telerehabilitation -- a new model for community-based stroke rehabilitation

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DOI: 10.1258/1357633041424340

2004 10: 199J Telemed TelecareJerry CK Lai, Jean Woo, Elsie Hui and WM Chan

a new model for community-based stroke rehabilitation−−Telerehabilitation

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Telerehabilitation — a new model forcommunity-based stroke rehabilitation

Jerry C K Lai, Jean Woo, Elsie Hui and W M ChanDivision of Geriatrics, Department of Medicine and Therapeutics, Chinese University of Hong Kong, China

Summary

Community resources for stroke clients are underdeveloped in Hong Kong and stroke survivors often face

difficulties in community reintegration. We have examined the feasibility of using videoconferencing for

community-based stroke rehabilitation. The sample comprised 21 stroke patients living at home. All the

subjects participated in an eight-week intervention programme at a community centre for seniors. The

intervention, which comprised educational talks, exercise and psychosocial support, was conducted by a

physiotherapist via a videoconference link. The Berg Balance Scale (BBS), State Self-Esteem Scale (SSES),

Medical Outcomes Study 36-item Short Form (SF-36) and a stroke knowledge test were administered at the

start and end of the programme. In addition, at the start of the study the Geriatric Depression Scale 15-item

Short Form, the Elderly Mobility Scale and the Lawton Instrumental Activities of Daily Living Scale were used to

assess subjects’ baseline status, and a focus group was also held at the end of the programme to gather

qualitative findings. Nineteen subjects completed the eight-week intervention. The baseline functional status

was high, although 52% had symptoms of depression. After the intervention, there were significant

improvements in BBS, SSES and knowledge test scores and scores on all subscales of the SF-36. All the subjects

accepted the use of videoconferencing for delivery of the intervention. The pilot study demonstrated the

feasibility, efficacy and high level of acceptance of telerehabilitation for community-dwelling stroke clients.

Introduction...............................................................................

Stroke, or cerebrovascular accident, is the third leading

cause of death in Hong Kong. According to the Hospital

Authority Statistical Report 2001–2002, there were 3130

deaths from stroke, of which 88% occurred in those

aged 65 years or above, and the number of patients

diagnosed with stroke doubled from 1981 to 20001.

Although the mortality rate has decreased in recent

decades, possibly due to advances in medical tech-

nology, stroke survivors still suffer from a variety of

disabilities and need costly long-term rehabilitation.

After the acute phase, stroke survivors usually undergo

three to six months of rehabilitation in extended-care,

day-care or outpatient units. This represents a

considerable economic burden and has societal

consequences.

Early-discharge rehabilitation programmes aim to

reduce the length of hospital stay. Such programmes

should be supplemented with well organized, post-

discharge, community-based rehabilitation in order to

provide additional rehabilitation and ensure a seamless

transfer of patients from hospital to community. In

some countries, community-based stroke rehabilitation

is well developed. Studies have found that community-

based stroke rehabilitation is cost-effective2,3 and can

significantly improve the mobility of stroke patients4.

Community-based stroke rehabilitation in Hong

Kong is underdeveloped. The current community-

based stroke rehabilitation services are mainly run by

the Hospital Authority, a non-governmental associ-

ation (the Community Rehabilitation Network) and a

self-help group (the Hong Kong Stroke Association).

The service run by the Hospital Authority mainly

involves home-based rehabilitation and so often lacks

the element of psychosocial support3. The Community

Rehabilitation Network offers educational talks, group

therapeutic classes and peer support, at community

centres, but this service is poorly utilized because of

insufficient promotion, poor access to services due to

Original article......................................................................................................................................................

"

Journal of Telemedicine and Telecare 2004; 10: 199–205

Accepted 13 April 2004

Correspondence: Professor Jean Woo, Department of Medicine and

Therapeutics, Prince of Wales Hospital, Shatin, NT, Hong Kong, China

(Fax: +852 2632 3141; Email: [email protected])

at GEORGE MASON UNIV on October 1, 2014jtt.sagepub.comDownloaded from


transportation problems and inadequate collaboration

between hospital and community service providers.

Thus there is a need for a convenient, easily accessible

and cost-effective model of community-based stroke

rehabilitation.

