Telemedicine Chapter 18: Telemedicine and Stroke Rehabilitation

This chapter is part of Literature reviews carried out for the Heath Service Executive National Telehealth Steering Group April – July 2020

Systematic Reviews

Laver, KE et al (2020)[Cochrane Systematic Review] Telerehabilitation Services for Stroke [1]

Authors’ Conclusions: While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate-level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short-term post-hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in-person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost-effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.

Appleby, E et al (2019) [Systematic Review]Effectiveness of Telerehabilitation in the Management of Adults With Stroke: A Systematic Review[2]

Discussion: Telerehabilitation, as an alternate form of rehabilitation for people with stroke, shows potential. However, due to methodological and practical concerns, an unequivocal recommendation cannot be made. Findings from this review may inform future policies and practices regarding the use of telerehabilitation for stroke patients.

Chen, Yu et al (2019) [Systematic Review] Home-based Technologies for Stroke Rehabilitation: A Systematic Review[3]

Results: The search yielded 832 potentially relevant articles, leading to 31 articles that were included for in-depth analysis. The types of technology of reviewed articles included games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets. We present the merits and limitations of each type of technology. We then derive two main human factors in designing home-based technologies for stroke rehabilitation: designing for engagement, including external and internal motivation, and designing for the home environment, including understanding the social context, practical challenges, and technical proficiency. Conclusion: This systematic review presents an overview of key technologies and human factors for designing home-based technologies for stroke rehabilitation.

Lee, HS et al (2019) [Systematic Review and Meta-Analysis] The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis [4]

The aim of this study was to perform a meta-analysis to examine whether virtual reality (VR)training is effective for lower limb function as well as upper limb and overall function in chronic stroke patients. Three databases, OVID, PubMed, and EMBASE, were used to collect articles. The search terms used were “cerebrovascular accident (CVA),” “stroke”, and “virtual reality”. Consequently, twenty-one studies were selected in the second screening of meta-analyses. The PEDro scale was used to assess the quality of the selected studies. The total effect size for VR rehabilitation programs was 0.440. The effect size for upper limb function was 0.431, for lower limb function it was 0.424, and for overall function it was 0.545. The effects of VR programs on specific outcomes were most effective for improving muscle tension, followed by muscle strength, activities of daily living (ADL), joint range of motion, gait, balance, and kinematics. The VR training was effective in improving the function in chronic stroke patients, corresponding to a moderate effect size. Moreover, VR training showed a similar effect for improving lower limb function as it did for upper limb function.

Maier, M et al (2019) [Meta-Analysis] Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-Analysis[5]

Maier et al evaluated the efficacy of specific VR (SVR) and nonspecific VR (NSVR) systems for rehabilitating upper-limb function and activity after stroke. They conducted a systematic search for randomised controlled trials with adult stroke patients to analyse the effect of SVR or NSVR systems versus conventional therapy (CT). They identified 30 studies including 1473 patients. SVR showed a significant impact on body function (standardised mean difference [SMD] = 0.23; 95% CI = 0.10 to 0.36; P = .0007) versus CT, whereas NSVR did not (SMD = 0.16; 95% CI = -0.14 to 0.47; P = .30). This result was replicated in activity measures. Their results suggest that SVR systems are more beneficial than CT for upper-limb recovery, whereas NSVR systems are not. Additionally, they identified six principles of neurorehabilitation that are shared across SVR systems and are possibly responsible for their positive effect. These findings may disambiguate the contradictory results found in the current literature.

Moral-Munoz, J.A. et al (2019) [Systematic Review] Smartphone-based Systems for Physical Rehabilitation Applications: A Systematic Review [6]

This paper presents a systematic review of the literature on smartphone-based systems designed for remote facilitation of physical rehabilitation. A total of 74 documents from Web of Science search results were reviewed. Systems were classified based on target medical conditions, and a taxonomy of technology was created along with identification of monitored activities. Beyond monitoring, some systems also provide patient-caregiver communication and progress management functions. The review identifies major research interests in stroke, cardiac disease, balance impairment and joint/limb rehabilitation; however, there is a lack of attention to other diseases. There are also few systems that have computerized existing clinical tests. On the basis of the review, design recommendations are formulated to encourage implementation of advanced functionalities, usability considerations, and system validation based on clinical evidence. Results of this study may help researchers and companies to design functions and interactions of smartphone-based rehabilitation systems or to select technology.

Piran, P et al (2019) [Systematic Review] Medical Mobile Applications for Stroke Survivors and Caregivers[7]

Objective: To identify apps 1. designed for stroke survivors/caregivers; 2. dealing with a modifiable stroke risk factor (SRF); or 3. that were developed for other purposes but could potentially be used by stroke survivors/caregivers. Methods: A systematic review of the medical apps in the US Apple iTunes store was conducted between August 2013 and January 2016 using 18 predefined inclusion/exclusion criteria. SRFs considered were: diabetes, hypertension, smoking, obesity, atrial fibrillation, and dyslipidemia. Conclusions: Over 70 medical apps exist to specifically support stroke survivors/caregivers and primarily targeted language and communication difficulties. Apps encompassing most stroke survivor/caregiver needs could be developed and tested to ensure the issues faced by these populations are being adequately addressed.

Rintala, A et al (2019)[Systematic Review and Meta-Analysis] Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials[8]

Objective: To study the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning in stroke. Conclusions: The findings suggest that the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning might be similar compared to traditional treatments in stroke. Further research should be performed to confirm the effectiveness of technology-based distance physical rehabilitation interventions for improving physical functioning of persons with stroke.

