In some cases outcomes were better than conventional therapy

Telerehabilitation after stroke was non-inferior to conventional rehabilitation — and was superior in some measures — after 12 weeks of therapy, a small randomized study showed.

In assessments of both extremity function and activities of daily living, both conventional therapy and home-based motor training telerehabilitation produced positive effects, reported Chuancheng Ren, PhD, of Fudan University in Shanghai, China and coauthors in Neurology.

“This study provides Class II evidence that for stroke patients with hemiplegia, home-based telerehabilitation compared to conventional rehabilitation significantly improves some motor function tests,” Ren and colleagues wrote. “Relative to conventional rehabilitation training, the home-based motor training telerehabilitation approach led to a significant improvement in motor function, as evaluated by the FMA.”

“The resting-state functional connectivity alteration was positively associated with FMA changes in the telerehabilitation group but not in the conventional rehabilitation group,” they added. “After 12 weeks of follow-up [week 24 of the study], the differences in significant FMA and resting-state functional connectivity changes between the two groups disappeared, which may be due to the rehabilitation duration having not long enough to yield long-term effects on the structural plasticity changes detected by structural MRI.”

Primary outcomes of the study were the Fugl-Meyer assessment (FMA) subscales for upper and lower extremity function and the modified Barthel Index (MBI) for activities of daily living.

Compared with conventional treatment, the telerehab group showed significant improvement in the FMA (mean difference 5.8 points, P =0.011). The difference in MBI mean scores was nonsignificant.

MRI diffusion tensor imaging (DTI) measures of connectivity showed improvements within both groups. Comparing conventional therapy and telerehab, DTI imaging showed resting-state functional connectivity between bilateral primary motor cortex areas was significantly increased (P = 0.031) in the telerehab group. Other structural and DTI imaging findings from baseline to week 12 were non-significant.

In an accompanying editorial, Susan Hillier, PhD, and Brenton Hordacre, PhD, both of the University of South Australia, Adelaide, wrote: “Importantly for a study of this type no adverse events were reported for either group – the comparative intervention did no harm.”

Recovery after stroke involves structural brain reorganization of motor cortex as well as interhemispheric connections between motor areas.

Whether conventional outpatient rehabilitation is preferred over telerehabilitation depends on many variables, and each have their positive and negative aspects, Hillier and Hordacre observed, noting that “outpatient models arguably enable closer professional input and access to therapeutic equipment and environments; home delivery offers a more naturalistic or ecologically-valid setting so potentially avoiding issues of failure to transfer learning.”

“The personal factors for and against are also mixed – the literature reports that some people with stroke value a visit to experts whereas others value the reduced burden of travel and appointment-keeping and appreciate the increased potential for family and supporters to be part of the rehabilitation process when it is conducted in the home,” they added.

Telerehab has been shown to be effective in increasing measures of function and independence as well as compliance in prior work, although a 2017 randomized study found no between-group differences for outcomes including the modified Barthel Index while demonstrating within group differences.

In this study, Ren and collaborators looked at successive stroke admissions between July 2017 and January 2019, including 52 patients who were age 30-85, right handed, screened within 3 weeks of stroke, and were medically stable. Included patients had a first stroke with a single subcortical lesion in the motor pathway and clinical hemiplegia, with culprit lesion seen on imaging. Researchers excluded those with cerebellar or pontine lesions, psychiatric disorders, inability to have MRI studies done, or who had psychiatric disorders.

National Institutes of Health Stroke Scale (NIHSS) scores for study participants were 2 to 20 (mean was 5 in both groups), and they had good family support for rehabilitation. Mean age in the telerehab group was 64 and in the conventional treatment group, 59. The telerehab group was 54% male and the conventional treatment group 46% male.

Patients were randomized to home-based motor training telerehabilitation (n=26) or conventional therapy (n=26) for 12 weeks. In each group, patients had 10 targeted sessions per week that involved 60 minutes of occupational therapy and physical therapy, with 20 minutes of electromyography-triggered neuromuscular stimulation each session. Telerehab was provided through video consultations and conventional treatment was provided in an outpatient setting.

FMA and BMI were assessed at baseline, after each session, and at 12 weeks. DTI imaging was obtained for secondary imaging outcomes at baseline and study end. Of the original 52 patients, 39 completed the trial. No study-related adverse events were reported during the rehabilitation intervention in either group.

Limitations of the study include a relatively short followup period with diminishing improvements in motor function at the end of the study. A longer intervention period may be needed to develop durable results, the researchers noted.

  1. Telerehabilitation after stroke was non-inferior to conventional rehabilitation — and was superior in some measures — after 12 weeks of therapy, a small randomized study showed.

  2. Some improvements diminished after 12 weeks of follow-up (week 24 of the study), suggesting a longer intervention period may be needed to develop durable results.

Paul Smyth, MD, Contributing Writer, BreakingMED

This study was supported by Shanghai Strategic Emerging Industries Project Plan and the National Natural Science Foundation of China.

The researchers had no disclosures.

Hordacre is funded by a National Health and Medical Research Council fellowship. Hillier had no disclosures.

Cat ID: 130

Topic ID: 82,130,8,130,748,192,925