Telerehabilitation of Post-Stroke Patients with Motor Function Disorders: A Review

J.P. Held et al. [9] investigated a home-based rehabilitation system (REWIRE) for balance and gait training of 16 post-stroke individuals with first stroke onset (3–74 months) and mild to moderate impairments. The telerehabilitation platform was consisted of the patients’ system, the hospital and networking stations. The home-based system included a laptop, the Microsoft Kinect camera, and the Tyromotion balance board. During rehabilitation session (10–40 min/day) each patient performed exergames standing in front of the TV screen, moving in real-time, and interacting with digital avatar in VR environment. Also, some exergames required a force plate for tracking the centre of pressure. Additionally, there was a virtual therapist, endowed with an artificial intelligence based on a fuzzy control system. The virtual therapist guided the patients, including both advices and encouragement, summarizing the results in the end of each session. Moreover, the patient station logged the gaming data, recorded the patients’ performance, and sent it to the hospital station at the end of the session. The clinicians instructed the fuzzy system before starting the therapy, used the hospital station to assess the patients’ performance and reviewed the therapy outcomes, configured and scheduled the sessions. The findings showed that REWIRE system feasible supporting the autonomous home-based rehabilitative therapy.

A randomized pilot trial implementing telerehabilitation for balance training of 10 post-stroke patients was undertaken in the research [4]. Specifically, multiple exergames (balancing and standing up, single-leg exercises, and weight shifting) were used to customize rehabilitation of post-stroke inpatients aged 33–65. The rehabilitation system included an LCD screen, a computer, an RGB camera, and Wii Balance Board. The system required 6 m2 of space to perform exercises. In addition to neurotherapeutic treatment, the stroke survivors underwent three different exergames with overall intensity of 15 min/day during 5 days. When training, each participant stood on the board in front of the LCD screen performing different motions and exercises depending on the game plan. Although the patients performed their training on their own a physiotherapist supervised the rehabilitation process during the session ensuring safety and preventing potential accidents. The rehabilitation system provided calm and relaxed conditions for post-stroke individuals’ rehabilitation with a variety of exergames and adjustable levels of difficulty to personalize the rehabilitation process. Clinical data were collected through Clinical Test for Sensor, Romberg, Sharpened Romberg, Timed Up and Go tests, 10 m Walk Test, and Four Square Step Test, monitoring a center of pressure during studies. The findings imply that exergames rehabilitation is similar to conventional rehabilitation in terms of clinical outcomes, having the advantage of the accessibility of the objective and measurable information relating to the center of the press. Moreover, selecting individualized exergames at the stage of planning of rehabilitation allows adjusting regimen and improving balance training outcomes.

P.I. Burgos et al. [2] tested smartphones, inertial sensors, and a cloud database to improve the balance of six post-stroke patients using the exergames telerehabilitation system. The patients with early subacute stroke (6–8 weeks after stroke) in addition to conventional treatment at a hospital (Chile) were involved in telerehabilitation. Their home-based telerehabilitation using smartphones lasted for a month and consisted of nine 30-min sessions. Before the program, the patients and caregivers were instructed on technical (placement of sensors, their calibration, exergames adjustment, and performance) and safety issues. The system consisted of two wireless inertial movement sensors positioned at the lumbar level and the anterior thigh of the paretic side of each patient and was connected to an Android-based smartphone. The participants interacted with a custom-developed Android application performing exergames. Moreover, the difficulty level of exergames was adjusted by the patients depending on their progress. The telemedicine interventions were conducted by a physical therapist who daily contacted each participant to keep standard interaction and increase protocol adherence. To monitor the rehabilitation process the therapist either connected to the web-platform and observed daily games scores according to a timetable of the session or analyzed the results at any convenient time after training was completed. Furthermore, the System Usability Scale (SUS) was implemented to measure a user experience. To train balance the participants performed tasks through exergames that were based on smartphones controlled by body motions. The findings revealed significant improvement in the Berg Balance Scale (11.3 ± 3.5 points), Mini-BESTest (8.3 ± 3.01 points), and in the Barthel scale (17.5 ± 9.87 points), although the improvements of Barthel and Berg scales were statistically higher for the telerehabilitation of patients than for the control group that was undergoing a traditional rehabilitation in a hospital. Positive effects of tele-interventions can be attributed to that the telerehabilitation took place at the early subacute post-stroke stage with the high training dosage. Moreover, the smartphone-based rehabilitation system demonstrated high values of usability on SUS that was 87.5 ± 11.61. Feasibility of the proposed exergames system with low costs as a complementary therapy was confirmed demonstrating significant improvements of the balance of stroke patients. Despite the system showed a solid performance on small groups of patients, further research on large groups is needed.

