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Virtual Rehabilitation Is Said to Be Effective After Subcortical Stroke

Article In Brief

New research findings suggest that home-based stroke rehabilitation treatment implemented a few weeks after subcortical stroke was more effective in improving leg and arm strength than a traditional in-clinic program. Virtual home-based rehabilitation is important, especially now in light of the current COVID-19 pandemic, stroke experts say.

A 12-week home-based stroke rehabilitation treatment initiated a few weeks after a subcortical stroke was more effective at improving arm and leg strength than a traditional in-clinic program, according to a randomized controlled study published ahead of print on September 30 in Neurology.

Other studies have reported that home-based telerehabilitation is as effective in improving limb movements and enhancing activities of daily living as traditional in-clinic programs but without the stress to travel many times a week to a clinic and the time it takes, and the cost. Particularly now, during the COVID-19 pandemic, the option to do virtual home-based rehabilitation is important, independent stroke experts told Neurology Today.

However, the current study, which suggests that stroke patients could do well with interventions they can do in the privacy of their home, was conducted before COVID-19.

The team, led by Chuancheng Ren, PhD, of the neurology department at Shanghai Fifth People's Hospital of Fudan University and Shanghai East Hospital of Tongji University, has been working on a home-based training program for several years and published the methodology in 2018 in the journal Medicine.

Study Design, Findings

The researchers tested the 12-week home-based motor-training program on 52 patients who had been diagnosed with a subcortical stroke at the Shanghai Fifth People's Hospital between July 2017 and January 2019. Two senior neurologists and a radiologist on the study team screened each person within a week to three weeks of the stroke.

The participants, who ranged in age from 30 to 85, had subcortical lesions but no cerebellar or pontine lesions; they had no cognitive impairment or other brain or psychiatric abnormalities. Their strokes were mild to moderate in severity.

Participants were randomized 1:1 to a telerehabilitation arm from the privacy of their homes or to an in-clinic conventional rehabilitation program for the same 12-week period. The home-based rehab program was done remotely by video between the patient at home and the rehabilitation therapist at the clinic.

The research team conducted motor assessments of the patients, who also had MRI at the beginning and the end of the study, to test for resting-state functional connectivity between motor imagery (MI) areas, gray matter volumes in the primary motor cortex, and white matter integrity of the corticospinal tract. The primary outcome measures were motor recovery and improved activities of daily living.

The imaging measures were assessed as a secondary outcome measure to determine whether the motor improvements were related to any changes observed on the magnetic resonance scans.

Both the in-clinic and at-home rehabilitation groups underwent 10 rehabilitation training sessions a week that included an hour of occupational therapy and physical therapy and 20-minutes of electromyography-triggered neuromuscular stimulation (ETNS) during each session. (Family members were trained to deliver the stimulation for the at-home group.)

All of the patients were assessed at baseline, and the therapy programs began within 72 hours of the baseline assessment. Assessments were completed within a week after the 12-week program was finished.

On both testing days, the team used the Fugl-Meyer assessment (FMA) to measure motor impairment in the upper and lower extremities. They also used the modified Barthel index (MBI) to assess ability to do activities of daily living.

The patients treated via telerehabilitation showed significant improvement in the FMA (p=0.011)—an 11-point change on the FMA—compared with a five-point change in the in-clinic group. There were no significant differences in the two groups in the mean change in resting-state functional connectivity between the bilateral MI areas.

Expert Commentary

Findings from the study become even more important at a time when the COVID-19 pandemic has kept many people at home, and out of hospital and clinic environments, two experts in stroke rehabilitation told Neurology Today. But they noted that the study did have certain limitations.

For one, the research was done on patients who did not have severe strokes, and the treatment was delivered at a time when the brain is still naturally healing. Each patient has their own rate of spontaneous recovery, so it makes it hard to compare patients during this acute stage, said Steven C. Cramer, MD, FAAN, a professor in the department of neurology at the David Geffen School of Medicine at UCLA, and medical director of research at the California Rehabilitation Institute. He said that spontaneous motor recovery is generally complete by three months.

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“Going to a medical appointment following a stroke is complicated, to begin with. It can be a half-day voyage for a 45-minute appointment. Throw in COVID, and it is really hard. Telerehabilitation and telemedicine, in general, is the way of the future. At this point, telerehabilitation is still experimental. But there is strong evidence that it is equally effective to what is being done in the clinic.”—DR. STEVEN C. CRAMER

His group conducted a multicenter randomized controlled study of a six-week in-person rehabilitation compared to telerehabilitation in 124 patients, but it was delivered on average after four months. Patients improved “just as much as people who received in-clinic rehab,” Dr. Cramer said, adding that the findings were published last year in JAMA Neurology.

“The strokes in the China study were pretty mild,” said Dr. Cramer. “This is a narrow slice of the pie. It limits generalizability.”

Dr. Cramer's study also measured several biomarkers, including resting-state MRI connectivity, and found that higher gains on functional recovery showed less connectivity between the left and right sides of the brain. He said that it may well be that treatment effects on M1-M1 connectivity are “different in more severe patients.”

Still, Dr. Cramer believes that telerehabilitation is a good option, especially now. “Going to a medical appointment following a stroke is complicated, to begin with. It can be a half-day voyage for a 45-minute appointment. Throw in COVID, and it is really hard. Telerehabilitation and telemedicine, in general, is the way of the future. At this point, telerehabilitation is still experimental. But there is strong evidence that it is equally effective to what is being done in the clinic.”

AM Barrett, MD, FAAN, professor of neurology and rehabilitation and neurorehabilitation division director at the Brain Health Center and executive director for the Center for Visual and Neurocognitive Neuroscience for the Atlanta VA Healthcare System, is also a proponent of telerehabilitation.

“Rehabilitation has been a really neglected area in virtual and telemedicine,” she said. “People with traumatic brain injuries and stroke have been at a disadvantage in getting the therapy they need.”

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“Rehabilitation has been a really neglected area in virtual and telemedicine. People with traumatic brain injuries and stroke have been at a disadvantage in getting the therapy they need.”—DR. AM BARRETT

“It's an interesting study,” she added. “I like to evaluate patients in their own homes. There is more to the brain following a stroke than just looking for improvements in motor function. When patients become more mobile, we need to evaluate their environment to make sure that they are safe during their recovery period. Activity and performance are important, not just arm and leg strength.”

She also agreed with Dr. Cramer that connectivity between the hemispheres is not always an indication of something positive. “Things can be more tightly connected, but they may not be functioning as well. Connectivity is not a measure of function. Everything can work badly together, too.”

Link Up for More Information

• Chen J, Sun D, Zhang S, et al. The effects of home-based telerehabilitation in stroke patients: A randomized controlled trial https://www.neurology.org/. Neurology 2020; Epub 2020 Sept 30.
    • Cramer SC, Dodakian L, Le V, et al. Efficacy of home-based telerehabilitation vs in-clinic therapy for adults after stroke https://jamanetwork.com/journals/jamaneurology/fullarticle/2736341. JAMA Neurol 2019;76(9):1079–1087.
    • Quinlan EB, Dodakian L, See J, et al. Biomarkers of rehabilitation therapy vary according to stroke severity https://www.hindawi.com/journals/np/2018/9867196/. Neural Plast 2018;2018:9867196
    • Chen J, Jin W, Dong WS, et al. Effects of home-based telesupervising rehabilitation on physical function for stroke survivors with hemiplegia: A randomized controlled trial https://journals.lww.com/ajpmr/Abstract/2017/03000/Effects_of_Home_based_Telesupervising.4.aspx. Am J Phys Med Rehabil 2017;96:152–160.