The evidence base for telehealth in stroke management

Susan Royer

This article on the evidence base for telehealth in stroke management was taken from the Whole Systems Demonstrator Action Research Network (WSDAN) database.

In January 2011, WSDAN News reported on a systematic review into telerehabilitation in stroke care. [1] Nine post-2000 studies were included in the review, having met certain criteria. Four of the studies were randomised controlled trials (RCTs), one was a qualitative analysis, and four used observational study designs or case series. In the majority of studies, sample sizes were relatively small – fewer than 25 participants.

The selected studies included three from the United States that related specifically to stroke patients' caregivers. Their objectives covered a range of issues:

  • Analysing caregivers' use and acceptance of telehealth – caregivers were generally accepting of the interventions.
  • Measuring the impact of 'problem-solving telephone partnerships' – caregivers were better prepared, and more able to utilise problem-solving skills among the intervention group compared with a control group.
  • Exploring the feasibility of internet-based education and support provision, aimed at caregivers living in rural communities – caregivers were satisfied that email contact with nurses provided the necessary information for their care function.

Four studies included in the review were concerned with physical post-stroke functioning. These involved stroke patients' use of sensors on the arm or hand combined with video-consulting, which allowed therapists to monitor patients’ exercises and offer real-time guidance and support. These therapy sessions lasted one hour and took place on five days each week. Using the Fugl-Meyer motor scale to assess motor function - the controlled use of movement - one study’s pre- and post-intervention measurements recorded improvements for the telerehabilitation group compared with the control group. [2] The same study, however, found no difference between the two groups in terms of the ABILHAND scale, which also assesses motor function.

Other research used telephone consulting or audio-videoconsulting for stroke rehabilitation. The latter found significant improvements in subscales among telerehabilitation patients who completed Short Form Health Surveys.

The systematic review concluded that, while promising results were evident across the range of interventions, more research was needed to assess the impact of stroke telerehabilitation on costs, effectiveness and utilisation.

Telehealth evidence database

The telehealth evidence database currently holds 12 entries on stroke. Two studies look at robot therapy as a means of treating paralysis. In February 2011, a Japanese-based team reported results for recent stroke sufferers who used daily robotic therapy to manipulate their arms which had been left paralysed. [3] The benefits of this treatment included an increased sense of motivation among patients towards rehabilitation, with the prospect of improvement seeming more realistic than with usual methods. The robotics' level of accuracy was also commended, as they had the ability to administer precisely the optimum pattern of movement.

Research carried out in 2009 in the United States also recorded successful use of robotic devices attached to the ankle or wrist. [4] Patients self-treated, and improvements remained in evidence six months after the trial ended.

Researchers identified an unmet need in terms of post-stroke support for veterans and carers in the United States. [5] This 2007 study was followed up in 2009 with a small-scale trial of a care co-ordination home telehealth programme (CCHT), which involved 18 veterans and 14 carers. [6] Incidence of depression, falls and post-stroke concerns were recorded for patients, along with the level of burden experienced by carers. Ninety per cent of participants felt that access to a care co-ordinator would be useful. The study concluded that home telehealth had potential for this patient group, alongside contact with health care workers.

From the perspective of clinical professionals, telemedicine has been shown to be useful in diagnosing the treatment needs of stroke patients, particularly those living in areas less well served by vascular neurologists. A 2009 study involving a range of professionals, including neurologists and emergency medicine experts, used clinical scenarios to test the efficacy of two-way audio-video links with patients. [7] The advantage of a video connection compared with a telephone-only link is the potential for clinicians to remotely see patients and to base decisions on their visible physical condition as well as reported symptoms. With the benefit of the visual link, the study recorded high levels of decision accuracy and subsequent treatment, particularly judgements about whether or not patients were appropriate candidates for thrombolytic therapy. Video telemedicine produced correct treatment decisions in 98 per cent of cases, compared with 82 per cent for telephone-only consultations.

Conclusions

With an estimated 150,000 people suffering a stroke each year in the UK alone, it represents a widespread chronic condition. [8] Ageing populations and the increased likelihood of stroke among the over-65s point to a need for improved stroke treatment services.

By increasing the delivery of these services in the home, whether administered by a carer, a visiting health professional or guided self-treatment, pressure on inpatient facilities is relieved and stroke patients are able to remain in familiar environments which, in many cases, are more conducive to recovery than hospital settings. However, the available evidence tends not to focus on costs, effectiveness and utilisation, and these areas require greater scrutiny in order to put forward a strong argument for the continued development of telemedicine technologies to support both stroke patients and their carers.

References

[1] Johansson T, Wild C (2011). 'Telerehabilitation in stroke care – a systematic review'. Journal of Telemedicine and Telecare, vol 17, no 1, pp 1-6. Available at: http://jtt.rsmjournals.com/cgi/content/abstract/17/1/1 (accessed on 23 March 2011).

[2] Piron L, Turolla A, Agostini M, Zucconi C, Cortese F, Zampolini M, Zannini M, Dam M, Ventura L, Battauz M, Tonin P (2009). 'Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach'. Journal of Rehabilitative Medicine, vol 41, no 12, pp 1016-102. Available at: www.ncbi.nlm.nih.gov/pubmed/19841835 (accessed on 23 March 2011).

[3] American Heart Association (2011). ‘Robot therapy can improve arm, shoulder mobility after stroke’. ScienceDaily, 10 February. Available at: www.sciencedaily.com/releases/2011/02/110210111259.htm (accessed on 23 March 2011).

[4] Cordo P, Lutsep H, Cordo L, Wright WG, Cacciatore T, Skoss R (2009). 'Assisted movement with enhanced sensation (AMES): coupling motor and sensory to remediate motor deficits in chronic stroke patients'. Neurorehabilitation and Neural Repair, vol 23, no 1, pp 67-77. Available at: www.ncbi.nlm.nih.gov/pubmed/18645190 (accessed on 23 March 2011).

[5] Lutz B, Chumbler N, Roland K (2007). 'Care coordination/home telehealth for veterans with stroke and their caregivers: addressing an unmet need'. Topics in Stroke Rehabilitation, vol 14, no 2, pp 32-42. Available at: www.ncbi.nlm.nih.gov/pubmed/17517572 (accessed on 23 March 2011).

[6] Lutz B, Chumbler N, Lyles T, Hoffman N, Kobb R (2009). 'Testing a home-telehealth programme for US veterans recovering from stroke and their family caregivers'. Disability and Rehabilitation, vol 31, no 5, pp 402–09. Available at: www.ingentaconnect.com/content/apl/tids/2009/00000031/00000005/art00008 (accessed on 23 March 2011).

[7] Capampangan D, Wellik K, Bobrow B, Aguilar M, Ingall T, Kiernan TE, Wingerchuk D, Demaerschalk B (2009). 'Telemedicine versus telephone for remote emergency stroke consultations: a critically appraised topic'. The Neurologist, vol 15, no 3, pp 163-66. Available at: http://journals.lww.com/theneurologist/Abstract/2009/05000/Telemedicine_Versus_Telephone_for_Remote_Emergency.11.aspx (accessed on 23 March 2011).

[8] The Stroke Association (2011). 'Facts and figures about stroke'.

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