The efficacy of motor-cognitive rehabilitation of individuals with chronic stroke using exergames improving balance control and cognition was evaluated by L. Kannan et al. [14]. In their randomized controlled trial, twenty-four patients participated in a highly intensive 6-week rehabilitation program. Specifically, 12 patients underwent motor-cognitive exergames treatment since the rest of the individuals were assigned to conventional rehabilitation. The experimental group used Wii-fit games in conjunction with cognitive tasks. During the training session, each person stood on a balance board sensing the symmetry of the body weight distribution. Also, the participants were motivated by an assistant to perform both exergames and cognitive tasks. The scores that appeared at the end of the game provided instant feedback and then a more difficult level of the exergames and cognitive tasks was adjusted to sustain progress. The results showed the patients in motor-cognitive exergame group improved motor and cognition since those in the conventional rehabilitation group showed improvements of motor function only. The authors recommend clinical implementation of exergames rehabilitation settings to improve balance control and cognition. These findings collocate to G. Morone et al. [17] highlighting the inextricable connection between motor and cognitive systems. They underline the importance of motor-cognitive rehabilitation employing innovative technological devices.

Recently M. Junata et al. [12] carried out a randomized controlled trial to examine the telerehabilitation improving balance recovery for stroke fall prevention. Specifically, 30 elderly chronic patients from Hong Kong Stroke Association were assigned into experimental and control groups. The telerehabilitation system included the Kinect-based platform. It allowed patients performing exercises standing in front of the screen. The system tracked their 3D movements and timing. In general, the patients required performing extremities movements in 22 different directions as far and as quickly as possible. During the training session the patients wore safety harness and performed 4 repetitions during 1 hour session. The control group performed conventional balance training exercises. Each session lasted 1 hour and included 3 repetitions. According to the study design the patients underwent 3 sessions per week for seven weeks. The findings showed the telerehabilitation is as effective as conventional treatment improving balance performance and motor function, and reducing fall risks. Specifically, the patients improved balance control (Berg Balance Scale) from 49.13 to 52.75 (p = 0.001) and gait control (Timed-Up-and-Go Test) from 14.66 to 12.62 s (p = 0.011). The study also showed the potential of balance training for home-based telerehabilitation.

A majority of studies reviewed proves feasibility of telerehabilitation for stroke survivors and at least similar or even more pronounced effects of telerehabilitation on motor function, engagement, and motivation, granting access to rehabilitation services of a large number of patients with immobility or living in remote areas, leading to sustainable recovery from stroke. To implement telerehabilitation conventional equipment (computers, laptops smartphones, etc.) that stroke survivors already own and use for daily activities can be used. Moreover, indigent patients can be provided with devices by healthcare or social care organizations. Furthermore, all of the patients, if necessary, can be equipped with other hi-tech rehab equipment and software, including exergames, VR, online conferencing applications, and educational materials.

Telerehabilitation programs are quite flexible and can be carried out in-clinic or in patients’ homes both online using the internet connection and utilizing up-to-date rehab web-based platforms and services or off-line with preinstalled software and training programs to prevent dependency of rehabilitation on internet affordability. In this context, supervised or unsupervised training is implemented to adjust rehabilitation programs. To achieve significant outcomes in rehabilitation a systematic training with a specific dose is required. Moreover, monitoring of the progress of treatment regimen is vital, which can be obtained online via web-based services and platforms, wearable e-health devices, videoconferencing, and telephone calls with or without the involvement of therapists. Alternatively, offline visits of clinicians or medical staff, delivering email and e-messages with rehabilitation data, including a video recording of patients’ performance can be used to monitor the progress. Delivering rehabilitation using telehealth is vital for homebound geriatric patients.