Telerehabilitation is the provision of distance

support, assessment and intervention to individuals

with disabilities via telecommunication, and is a

subcomponent of the broader area of telemedicine5.

Telerehabilitation can be used to extend post-acute

care into a non-clinical setting6. For example, by

extending rehabilitation beyond the hospital and into

the community or the home, providers can continue to

monitor patients’ progress, identify areas in need of

improvement before complications set in, and

ultimately improve patient function and decrease

long-term disability and costs7.

Previously reported telerehabilitation projects have

shown that telemedicine is feasible and effective in the

management of pressure ulcers in patients with spinal

cord injuries and multiple sclerosis8,9, orthopaedic

injuries10 and brain injuries7,11. However, there have

been only a few studies on the application of

telemedicine in stroke. These examined the use of

telecommunication for the management of acute

stroke in rural areas12–14, speech–language problems15,

support for the carers of stroke patients16 and post-stroke

follow-up care at home17.

There are several advantages of using telemedicine in

community-based rehabilitation. First, it allows

participants to access the service more readily if video-

conference systems can be installed at community

centres near their homes. Second, therapy conducted

as a group may enhance the atmosphere for learning.

Third, it allows realtime interaction between the

participants and medical professionals.

Multi-site links can increase the number of partici-

pants at any one time. However, traditional stroke

rehabilitation has always been conducted face to face

with the client. Therefore, the feasibility of tele-

rehabilitation in stroke patients is unknown. The aim

of the present study was to evaluate the feasibility,

efficacy and acceptability of a community-based stroke

rehabilitation programme conducted via video-

conferencing.

Methods...............................................................................

The subjects participated in an eight-week intervention

programme (1 session per week and 1.5 h per session) at

a community centre for seniors. The intervention was

conducted by a physiotherapist via a videoconference

link. The class size was about six to eight subjects. A

non-professional assistant was stationed at the

community centre to facilitate the smooth running of

the programme.

Equipment

The two videoconferencing sites were the Shatin

Hospital and a community centre for seniors in the

same district. The videoconferencing equipment at the

hospital (Model 880, Tandberg) and the community

centre (ViewStation FX, Polycom) had similar

capabilities. They were connected by a 10 Mbit/s

broadband line (Hutchison Global Crossing) and could

transmit images at 30 frames/s. Dual video output

allowed the subjects to see the physiotherapist and

slide presentation on two separate 86 cm television

screens.

Sampling method

Subjects were recruited by a physiotherapist either after

discharge from the geriatric day hospital (Shatin

Hospital) or from the community centre for seniors

(Evangelical Lutheran Church of Hong Kong). They

had had a stroke at least six months previously and

were able to walk independently, with or without

walking aids (Modified Functional Ambulatory

Categories VI and VII18). Those with Mini Mental State

Examination (MMSE) scores19 of less than 18

(indicating mild or worse impairment of cognitive

function) were excluded to ensure that all subjects

would be able to comprehend the instructions,

questionnaires and test procedures involved. Those

with significant communication barriers or uncom-

pensated cardiac or pulmonary insufficiency were also

excluded.

Intervention

The intervention consisted of education, exercise and

social support. The education component included

talks covering the pathophysiology of stroke, signs and

symptoms, medical management, rehabilitation

pathways, the identification and modification of risk

factors, psychosocial impact, community support, and

home and environmental safety.

The exercise programme was designed to improve

strength and balance. Each exercise session lasted for

about 30 min and was divided into three blocks. It

comprised a 5 min warm-up session of stretching and

flexibility exercise, a 20 min strength and balance

exercise, and a 5 min cool-down exercise. The strength

and balance exercise mainly involved leg muscles.

Blood pressure and heart rate were recorded before and

after the exercise. The participants were encouraged to

J C K Lai et al. New model for stroke rehabilitation

200 Journal of Telemedicine and Telecare Volume 10 Number 4 2004



do the same exercise at home at least three times a

week. An exercise logbook was given to each subject to

record exercise compliance.