Schroder, Jonas et al (2019) [Systematic Review] Combining the Benefits of Tele-Rehabilitation and Virtual Reality-Based Balance Training: A Systematic Review on Feasibility and Effectiveness[9]

This review aims to investigate whether it is feasible to combine virtual reality (VR) which allows exercising in game-like environments with telerehabilitation in a community-dwelling stroke population. Conclusions: Telerehabilitation could be a promising tool to overcome burdens that restrict accessibility to rehabilitation in the future. VR can increase motivation allowing longer and more training sessions in community-dwelling stroke survivors. Therefore, combining the benefits of both approaches seems convenient. Although evidence is still sparse, functional improvements seem to be equal compared to a similar intervention with therapist-supervision in the clinic, suggesting that for cost-efficient rehabilitation parts of therapy can be transferred to the homes. Implications for rehabilitation The use of tele-rehabilitation could be a promising tool to overcome burdens that restrict the access of stroke survivors to long-term rehabilitative care. VR-based interventions are game-like and therefore seem to provide a motivational environment which allows longer exercise sessions and greater adherence to therapy.

Bonnechere, Bruno et al (2016) [Systematic Review] The use of
commercial videogames in rehabilitation: a systematic review[10]

The aim of this paper was to investigate the effect of commercial video games (VGs) in physical rehabilitation of motor functions. Several databases were screened using combinations of the following free-text terms: commercial games, video games, exergames, serious gaming, rehabilitation games, PlayStation, Nintendo, Wii, Wii Fit, Xbox, and Kinect. The search was limited to peer-reviewed English journals. The beginning of the search time frame was not restricted and the end of the search time frame was 31 December 2015. Only randomized controlled trial, cohort, and observational studies evaluating the effect of VGs on physical rehabilitation were included in the review. A total of 4728 abstracts were screened, 275 were fully reviewed, and 126 papers were eventually included. The following information was extracted from the selected studies: device type, number and type of patients, intervention, and main outcomes. The integration of VGs into physical rehabilitation has been tested for various pathological conditions, including stroke, cerebral palsy, Parkinson’s disease, balance training, weight loss, and aging. There was large variability in the protocols used (eg number of sessions, intervention duration, outcome measures, and sample size). The results of this review show that in most cases, the introduction of VG training in physical rehabilitation offered similar results as conventional therapy. Therefore, VGs could be added as an adjunct treatment in rehabilitation for various pathologies to stimulate patient motivation. VGs could also be used at home to maintain rehabilitation benefits.

Randomised Controlled Trials

Cho, Deng-Rae et al (2019) [Randomised Controlled Trial] Effects of Virtual Reality Immersive Training With Computerized Cognitive Training on Cognitive Function and Activities of Daily Living Performance in Patients With Acute Stage Stroke: A Preliminary Randomized Controlled Trial[11]

The purpose of this study was to investigate the impact of virtual reality immersive training with computerized cognitive training on the cognitive function and activity of daily living in patients with acute stroke. Cho and Lee included 42 patients with acute stage stroke from C hospital in Sungnam from May 2017 to September 2017. The patients were randomly selected and divided into the experimental (n = 21) and control (n = 21) group. The experimental group performed virtual reality training, including Head Mount Display with computerized cognitive therapy, and the control group performed computerized cognitive therapy. Both groups trained for 30 minutes a day 5 times a week; the intervention lasted 4 weeks. To evaluate the improvement in each group, pre-post-test evaluation was conducted using the Loewenstein Occupational Therapy Cognitive Assessment and Computerized Neurocognitive Function Test for cognitive function, and Functional Independent Measure for activities of daily living. Attention and memory in cognitive function and activity of daily living performance were improved in the both groups. Virtual reality immersive training might be an affordable approach for cognitive function and activity of daily living performance recovery for patients with acute stroke.

Maresca, G et al (2019) Toward Improving Poststroke Aphasia: A Pilot Study on the Growing Use of Telerehabilitation for the Continuity of Care[12]

Background: Aphasia is a quite common and very disabling symptom following stroke, negatively affecting patient’s quality of life. The aim of this study is to evaluate the effectiveness of rehabilitation training for aphasia that employ a touch-screen tablet using a virtual reality rehabilitation system (VRRS-Tablet). Thirty patients with aphasia due to ischemic or haemorrhagic stroke were randomised into either the control or the experimental group and assessed by means of a specific neuropsychological evaluation. The study lasted 6 months and included 2 phases. During the former, the experimental group underwent an experimental linguistic treatment performed using the VRRS-Tablet, while the control group was trained with a traditional linguistic treatment. In the latter, the control groups were delivered to territorial services, while the experimental group was provided with the VRRS-Tablet. The experimental group improves in all the investigated areas, except for writing, while the control group only improves in comprehension, depression, and quality of life. The study has demonstrated the effectiveness of a home-based telerehabilitation program specific for poststroke aphasia. The use of telerehabilitation by means of VRRS-Tablet could be one of the best solutions to treat aphasic patients after their discharge, promoting continuity of care by monitoring functional outcomes, maintaining preserved abilities, reducing depression, and improving linguistic functions, besides the psychological well-being.

