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

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.

Using Telehealth Technology to Support Family Caregivers: Description of a Pilot Intervention and Preliminary Results

ABSTRACT This project was funded by the Department of Veterans Affairs (VA) as a part of a national pilot program to design interventions that would support caregivers of older veterans. The specific project described here employed in-home messaging units, which are already widely used by the VA in disease-management programs, as a device to educate and support family caregivers (CGs) of older, functionally impaired veterans. The primary goal of the pilot program was to improve the well-being of both family CGs and their veteran care recipients (CRs) by (a) engaging CGs more actively and effectively in their veterans’ care, and (b) directly addressing the emotional needs of caregivers themselves. A three-group quasi-experimental design (instrumental support, instrumental+emotional support, wait-list control) was employed. Outcomes from the perspective of the caregiver, care recipient, and the health system were evaluated. In this paper, we further describe the experimental design of the program, the role of the technology employed in the program, a brief summary of common opinions of the intervention as voiced by caregivers and care recipients in the program, and a preliminary look at interim quantitative results 3 months prior to the planned final 6-month outcomes analysis.

Tele-Savvy: An Online Program for Dementia Caregivers:

Introduction: This study examined the feasibility and efficacy of Tele-Savvy, an online version of the Savvy Caregiver Program, a psychoeducation program for caregivers caring for a person with dementia. Methods: A convenience sample of 22 caregivers from the Atlanta VA and 42 caregivers from 14 different states enrolled in Tele-Savvy. Pre- and post-program evaluations assessed caregiver burden, caregiver competency, and frequency of behavioral and psychological symptoms of dementia (BPSD). Results: Fifty-seven caregivers completed the 6-week Tele-Savvy program. Caregivers whose care recipients exhibited higher average BPSD frequency at baseline demonstrated significantly greater burden decreases post-program. Caregivers of care recipients in more advanced dementia stages demonstrated a significantly greater improvement in caregiver competence. Discussion: The results point to the feasibility of achieving significant results in caregivers’ well-being and care recipients’ BPSD with a fully online program. Tele-Savvy may be particularly efficacious for caregivers whose care recipients exhibit higher BPSD frequency and are in later dementia stages.

An Online Program for Caregivers of Persons Living With Dementia: Lessons Learned

The population of individuals living with dementia and their caregivers and the need to provide caregiver training will increase in the next several decades. In-person caregiver educational programs are delimited by logistical and resource boundaries that could be overcome with online programs. The purpose of this qualitative descriptive study was to explore the acceptability and ways to improve the content and delivery of an online 7-week psychoeducational pilot program—Tele-Savvy. Thirty-six caregivers who completed the pilot were interviewed about their experience with Tele-Savvy and their suggestions for its improvement. Conventional content analysis allowed for the identification of three themes: barriers and facilitators to establishing rapport with participants and instructors, content enrichment and diversification, and structural refinement. These lessons learned directly from the caregivers provide evidence to guide the refinement of analogous online interventions and highlight the need for their wider availability.

The accuracy of new wheelchair users' predictions about their future wheelchair use.

Objective This study examined the accuracy of new wheelchair user predictions about their future wheelchair use. Design This was a prospective cohort study of 84 community-dwelling veterans provided a new manual wheelchair. Results The association between predicted and actual wheelchair use was strong at 3 mos (ϕ coefficient = 0.56), with 90% of those who anticipated using the wheelchair at 3 mos still using it (i.e., positive predictive value = 0.96) and 60% of those who anticipated not using it indeed no longer using the wheelchair (i.e., negative predictive value = 0.60, overall accuracy = 0.92). Predictive accuracy diminished over time, with overall accuracy declining from 0.92 at 3 mos to 0.66 at 6 mos. At all time points, and for all types of use, patients better predicted use as opposed to disuse, with correspondingly higher positive than negative predictive values. Accuracy of prediction of use in specific indoor and outdoor locations varied according to location. Conclusions This study demonstrates the importance of better understanding the potential mismatch between the anticipated and actual patterns of wheelchair use. The findings suggest that users can be relied upon to accurately predict their basic wheelchair-related needs in the short-term. Further exploration is needed to identify characteristics that will aid users and their providers in more accurately predicting mobility needs for the long-term.