Systematic videoconferencing with a therapist or other feedbacks from healthcare professionals positively affect patients as they feel visiting a doctor and they are in charge for their rehabilitation outcomes, and hence, must be prepared to keep on training, improving motivation and enhancing recovery. Interestingly, telerehabilitation significantly enhances self-motivation and engagement of post-stroke patients as compared to conventional rehabilitation, especially through exergames where the patients are involved in keeping on track and monitoring the progress to obtain continuing improvements.

The advantage of exergames and VR over conventional rehabilitation means that treatment occurs 24/7 at a self-paced training regimen at the most convenient time for patients. This also includes instant and continuous feedback between the rehabilitation system and the patient, obtaining measurable information, motivating the post-stroke survivors to keep training and improving their state of health and stroke recovery. Although early rehabilitation is beneficial with respect to outcomes, it seems the telerehabilitation is also applicable at different stroke stages.

More importantly, the telerehabilitation programs can be adjusted to the needs of post-stroke patients depending on their level of health and mobility. Furthermore, the telerehabilitation can be delivered in parallel to conventional in-clinic rehabilitation as adjunctive therapy, and used as a therapy after hospital discharge or as a prolonged home-based self-rehabilitation program.

Apparently, the number of individuals with motor function disabilities and balance problems due to stroke will increase significantly over future decades because of demographic growth changes. Since a majority of post-stroke individuals across the globe cannot access conventional rehabilitation facilities for improving their motor function due to immobility, health status, lack of rehabilitation services and clinicians, distant living from medical centers, pandemic restrictions, or economical reasons, there is a growing post-stroke population that could benefit from the use of telerehabilitation.

Despite generalization of telerehabilitation, predictive and preventive treatment seems beneficial for patients without access to face-to-face rehabilitation, recurring prevention of stroke and significantly decreasing mortality and psychological drawbacks, preventing social isolation and physiological diseases. Specifically, personalization meets the needs of the patients, customizing rehabilitation programs with respect to disease consequences, age, health status, difficulty level, and intensity of treatment. Duration and intensity of the programs, sets of exercises, interactions between patients, rehabilitation systems and therapists are varied and must be tailored to meet the clinical outcomes and patients’ needs.

Also, stroke survivors play an important role in the rehabilitation process, and hence, their awareness, involvement and engagement in the training process are essential to gain self-motivation leading to significant improvements in stroke recovery. Moreover, their relatives, carers and healthcare professionals should also be involved through education and motivation sessions.

Finally, telerehabilitation allows implementing stroke recovery during a pandemic or under other restrictions, preventing infection, inactivity and social isolation, making geriatric patients more confident and independent, preventing psychological drawbacks, and improving their life quality.

Although telerehabilitation showed improvements in post-stroke recovery, there were also limitations. First, the lack of equipment and software, which partially can be overcome using conventional equipment and freeware software or with the support of healthcare organizations. Then, a deficit of proficiency in digital technologies and education arises for both post-stroke patients and healthcare professionals, which can be managed by utilizing easy-to-learn equipment, friendly interface, clear instructions or short courses, and trials before and at the beginning of telerehabilitation programs. Importantly, to overcome differences in technical and digital proficiency for geriatric patients the telerehabilitation equipment and software can become more intuitive and easy to learn.

Since most studies underline the convenience of home-based exercises, some observations report the lack of space for exercises at patients’ homes, although, they can be performed outdoors or with the support of relatives and carers. Moreover, substantial work remains to establish the optimal dose and intensity of telerehabilitation treatment. Also, the side effects should be further researched. Finally, most reviewed studies used small samples, and hence, future research should involve large samples of post-stroke patients to verify clinical outcomes.

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