Torrisi, M et al (2019)[Randomised Controlled Trial] Using telerehabilitation to improve cognitive function in post-stroke survivors: is this the time for the continuity of care?[13]

The aim of our study is to evaluate the efficacy of a virtual reality rehabilitation system in improving cognitive function in stroke survivors. Forty patients affected by stroke were enrolled in this study and randomized into either the control or the experimental groups in order of recruitment. The study lasted 6 months, and included two phases: 1. during the first phase the experimental group underwent cognitive rehabilitation training using the Virtual Reality Rehabilitation System-Evo, whereas the control group was submitted to standard cognitive training; 2. in the second phase after discharge, the experimental group was treated by means of virtual reality rehabilitation system Home Tablet [three sessions per week, each session lasting about 50 minutes], and the control group continued the traditional training, with the same amount of treatment. The patients underwent a neuropsychological evaluation before and at the end of the treatment. Linear mixed-effects analysis results showed that the scores of Montreal overall cognitive assessment, attentive matrices, Trail Making Test B, Phonemic Fluency, Semantic Fluency, Rey Auditory Verbal Learning Test I, Hamilton Rating Scale-Anxiety and Hamilton Rating Scale-Depression were affected by the type of the rehabilitative treatment. Our data show the effectiveness of telerehabilitation for the treatment of cognitive disorders following stroke.

Yacoby, Anat et al (2019) [Randomised Controlled Trial] Feasibility of, Adherence to, and Satisfaction With Video Game Versus Traditional Self-Training of the Upper Extremity in People With Chronic Stroke: A Pilot Randomized Controlled Trial [14]

Yacoby et al compared the feasibility of, adherence to, and satisfaction with a newly developed upper extremity (UE) self-training protocol using commercial video games with a traditional self-training programme for people with chronic stroke. 24 participants with mild to moderate UE weakness were randomised to a video game (n = 13) or a traditional (n = 11) self-training programme. Participants were requested to train 60 min/day, 6×/wk. During the 5-wk self-training programme and 4-wk follow-up, participants documented their self-training time and rated their perceived enjoyment and exertion. 11 participants completed video game training; 9 completed traditional self-training. During the follow-up period, 8 participants (72.7%) continued the video game training, and 4 (44.4%) continued traditional training. Perceived enjoyment, satisfaction, and benefit for UE improvement were relatively high. Participants demonstrated high adherence to and satisfaction with both self-training programmes. More participants continued to play video games after the intervention, indicating its potential to maintain ongoing activity.

Laver, KE et al (2017) [Cochrane Systematic Review -update] Virtual Reality for Stroke Rehabilitation[15]

This is an update of a Cochrane Review published first in 2011 and then again in 2015. Objectives: Primary Objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity. Secondary Objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events. Primary outcome: results were not statistically significant for upper limb function (standardised mean difference (SMD)0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care, providing a higher dose of therapy for those in the intervention group, there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence). Secondary outcomes: when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild. Authors’ Conclusions: We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care to increase overall therapy time. There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device [commercial or customised] were not strong influencers of outcome. There was a trend suggesting that higher dose of more than 15 hours of total intervention was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Miscellaneous

Chen, Yu et al (2020) A Qualitative Study on User Acceptance of a Home Based Stroke Telerehabilitation System[16]

This paper reports a qualitative study of a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education in the patient’s home. The aims of the current report are to investigate patient perceived benefits of and barriers to using the telerehabilitation system at home. Conclusion: Telerehabilitation systems can be used as an efficient and user-friendly tool to deliver home-based stroke rehabilitation that enhance patients’ physical recovery and mental and social-emotional wellbeing. Such systems need to be designed to offer engaging experience, display of recovery progress, and flexibility of schedule and location, with consideration of facilitating and social factors.

This study aimed to investigate paretic upper limb activity and function with home-based robotic therapy involving a single-joint hybrid assistive limb (HAL-SJ)in stroke patients. A home-based robotic therapy programme involving a HAL-SJ was performed for 30 min per session followed by standard therapy for 30 min per session, 2 times a week, for 4 weeks (i.e., completion of all 8 sessions involved 8 h of rehabilitation), at home. After the intervention, patients were followed up by telephone and home visits for 8 weeks. The paretic upper limb activity and function were assessed using the Motor Activity Log (MAL; amount of use (AOU)), arm triaxial accelerometry (laterality index (LI)), the Fugl-Meyer assessment (FMA), and the action research arm test (ARAT), at baseline and week 4 and week 12 after the start of training. The AOU scores and LI significantly improved at week 4 after the start of training (p<0.05). However, no significant changes were observed in the LI at week 12 (p=0.161) and the FMA scores at both week 4 and week 12 (p=0.059 and p=0.083, respectively). The ARAT scores significantly improved at both week 4 and week 12 (p<0.05). Home-based robotic therapy combined with conventional therapy could be a valuable approach for increasing paretic upper limb activity and maintaining paretic upper limb function in the chronic phase of stroke.

Norouzi-Gheidari, N et al (2019) [Clinical Trial] Feasibility, Safety and Efficacy of a Virtual Reality Exergame System to Supplement Upper Extremity Rehabilitation Post-Stroke: A Pilot Randomized Clinical Trial and Proof of Principle[18]

Rehabilitation-based virtual reality exergame systems, such as Jintronix, can be offered to stroke survivors as an adjunct to traditional therapy. The goal of this study was to examine the safety and feasibility of providing additional therapy using an exergame system and assess its preliminary clinical efficacy. The efficacy measures showed statistically meaningful improvements in the activities of daily living measures ie MAL-QOM and both mobility and physical domains of the SIS with mean difference of 1.0%, 5.5%, and 6.7% between the intervention and control group, respectively at post-intervention. Conclusion: Using virtual reality exergaming technology as an adjunct to traditional therapy is feasible and safe in post-stroke rehabilitation and may be beneficial to upper extremity functional recovery.

