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Evidence-Based Physiatry

Evidence-Based Physiatry

Efficacy of Home-Based Telerehabilitation Versus In-Clinic Therapy for Adults After Stroke

Tenforde, Adam S. MD; Zafonte, Ross DO; Hefner, Jaye MD; Iaccarino, Mary A. MD; Silver, Julie MD; Paganoni, Sabrina MD, PhD

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American Journal of Physical Medicine & Rehabilitation: August 2020 - Volume 99 - Issue 8 - p 764-765
doi: 10.1097/PHM.0000000000001475
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Stroke is a common neurological condition that has significant morbidity and mortality. Motor, cognitive, speech, and language impairments frequently occur, and deficits may persist requiring prolonged treatment to optimize recovery. In addition to the challenges in management of a chronic condition, other barriers to care include access, travel, and costs of treatment.

The novel coronavirus pandemic (referred to as COVID-19) has resulted in significant changes in health care delivery that may influence management across health systems and conditions, including stroke. To reduce spread of disease, essential medical services are limited for both healthy populations and those with acute, life-threatening conditions, such as stroke. Although studies are inconclusive, patients with risk factors of male sex, older age, cardiovascular disease, hypertension, respiratory disease, and diabetes may be at higher risk for mortality from COVID-19. Notably, most of these risk factors overlap with patients who have experienced stroke. Furthermore, COVID-19 infections cause a hypercoagulable state in some patients that may result in stroke. Limitations in physical distancing, commonly referred to as social distancing, also reduce contact of medical providers with patients. These combined factors create barriers for treatment required to evaluate acute concern of stroke and long-term sequelae. Changes in health care delivery including coverage of telehealth visits may address these challenges in delivering effective care.

What Is Telehealth?

Telehealth is broadly defined as treatment that can be provided without direct contact with patients through use of technologies, including auditory, visual, tactile, and other forms of communication. The benefits of telehealth have been previously reviewed within the field of physiatry and additional evidence supports use.1 Telehealth can be delivered as synchronous (communication directly with patient) or asynchronous (communication that is provided at different times). Telerehabilitation refers to rehabilitation treatments that are usually delivered in person (e.g., by physical, occupational, and speech therapists). Telehealth serves as a method to provide medical care during a pandemic to control contagion and also addresses other barriers to care including access and transportation limitations that are seen in patients with disability. Here, we review a recent report that highlights the potential of telerehabilitation (TR) in the management of adults with motor impairments after stroke.2 The report highlights its value and is especially pertinent to consider for other domains of physiatry during COVID-19.

Telerehabilitation Compared With in Clinic Rehabilitation: Key Findings

The Health StrokeNet Telerehab Investigators completed a randomized, assessor-blinded, noninferiority trial in 124 patients across 11 sites within the United States. Eligibility criteria included previous stroke (4–36 wks from enrollment) with motor impairments affecting the upper limb. Patients were randomized to TR or in-clinic (IC) treatments consisting of 36 total sessions for 6 wks (18 supervised and 18 unsupervised with patient instructions). During the sessions, the same exercises, therapy approaches, and stroke education were provided along with access to Internet connectivity and required equipment for augmented reality gaming device. Telerehabilitation used video conference during supervised and unsupervised sessions and was also aided by a computer screen and 12 gaming input devices for functional tasks, compared with in-person visits and standard hardware used in the IC treatment. The primary outcome was changes in the Fugl-Meyer Arm Motor Scale and secondary measures included patient motivation and stroke education. Both TR and IC achieved similar gains in Fugl-Meyer that exceeded minimal clinically important difference, regardless of stroke duration (<90 or >90 days). Education measures and patient compliance were similar between groups, although slightly higher satisfaction and motivation suggested preference for in-person or longer duration of education offered for IC over TR.

How Does This Change Physiatry Practice?

Results suggest that TR can have similar gains to IC therapy for management of upper motor deficits after stroke. These findings are important in stroke patients who may benefit from addressing motor recovery during time of limited access to care. Expanding on this concept, telerehabilitation has the potential to transform health care delivery beyond stroke to other neurological and musculoskeletal conditions. Limitations in equipment (e.g., gaming devices) and Internet connectivity remain a challenge in universal delivery of this rehabilitation strategy. Medical payment models have been expanded during the COVID-19 pandemic, including current coverage for rehabilitation. Further applied research on telerehabilitation will validate this model of health care delivery and document value beyond the pandemic into future payment models.


1. Tenforde AS, Hefner JE, Kodish-Wachs JE, et al.: Telehealth in physical medicine and rehabilitation: a narrative review. PM R 2017;9(5S):S51–8
2. Cramer SC, Dodakian L, Le V, et al., National Institutes of Health StrokeNet Telerehab Investigators: Efficacy of home-based telerehabilitation vs in-clinic therapy for adults after stroke: a randomized clinical trial. JAMA Neurol 2019;76:1079–87

Motor Function; Upper Extremity; Therapy

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