Read Full Text: Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial (Not available for free, but we felt it was important to discuss)
Journal: JAMA Neurology
Year Published: 2019
This week’s article was chosen in response to the coronavirus pandemic.
Therapists across the globe are advocating that telehealth delivery be covered by our licenses (and reimbursed by insurers). Now, more than ever, I think it’s important to examine the research that backs up these efforts.
The reality is that even before COVID-19, telehealth was showing significant promise to help reach more clients, and even improve outcomes.
This week’s article is a randomized control trial from one of the world’s most influential journals: The Journal of the American Medical Association (JAMA). And, the results indicate that telehealth delivered to stroke patients to address UE motor deficits appeared to be just as effective as similar care care that was delivered in a clinic.
A little history on post-stroke therapy dosing (and the dilemma therapists have found themselves in)
The type and amount of therapy that is indicated following stroke is not universally agreed upon at this point.
But, the article Rehabilitation of Motor Function After Stroke remains one of my favorite summaries of where we are on this matter.
The stroke-related articles we’ve studied so far have looked at how many repetitions are needed to impact brain plasticity. This week’s article alludes to research which indicates that the number of repetitions may be much higher than most patients receive.
Think: Around 1000 repetitions in a day (as opposed to the usual therapy approach, which is typically fewer than 50 reps per day).
Teletherapy is one viable option for helping people achieve this higher dosage.
What was the primary research question in this article?
The researcher hypothesized the following: Activity-based training targeting arm movement post-stroke—delivered through telerehabilitation—would show comparable efficacy to the equivalent delivered in the clinic.
And, by “equivalent,” they meant dose-matched, intensity-matched, activity-based training delivered in the clinic.
What were the demographics of the patients?
124 patients participated in the study; here are the inclusion criteria:
- 18 years or older
- Experienced an ischemic or intracerebral hemorrhage 4-6 weeks prior
- As a result, had arm motor deficits
- No major deficits in mood or cognition
What details were given about the intervention?
Here were the logistical details of the sessions:
- 36 treatment sessions
- Session were 70 minutes each (plus one 10-minute break)
- 18 sessions were supervised; 18 were unsupervised
- Treatment took place over a 4-6 week period
Here are some intervention details, which applied to both groups:
- All patients signed a behavioral contract that included a personal treatment goal.
- The treatment approach was based on an upper extremity task-specific training manual and Accelerated Skill Acquisition Program.
- Therapists could revise the treatment plans as often as desired. Revision was required every 2 weeks.
- 15 minutes per session were spent on arm exercises.
- At least 15 per session were spent on functional training.
- 5 minutes per session were spent on general stroke education.
Here’s some details that applied to the in-clinic group:
- For unsupervised sessions, patients were in their home-setting and were guided by an individualized printed booklet.
Here’s some details that applied to the telerehabilitation group:
- At a baseline visit, patients were trained in a telerehabilitation system that included:
- A computer
- A table and chair
- 12 gaming input devices (such as PlayStation Move controller and trackpad, but no keyboard.)
- Supervised sessions began with a 30-minute patient-therapist video conference, during which time the therapist answered questions, reviewed treatment plans, performed assessments, and supervised therapy.
Please see the article for more details on the sessions!
What assessments were used?
Primary assessment:
Secondary assessments:
- Box and Block Test (BBT)
- Stroke Impact Scale (SIS)
- Stroke knowledge examination (unpublished)
What were the results/conclusions?
Both treatment groups showed substantial gains in arm motor function. In fact, the difference between the two groups was narrow enough that the researcher concluded that the telehealth program was just as effective as the in-clinic program.
The researchers also concluded that the telerehabilitation was also:
- Safe
- Rated favorably by patients
- Associated with excellent treatment adherence
The discussion section is a great read, but I did want to highlight that the researchers keyed in on the high patient motivation in the telerehabilitation group, which they say may have been related to:
- Ease of use
- Convenience
- Frequent interaction with clinicians
- Multiple means of providing feedback
- Using a behavioral contract
- Games to drive adherence
- Using several input devices to practice movement
- And using the teletherapy system to generate reminders
Takeaways for OT practitioners
(These are my personal takeaways, and were not mentioned in the article.)
1. It is possible to be effective via telehealth.
One of the items we see being discussed right now is which populations can benefit from telehealth. And, one of the assumptions is that populations that historically have received more “hands-on” therapies will be more difficult to translate to this medium.
But, this article really pushes us to think about how recent developments in technology have opened new opportunities for us and our patients. The article has shown us how telehealth can help us meet needs in adult rehab, just like the article last week showed us how we can meet needs in pediatrics.
2. In fact, we may be able to reach more people, and improve outcomes over our traditional methods.
What’s especially crazy is that even before COVID-19, the authors were suggesting that telehealth may help us:
- Reach more patients
- Improve outcomes beyond the gains that many patients see in a traditional setting
So, with this in mind, we shouldn’t think of switching to telehealth as a desperate second option, but rather as an opportunity to deliver better, more needed care than we ever have before.
3. Keep advocating.
Of course, to be able to deliver telehealth, we need the appropriate licensure—and, ideally, telehealth should also be covered by insurance. Some insurance companies and some states have started making important coverage decisions, but we’re not there yet.
So, please keep advocating. Many policy makers want to hear your voice. They want to see this research. Almost everyone is being called to make many difficult decisions right now, but approving telehealth OT for coverage should not be one of them
The research is there, and your skillset is needed.
Listen to my takeaways in podcast form:
Find platforms for listening to the OT Potential Podcast here.
(Possibly) Earn CEUs/PDUs for reading this article.
Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.
And, here’s the full APA citation you many need:
Cramer, S. C., Dodakian, L., Le, V., See, J., Augsburger, R., Mckenzie, A., … Janis, S. (2019). Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke. JAMA Neurology, 76(9), 1079. doi: 10.1001/jamaneurol.2019.1604
Virtual assessments or treatments can not universally be comparable to in-person visits.
This argument opens the door for payers and regulators to decide that they simply won’t cover “in-person” visits if Telehealth is an option.
It has the potential to commoditize healthcare services, discounting the skills, knowledge, and expertise that clinicians possess in their given area of specialization.