Seo, Na Jin et al (2019) Capturing Upper Limb Gross Motor Categories Using the Kinect® Sensor[19]

Seo et al examined the feasibility of using the Kinect sensor in an objective, computerised clinical assessment of upper limb motor categories. They developed a computerised Mallet classification using the Kinect sensor. Accuracy of computer scoring was assessed based on reference scores determined collaboratively by multiple evaluators from reviewing video recording of movements. In addition, using the reference score, they assessed the accuracy of the typical clinical procedure in which scores were determined immediately based on visual observation. The accuracy of the computer scores was compared with that of the typical clinical procedure. Seven patients with stroke and 10 healthy adults participated in the laboratory-based study. Healthy participants intentionally achieved predetermined scores. The outcomes and measures were the accuracy of the computer scores in comparison with accuracy of the typical clinical procedure (immediate visual assessment). The computerised assessment placed participants’ upper limb movements in motor categories as accurately as did typical clinical procedures. Computerised clinical assessment using the Kinect sensor promises to facilitate tele-evaluation and complement telehealth applications.

Zanona, Aet al (2019) Use of Virtual Rehabilitation to Improve the Symmetry of Body Temperature, Balance, and Functionality of Patients with Stroke Sequelae [20]

Purpose: The objective of this study was to evaluate the acute effect of an occupational therapy protocol associated with virtual reality (VR) on the symmetry of body temperature (BTP), balance, and functionality of patients with stroke sequelae. Conclusion: VR associated with occupational therapeutic planning can amplify and potentiate neurological recovery following stroke

Carregosa, AA et al (2018) Virtual Rehabilitation Through Nintendo Wii in Poststroke Patients: Follow-Up[21]

The objective of this study was to evaluate the follow-up of the sensory-motor recovery and quality of life patients two months after completion of the Nintendo Wii console intervention and determine whether learning retention was obtained through the technique. Five hemiplegics patients participated in the study, of whom 3 were male with an average age of 54.8 years (SD = 4.6). Everyone practiced Nintendo Wii therapy for 2 months (50 minutes/day, 2 times/week, during 16 sessions). Each session lasting 60 minutes, under a protocol in which only the games played were changed, plus 10 minutes of stretching. In the first session, tennis and hula hoop games were used; in the second session, football (soccer) and boxing were used. For the evaluation, the Fulg-Meyer and Short Form Health Survey 36 (SF-36) scales were utilized. The patients were immediately evaluated upon the conclusion of the intervention and 2 months after the second evaluation (follow-up). Values for the upper limb motor function sub-items and total score in the Fugl-Meyer scale evaluation and functional capacity in the SF-36 questionnaire were sustained, indicating a possible maintenance of the therapeutic effects. The results suggest that after Nintendo Wii therapy, patients had motor learning retention, achieving a sustained benefit through the technique.

Ding, WL et al (2018) [Case Study] Kinect-based virtual rehabilitation and evaluation system for upper limb disorders: A case study[22]

Objective: To help patients with disabilities of the arm and shoulder recover the accuracy and stability of movements, a novel and simple virtual rehabilitation and evaluation system called the Kine-VRES system was developed using Microsoft Kinect. Methods: First, several movements and virtual tasks were designed to increase the coordination, control and speed of the arm movements. The movements of the patients were then captured using the Kinect sensor, and kinematics-based interaction and real-time feedback were integrated into the system to enhance the motivation and self-confidence of the patient. Finally, a quantitative evaluation method of upper limb movements was provided using the recorded kinematics during hand-to-hand movement. Results: A preliminary study of this rehabilitation system indicates that the shoulder movements of two participants with ataxia became smoother after three weeks of training (one hour per day). Conclusion: This case study demonstrated the effectiveness of the designed system, which could be promising for the rehabilitation of patients with upper limb disorders.

Givon Schaham, N et al (2018) Game analysis and clinical use of the XboxKinect for stroke rehabilitation[23]

Whole-body movement is required to interact with Microsoft Xbox with the 3D Kinect sensor (Xbox-Kinect) and, therefore, may be suitable for encouraging and practicing movements as part of stroke rehabilitation. We aimed to describe:1. game analysis; 2. clinical use; and 3.the Xbox-Kinect game experience with individuals with chronic stroke. Four therapists played the Xbox-Kinect games and then carried out a games analysis on the basis of the categories suggested by Deutsch. Eleven participants aged 29-69 years with chronic stroke and varying motor deficits played Xbox-Kinect games for 4-22 sessions as part of a video-game group intervention and the clinical use was documented. The game experience was characterized by self-report questionnaires. Detailed tables of game analysis are provided. The clinical use of the console with the participants is presented. Participants reported high enjoyment and ‘somewhat-high’ perceived exertion after playing the two games and stated that overall the console suited their therapeutic goals. This information can assist clinicians with their clinical reasoning and decision-making for incorporating the Xbox-Kinect into stroke rehabilitation. Potentially, the Xbox-Kinect could be used as an on-going tool to facilitate whole-body movement and physical activity of individuals with chronic stroke.

