The Future of Stroke Rehabilitation

Introduction

A stroke is a neurological condition where the blood supply to the brain is disrupted with on following cell death as a result. Strokes can be divided into ischemic strokes and hemorrhagic strokes. Depending on the affected area, the symptoms of a stroke and the problems which arises from the stroke can vary. Complications can include hemiparesis, spasticity, pain, behavioral changes, cognitive impairments and fatigue. Strokes are more common among men and women are usually almost five years older than men when having their first stroke. Finland has a low mortality rate due to strokes as a result of great management of stroke patients in the acute setting.

In 2015 36,500 strokes occurred in Finland and 4,866 people died as a result of their stroke. The health care costs of strokes were about 721.1 million euro. As rehabilitation of stroke patients remains a costly business, alternative cheaper and more effective treatment strategies are needed to improve healthcare simultaneously as the eHealth evolution is on the rise. Lots of new innovations which can improve and advance the healthcare are getting created. This generates a curiosity about if eHealth solutions could be useful as a lifelong and cost-effective integrated part of the rehabilitation.

Aiding eHealth Solutions

A treatment challenge for stroke patients that has been noted in the literature is that medication adherence in stroke patients is poor. Reasons include patient’s lack of motivation, knowledge and memory. A study by Kamal et al. (2015) found a way to remind the stroke patient about taking the medicines on time and simultaneously reducing costs.

An eHealth solution to tackle this problem has been the introduction with short automatic text messages to the patient's phones when it’s time to take their medications. Additionally, the patient needs to confirm that they have taken their medications by responding to the message. If no reply is sent the patient will receive a phone call inquiring whether they have taken their medications or not.

eHealth has also allowed for improvement of patient self-management. Examples include the UbiCare SmarteXp’s technology. This is a stroke recovery engagement solution that connects hospitals and other care providers to the stroke patient and caregivers through an interactive platform. This program has shown to improve quality of care and has allowed for secondary prevention of a second stroke. With this technology, patient receives targeted educational and health messages via a mobile device. Research into this software has shown that 90% of patients feel more connected to their treatment and 86% report that they are better able to manage their care.

An already implemented part of the telecare concept is the usage of telemedicine in stroke care. Telemedicine enables experts from stroke centers or university hospitals to be a part in the care of a stroke patient in another hospital without them physically assessing the patient themselves. This can ensure that a high qualitative care is given to the patient regardless of if treating hospital has the best expertise on the issue or not. Telestroke is a Finnish example of this type of service that take advantage of telemedicine to aid the general hospitals and therefor improves the management of stroke patients in the acute setting. What is a likewise solution could be implemented in the rehabilitation of stroke patients?

Introducing Telerehabilitation

Telerehabilitation uses information and communication technologies, such as internet-based videoconferencing, telephones and sensors, as the means of interaction between the clinician and the patient. The gathered data can then be analysed by the health care professional without the need of physical contact between the parties. The study by Peretti et al. (2017) concludes that telerehabilitation as a rehabilitative method can reduce healthcare costs, both for patients and the healthcare providers. The study further emphasizes the importance of giving the professionals adequate training.

A few great benefits of telerehabilitation is the possibility for the patient and the health care professionals to maintain contact without them needing to be geographically near one another as well as it is enabling patients to be at home and still receive continuous rehabilitation. Some patients can however be skeptical about the remote interaction. Safro and colleagues (2018) concludes that some parts of the therapy might need face to face interactions, such as the physiotherapy assessments. They nevertheless further argue that telerehabilitation, when compared to conventional in-clinic therapy, might be more cost-effective as well as having either grater or equal salutary effects on higher cortical-, motor- and mood disorders.

Virtual Reality (VR), a somewhat established form of therapy for patients with phobias and post-traumatic stress disorders, can be an integrated part in telerehabilitation. Significant improvements of Timed Up and Go Test, balance and the performance of basic activities of daily living, can be generated with VR-training when compared to conventional therapy alone. It does, however, not seem to show any major significant results when compared to conventional therapy.

One of the main benefits with VR is that it enables the person to be training functions and in situations that otherwise could be dangerous. For example, car driving training. It can also enable the possibility to increase the dosage of therapy without increasing staff levels. VR might however increase the patients muscle tone and should therefore be used with some additional monitoring of the spasticity.

Gesture therapy is a form of telerehabilitation that allows for patients to practice physiotherapy without a clinician present. Gesture therapy has a computer vision-based system where a stroke patient can practice arm movement exercises at home or at the clinic. The system provides a virtual environment for facilitating movement training while tracking the hand of the patient. The system comes with a grip pressure sensor to include hand and finger rehabilitation. The program can also track the patient’s head to detect trunk compensation. It remains of great value to the rehabilitation progress as patients have been shown to be more motivated through gesture therapy and has contributed to rehabilitation success.

Obstacles

The computerized form of rehabilitation can be too hard to grasp when dealing with a neurological condition. Many brain injuries involve disturbances in an individual’s ability to plan, organize, control impulses, concentrate and recall information, to do rehabilitation via electronic devices can be a disturbing element to some patients. Unexpected changes, such as computer freezes or interruptions in software services can overwhelm a patient who already experiences difficulties with sudden changes. During the rehabilitation the patients get accustomed to their situation and their self-esteem as well as self-efficacy improves.

However, in the beginning of the rehabilitation process telerehabilitation can add to the common effect of loneliness by cutting of the real interaction with people. It is likely that telerehabilitation would not provide the patients with experience to concentrate on verbal cues and communicating with other people. For example, in a group setting, the rehabilitation often provide support network and individuals may gain insight from these group experiences that provide visual, auditory, tactile and olfactory stimuli.

The Future, What’s Next

The future of telerehabilitation looks bright and is set to offer significant benefits to the healthcare profession. Despite all the advantages of using telerehabilitation in the treatment of stroke patients there are however some challenges that needs to be addressed. Such challenges include practical, technical as well as user-based challenges. For example, client involvement and effective use of health device. Some of these challenges need to be met with innovation and willingness to adapt to current approaches when necessary.

Some of the hospitals in the Helsinki-Uusimaa hospital region, HUS, are piloting a new telerehabilitation project in some hospitals where physical therapy and occupational therapy can be delivered through the Terveyskylä-site. The distance rehabilitation is meant to be a predecessor for the rest of the HUS hospitals and aims to enabling high qualitive care in the patients’ home milieu. The piloted telerehabilitation is only available for some patient groups. Jorv is e.g. using telerehabilitation with some burn injury patients in their continuous rehabilitation after the discharged from the Burn Centre.

The plan is to expand the telerehabilitation to all HUS-hospitals' physical- and occupational therapy units. The future of telerehabilitation is promising as a new, yet complex, form of health care services with the capacity to provide a wide range of services specifically designed to suit the needs of individuals. It has the capacity of generating a more individual and safer care at a lower cost. It most surely will be interesting to see what the future holds.