Held, JP et al (2018) Autonomous rehabilitation at stroke patients home for balance and gait: safety, usability and compliance of a virtual reality system[24]

Aim: To study the safety, usability and patient acceptance of an autonomous telerehabilitation system for balance and gait [the REWIRE platform]in the patient’s home. Methods: Autonomous rehabilitation based on virtual rehabilitation was provided at the participants’ home for twelve weeks. The primary outcome was compliance (the ratio between days of actual and scheduled training), analyzed with the two-tailed Wilcoxon Mann-Whitney test. Furthermore safety is defined by adverse events. The secondary endpoint was the acceptance of the system measured with the Technology Acceptance Model (TAM). Additionally, the cumulative duration of weekly training was analyzed. Results: During the study there were no adverse events related to the therapy. Patients performed on average 71% (range 39 to 92%) of the scheduled sessions. The TAM Questionnaire showed excellent values for stroke patients after the training. The average training duration per week was 99±53min. Conclusions: Autonomous telerehabilitation for balance and gait training with the REWIRE-system is safe, feasible and can help to intensive rehabilitative therapy at home.

Triandafilou, KM et al (2018) Development of a 3D, networked multi-user virtual reality environment for home therapy after stroke[25]

Methods: We developed a 3D, networked multi-user Virtual Environment for Rehabilitative Gaming Exercises (VERGE) system for home therapy. Within this environment, stroke survivors can interact with therapists and/or fellow stroke survivors in the same virtual space even though they may be physically remote. Each user’s own movement controls an avatar through kinematic measurements made with a low-cost, Kinect™ device. The system was explicitly designed to train movements important to rehabilitation and to provide real-time feedback of performance to users and clinicians. To obtain user feedback about the system, 15 stroke survivors with chronic upper extremity hemiparesis participated in a multisession pilot evaluation study, consisting of a three-week intervention in a laboratory setting. For each week, the participant performed three one-hour training sessions with one of three modalities: 1. VERGE system; 2. an existing virtual reality environment based on Alice in Wonderland (AWVR); or 3. a home exercise program (HEP). Results: Over 85% of the subjects found the VERGE system to be an effective means of promoting repetitive practice of arm movement. Arm displacement averaged 350 m for each VERGE training session. Arm displacement was not significantly less when using VERGE than when using AWVR or HEP. Participants were split on preference for VERGE, AWVR or HEP. Importantly, almost all subjects indicated a willingness to perform the training for at least 2-3 days per week at home. Conclusions: Multi-user VR environments hold promise for home therapy, although the importance of reducing complexity of operation for the user in the VR system must be emphasized. A modified version of the VERGE system is currently being used in a home therapy study.

Dobkin, Bruce (2017) A Rehabilitation-Internet-of-Things in the Home to Augment Motor Skills and Exercise Training[26]

Although motor learning theory has led to evidence-based practices, few trials have revealed the superiority of one theory-based therapy over another after stroke. Nor have improvements in skills been as clinically robust as one might hope. We review some possible explanations, then potential technology-enabled solutions. Over the Internet, the type, quantity, and quality of practice and exercise in the home and community can be monitored remotely and feedback provided to optimize training frequency, intensity, and progression at home. A theory-driven foundation of synergistic interventions for walking, reaching and grasping, strengthening, and fitness could be provided by a bundle of home-based Rehabilitation Internet-ofThings (RIoT) devices. A RIoT might include wearable, activity-recognition sensors and instrumented rehabilitation devices with radio transmission to a smartphone or tablet to continuously measure repetitions, speed, accuracy, forces, and temporal spatial features of movement. Using telerehabilitation resources, a therapist would interpret the data and provide behavioral training for self-management via goal setting and instruction to increase compliance and long-term carryover. On top of this user-friendly, safe, and conceptually sound foundation to support more opportunity for practice, experimental interventions could be tested or additions and replacements made, perhaps drawing from virtual reality and gaming programs or robots. RIoT devices continuously measure the actual amount of quality practice; improvements and plateaus over time in strength, fitness, and skills; and activity and participation in home and community settings. Investigators may gain more control over some of the confounders of their trials and patients will have access to inexpensive therapies

Dodakian, Lucy et al (2017) A Home-Based Telerehabilitation Program for Patients With Stroke[27]

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. 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.

Minge, Met al (2017) BeMobil: Developing a User-Friendly and Motivating Telerehabilitation System for Motor Relearning After Stroke [28]

Motor relearning after stroke is a lengthy process which should be continued after patients get discharged from the clinic. This project aims at developing a system for telerehabilitation which enables stroke patients to exercise at home autonomously or under supervision of a therapist. The system includes haptic therapy devices which are more promising and beneficial for stroke rehabilitation than non-haptic approaches. In this paper, we present the results of two initial studies investigating specific design solutions for the patient’s user interface. In the first study, we developed four interactive prototypes illustrating different navigation concepts. A usability test was conducted to identify the best suitable concept. In the second study we followed a participatory design approach to create a set of design solutions for a motivating instant visual feedback for exercising with the haptic devices. The current project status and next steps are described.

Simpson, Lisa A et al (2017) H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for individuals post stroke[29]

Purpose: To investigate the feasibility of a phone-monitored home exercise program for the upper limb following stroke. Methods: A pre-post double baseline repeated measures design was used. Participants completed an 8-week home exercise program that included behavioural strategies to promote greater use of the affected upper limb. Participants were monitored weekly by therapists over the phone. The following feasibility outcomes were collected: process [eg recruitment rate]; resources [eg exercise adherence rate]; management [eg therapist monitoring] and scientific [eg safety, effect sizes]. Clinical outcomes included: The Chedoke Arm and Hand Inventory, Motor Activity Log, grip strength and the Canadian Occupational Performance Measure. Conclusions: Community dwelling individuals with stroke may benefit from a phonemonitored upper limb home exercise program that includes behavioural strategies that promote transfer of exercise gains into daily upper limb use. Implications for Rehabilitation A repetitive, task-oriented home exercise program that utilizes telephone supervision may be an effective method for the treatment of the upper limb following stroke This program is best suited for individuals with mild to moderate level impairment and experience a sufficient level of challenge from the exercises An exercise program that includes behavioural strategies may promote transfer of exercise gains into greater use of the affected upper limb during daily activities.

Buick, Alison R et al (2016) Tele-Supervised FES-Assisted Exercise for Hemiplegic Upper Limb[30]

Stroke survivors often have upper limb hemiparesis, limiting their ability to perform activities of daily life. Intensive, task-oriented exercise therapy can improve UL function, but motivation to perform sufficient ET is difficult to maintain. Here, we report on a trial in which a workstation was deployed in the homes of chronic stroke survivors to enable tele-coaching of ET in the guise of computer games. Participants performed six weeks of 1 h/day, five days/week ET. Hand opening and grasp were assisted with functional electrical stimulation. The primary outcome measure was the Action Research Arm Test. Secondary outcome measures included a quantitative test of UL function performed on the workstation, grasp force measurements and transcranial magnetic stimulation. Improvements were seen in the functional tests, but surprisingly, not in the TMS responses. An important finding was that participants commencing with intermediate functional scores improved the most. Conclusions: 1. daily, tele-supervised FES-ET in chronic stroke survivors is feasible with commercially-available technology; 2.the intervention can significantly improve UL function, particularly in people who start with an intermediate level of function; 3. significant improvements in UL function can occur in the absence of changes in TMS responses.

Paul, Lorna et al (2016) [Pilot Study] Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study[31]

We developed STARFISH, a mobile phone app-based intervention, which incorporates evidence-based behavior change techniques [feedback, self- monitoring and social support], in which users’ physical activity is visualized by fish swimming. Objective: To evaluate the potential effectiveness of STARFISH in stroke survivors. Method: Twenty-three people with stroke (12 women; age: 56.0 ± 10.0 years, time since stroke: 4.2 ± 4.0 years)from support groups in Glasgow completed the study. Participants were sequentially allocated in a 2:1 ratio to intervention (n = 15) or control (n = 8) groups. The intervention group followed the STARFISH program for six weeks; the control group received usual care. Outcome measures included physical activity, sedentary time, heart rate, blood pressure, body mass index, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, TenMeter Walk Test, Stroke Specific Quality of Life Scale, and Psychological General Well-Being Index. Results: The average daily step count increased by 39.3% (4158 to 5791 steps/day)in the intervention group and reduced by 20.2% (3694 to 2947 steps/day)in the control group (p = 0.005 for group-time interaction). Similar patterns of data and group-time interaction were seen for walking time (p = 0.002) and fatigue (p = 0.003). There were no significant group-time interactions for other outcome measures. Conclusion: Use of STARFISH has the potential to improve physical activity and health outcomes in people after stroke and longer term intervention trials are warranted.

Staszuk, Arleta et al (2016) Telerehabilitation approach for patients with hand impairment[32]

The professional and advanced systems for telerehabilitation are presented in papers, however, there is still lack of development of minor systems which provide therapeutic values and are more accessible to people. Therefore, we focus on a solution for hand telerehabilitation of poststroke patients, based solely on a personal computer and camera. Methods: We focused on the manipulative hand [fingers, metacarpus, wrist] movements trainings for patients with cerebral palsy. The contact between patient and physiotherapist is provided by using web cameras and web service. Additionally, the camera can be used to monitor the effectiveness of performed exercises. Computer vision system keeps track of the patient’s hand movement. The digital image processing is used to detect if the patient performs exercises correctly. Results: We created web service and software application TeleReh that provides therapeutic values for the hand impaired people. The system created was evaluated by three physiotherapists, one doctor and a cerebral palsy patient. Conclusions: Our solution applies to all patients who have undergone basic rehabilitation in hospital and need to continue hand rehabilitation at home. The main advantages are: easy adaptation to the individual needs and abilities, monitoring the progress by using automatically generated reports after each training session. It is worth noticing that discussion between IT specialists, rehabilitants and patients was necessary to achieve good results.

Ehn, Maria et al (2015) Users perspectives on interactive distance technology enabling home-based motor training for stroke patients[33]

The aim of this work has been to develop a technical support enabling homebased motor training after stroke. The basis for the work plan has been to develop an interactive technical solution supporting three different groups of stroke patients: 1. patients with stroke discharged from hospital with support from neuro team; 2. patients with stroke whose support from neuro team will be phased out and 3. patients living with impaired motor functions long-term. The technology has been developed in close collaboration with end-users using a method earlier evaluated and described. This paper describes the main functions of the developed technology. Further, results from early user-tests with end-users, performed to identify needs for improvements to be carried out during further technical development. The developed technology will be tested further in a pilot study of the safety and, usefulness of the technology when applied as a support for motor training in three different phases of the post-stroke rehabilitation process.

Jagos, Harald et al (2015) Tele-monitoring of the Rehabilitation Progress in Stroke Patients[34]

Preservation of mobility in conjunction with an independent lifestyle is one of the major goals of rehabilitation after stroke. The Rehab@Home framework shall support the continuation of rehabilitation in the domestic area. The framework consists of instrumented insoles, wireless linked to a tablet PC, a server and a web-interface for medical experts. The rehabilitation progress is estimated via automated analysis of movement data from standardized assessment tests which are executed via the tablet PC application designed according to the needs of stroke patients. Initial evaluation of the analysis algorithms shows reproducible results for the overall time of the Timed Up and Go Test. Therefore, it is assumed that the Rehab@Home framework is applicable as monitoring tool for the gait rehabilitation progress in stroke patients

Zhang, Songyuan et al (2015) Design o fa Novel Telerehabilitation System With a Force-Sensing Mechanism [35]

Many stroke patients are expected to rehabilitate at home, which limits their access to proper rehabilitation equipment, treatment, or assessment by therapists. We have developed a novel telerehabilitation system that incorporates a human-upper-limb-like device and an exoskeleton device. The system is designed to provide the feeling of real therapist-patient contact via telerehabilitation. We applied the principle of a series elastic actuator to both the master and slave devices. On the master side, the therapist can operate the device in a rehabilitation center. When performing passive training, the master device can detect the therapist’s motion while controlling the deflection of elastic elements to near-zero, and the patient can receive the motion via the exoskeleton device. When performing active training, the design of the force-sensing mechanism in the master device can detect the assisting force added by the therapist. The force-sensing mechanism also allows force detection with an angle sensor. Patients’ safety is guaranteed by monitoring the motor’s current from the exoskeleton device. To compensate for any possible time delay or data loss, a torquelimiter mechanism was also designed in the exoskeleton device for patients’ safety. Finally, we successfully performed a system performance test for passive training with transmission control protocol/Internet protocol communication.


[1] Laver KE, Adey-Wakeling Z, Crotty M, Lannin NA, George S, Sherrington C. Telerehabilitation services for stroke. Cochrane
Database Syst Rev. 2020;11.:CD010255. Published 2020 Jan 31. doi:10.1002/14651858.CD010255.pub3

[2] Appleby E, Gill ST, Hayes LK, Walker TL, Walsh M, Kumar S. Effectiveness of telerehabilitation in the managementof adults
with stroke: A systematic review. PLoS One. 2019;14(11):e0225150. Published 2019 Nov 12. doi:10.1371/journal.pone.0225150

[3] Chen Y, Abel KT, Janecek JT, Chen Y, Zheng K, Cramer SC. Home-based technologies for stroke rehabilitation: A systematic
review. Int J Med Inform.2019;123:11‐22. doi:10.1016/j.ijmedinf.2018.12.001

[4] Lee HS, Park YJ, Park SW. The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review
and Meta-Analysis. Biomed Res Int. 2019;2019:7595639. Published 2019 Jun 18. doi:10.1155/2019/7595639

[5] Maier M, Rubio Ballester B, Duff A, Duarte Oller E, Verschure PFMJ. Effect of Specific Over Nonspecific VR-Based
Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis. Neurorehabil Neural Repair. 2019;332.:112‐129.
doi:10.1177/1545968318820169

[6] Moral-Munoz JA PhD, Zhang W PhD, Cobo MJ PhD, Herrera-Viedma E PhD, Kaber DB PhD. Smartphone-based systems for
physical rehabilitation applications: A systematic review [published online ahead of print, 2019 May 21]. Assist Technol.
2019;1‐14. doi:10.1080/10400435.2019.1611676

[7] Piran P, Thomas J, Kunnakkat S et al Medical Mobile Applications for Stroke Survivors and Caregivers. J Stroke Cerebrovasc
Dis. 2019;28(11):104318. doi:10.1016/j.jstrokecerebrovasdis.2019.104318

[8] Rintala A, Päivärinne V, Hakala S et al Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for
Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Arch Phys
Med Rehabil. 2019;1007.:1339‐1358. doi:10.1016/j.apmr.2018.11.007

[9] Schröder J, van Criekinge T, Embrechts E et al Combining the benefits of tele-rehabilitation and virtual reality-based balance
training: a systematic review on feasibility and effectiveness. Disabil Rehabil Assist Technol. 2019;141.:2‐11.
doi:10.1080/17483107.2018.1503738

[10] Bonnechère B, Jansen B, Omelina L, Van Sint Jan S. The use of commercial video games in rehabilitation: a systematic review.
Int J Rehabil Res.2016;394.:277‐290. doi:10.1097/MRR.0000000000000190

[11] Cho DR, Lee SH. Effects of virtual reality immersive training with computerized cognitive training on cognitive function and
activities of daily living performance in patients with acute stage stroke: A preliminary randomized controlled trial. Medicine
(Baltimore).2019;98(11):e14752. doi:10.1097/MD.0000000000014752

[12] Maresca G, Maggio MG, Latella D et al Toward Improving Poststroke Aphasia: A Pilot Study on the Growing Use of
Telerehabilitation for the Continuity of Care. J Stroke Cerebrovasc Dis. 2019;28(10):104303.
doi:10.1016/j.jstrokecerebrovasdis.2019.104303

[13] Torrisi M, Maresca G, De Cola MC et al Using telerehabilitation to improve cognitive function in post-stroke survivors: is this
the time for the continuity of care?. Int J Rehabil Res. 2019;424.:344‐351. doi:10.1097/MRR.0000000000000369

[14] Yacoby A, Zeilig G, Weingarden H, Weiss R, Rand D. Feasibility of, Adherence to, and Satisfaction With Video Game Versus
Traditional Self-Training of the Upper Extremity in People With Chronic Stroke: A Pilot Randomized Controlled Trial. Am J
Occup Ther.2019;731.:7301205080p1‐7301205080p14.

[15] Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database
Syst Rev. 2017;11(11):CD008349. Published 2017 Nov 20. doi:10.1002/14651858.CD008349.pub4

[16] Chen Y, Chen Y, Zheng K et al A qualitative study on user acceptance of a home-based stroke telerehabilitation system. Top
Stroke Rehabil. 2020;272.:81‐92. doi:10.1080/10749357.2019.1683792

[17] Hyakutake K, Morishita T, Saita K et al Effects of Home-Based Robotic Therapy Involving the Single-Joint Hybrid Assistive
Limb Robotic Suit in the Chronic Phase of Stroke: A Pilot Study. Biomed Res Int. 2019;2019:5462694. Published 2019 Mar 18.
doi:10.1155/2019/5462694

[18] Norouzi-Gheidari N, Hernandez A, Archambault PS,Higgins J, Poissant L, Kairy D. Feasibility, Safety and Efficacy of a Virtual
Reality Exergame System to Supplement Upper Extremity Rehabilitation Post-Stroke: A Pilot Randomized Clinical Trial and
Proof of Principle. Int J Environ Res Public Health. 2019;171.:113. Published 2019 Dec 23. doi:10.3390/ijerph17010113

[19] Seo NJ, Crocher V, Spaho E et al Capturing Upper Limb Gross Motor Categories Using the Kinect® Sensor. Am J Occup Ther.
2019;734.:7304205090p1‐7304205090p10. doi:10.5014/ajot.2019.031682

[20] Zanona AF, de Souza RF, Aidar FJ et al Use of Virtual Rehabilitation to Improve the Symmetry of Body Temperature, Balance,
and Functionality of Patients with Stroke Sequelae. Ann Neurosci. 2019;253.:166‐173. doi:10.1159/000488581

[21] Carregosa AA, Aguiar Dos Santos LR, Masruha MR et al Virtual Rehabilitation through Nintendo Wii in Poststroke Patients:
Follow-Up. J Stroke Cerebrovasc Dis. 2018;272.:494‐498. doi:10.1016/j.jstrokecerebrovasdis.2017.09.029

[22] Ding WL, Zheng YZ, Su YP, Li XL. Kinect-based virtual rehabilitation and evaluation system for upper limb disorders: A case
study. J Back Musculoskelet Rehabil. 2018;314.:611‐621. doi:10.3233/BMR-140203

[23] Givon Schaham N, Zeilig G, Weingarden H, Rand D. Game analysis and clinical use of the Xbox-Kinect for stroke
rehabilitation. Int J Rehabil Res.2018;414.:323‐330. doi:10.1097/MRR.0000000000000302

[24] Held JP, Ferrer B, Mainetti R et al Autonomous rehabilitation at stroke patients home for balance and gait: safety, usability
and compliance of a virtual reality system. Eur J Phys Rehabil Med. 2018;544.:545‐553. doi:10.23736/S1973-9087.17.04802-X

[25] Triandafilou KM, Tsoupikova D, Barry AJ, Thielbar KN, Stoykov N, Kamper DG. Development of a 3D, networked multi-user
virtual reality environment for home therapy after stroke. J Neuroeng Rehabil. 2018;151.:88. Published 2018 Oct 5.
doi:10.1186/s12984-018-0429-0

[26] Dobkin BH. A Rehabilitation-Internet-of-Things in theHome to Augment Motor Skills and Exercise Training. Neurorehabil
Neural Repair. 2017;313.:217‐227. doi:10.1177/1545968316680490

[27] Dodakian L, McKenzie AL, Le V et al A Home-Based Telerehabilitation Program for Patients With Stroke. Neurorehabil Neural
Repair. 2017;31(10-11):923‐933. doi:10.1177/1545968317733818

[28] Minge M, Ivanova E, Lorenz K, Joost G, Thuring M, Kruger J. BeMobil: Developing a user-friendly and motivating
telerehabilitation system for motor relearning after stroke. IEEE Int Conf Rehabil Robot. 2017;2017:870‐875.
doi:10.1109/ICORR.2017.8009358

[29] Simpson LA, Eng JJ, Chan M. H-GRASP: the feasibility of an upper limb home exercise program monitored by phone for
individuals post stroke. Disabil Rehabil. 2017;39(9):874‐882. doi:10.3109/09638288.2016.1162853

[30] Buick AR, Kowalczewski J, Carson RG, Prochazka A. Tele-Supervised FES-Assisted Exercise for Hemiplegic Upper Limb. IEEE
Trans Neural Syst Rehabil Eng.2016;241.:79‐87. doi:10.1109/TNSRE.2015.2408453

[31] Paul L, Wyke S, Brewster S et al Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone
application: a pilot study. Top Stroke Rehabil. 2016;233.:170‐177. doi:10.1080/10749357.2015.1122266

[32] Staszuk A, Wiatrak B, Tadeusiewicz R, Karuga-Kuźniewska E, Rybak Z. Telerehabilitation approach for patients with hand
impairment. Acta Bioeng Biomech. 2016;184.:55‐62.

[33] Ehn M, Hansson P, Sjölinder M et al Users perspectives on interactive distance technology enabling home-based motor
training for stroke patients. Stud Health Technol Inform. 2015;211:145‐152.

[34] Jagos H, David V, Reichel M et al Tele-monitoring of the rehabilitation progress in stroke patients. Stud Health Technol
Inform. 2015;211:311‐313.

[35] Zhang S, Guo S, Gao B, Hirata H, Ishihara H. Design of a novel telerehabilitation system with a force-sensing mechanism.
Sensors (Basel).2015;155.:11511‐11527. Published 2015 May 19. doi:10.3390/s150511511