Subject assessment

At initial assessment, the following data were recorded:

age, sex, education level, smoking and drinking

history, exercise habit, disease duration, type of stroke,

side of hemiparesis, number of recurrent strokes, co-

morbidity, body mass index, fall history in previous

year, and scores on the Elderly Mobility Scale (EMS)20,

the Lawton Instrumental Activities of Daily Living

Scale (IADL)21 and the Geriatric Depression Scale

15-item Short Form (GDS-15)22. Assessment of the

subjects’ balance was conducted by a physiotherapist

using the Berg Balance Scale (BBS)23. The Medical

Outcomes Study 36-item Short Form (SF-36)24, State

Self-Esteem Scale (SSES)25 and a stroke knowledge test26

were administered by another research assistant. After

completion of the programme, evaluation of the

primary outcome measures but not of the secondary

measures (see below) was repeated.

Primary outcome measures

Berg Balance Scale (BBS)

The BBS records a subject’s ability to perform 14

activities, each of which is rated on a five-point Likert

scale (0¼worst, 4¼best, to give a highest possible score

of 56). A score of 45 or below represents a risk factor for

a fall. This tool has good levels of reliability, validity

and responsiveness for patients at different stages of

recovery after stroke23,27.

Medical Outcomes Study 36-item Short Form(SF-36)

The SF-36 questionnaire is a multidimensional generic

quality-of-life measure that is widely used to measure

health status after stroke24,28. It consists of 36 items in

eight subscales: physical functioning, limitations due

to physical health problems (role, physical), bodily

pain, general health, vitality, social functioning,

limitations due to emotional health problems (role,

emotional) and mental health. Subscores are

transformed to a scale of 0–100, with higher scores

representing better health status. In this study, the

Chinese (Hong Kong) version was used29.

State Self-Esteem Scale (SSES)

Self-esteem can affect a person’s response to illness30,31.

It is viewed both as a symptom of depression32 and as a

causal factor in reactive depression33. The SSES consists

of 20 statements that describe a subject’s feelings. Each

item is scored on a five-point scale (1¼not at all, to

5¼extremely). The highest possible score is therefore

100, and higher scores indicate more self-esteem. The

SSES Chinese version has been examined for its validity

with stroke patients34.

Stroke knowledge test

The knowledge test comprised 10 questions on the

signs, symptoms and risk factors of stroke, precautions

on taking medication and during exercise, and sources

of community support26.

Client satisfaction and feedback

A questionnaire adapted from a previous telemedicine

study conducted with Chinese residents of a nursing

home35 was used to evaluate the satisfaction of the

subjects after completion of the programme. The

questions covered visual and audio quality, class

frequency and duration, and the acceptance of

provision of services via videoconferencing. A focus

group was conducted by a social worker after the eight-

week intervention to collect feedback from subjects.

The dialogue was recorded and analysed.

Secondary outcome measures

The three secondary outcome measures, described

below, were assessed only upon recruitment into the

study, to define the baseline functional and clinical

status of the subjects.

Geriatric Depression Scale 15-item Short Form(GDS-15)

The GDS-15 is used to assess symptoms of depression. It

covers domains of mood and outlook, energy, agitation

or restlessness, and social withdrawal. Scores range

from 0 to 15; a score of 8 points or higher indicates

depression22.

Elderly Mobility Scale (EMS)

The EMS tests the following functions: lying to sitting,

sitting to lying, sitting to standing, standing, gait,

walking speed and functional reach. It is an assessment

of locomotion, balance and key position changes,

which are prerequisites to more complex activities of

daily living. The maximum possible score, which

represents independent mobility, is 2020.


Journal of Telemedicine and Telecare Volume 10 Number 4 2004 201



Lawton Instrumental Activities of Daily LivingScale (Lawton IADL)

The Lawton IADL comprises eight items: preparing

own meals, using the telephone, shopping for

groceries, getting to places out of walking distance,

doing own housework or handyman work, washing

clothes, managing own money, and taking own

medications. Each activity is reported as being done

without help (scored 2), with some help (scored 1) or

not at all (scored 0). The maximum possible score is

1621.

Statistical analysis

The data were analysed using SPSS version 11.0 for

Windows. Categorical variables were presented as

frequencies, and continuous variables were presented

as means and standard deviations. The pre- and post-

intervention outcomes were compared using paired

t-tests. The alpha level was set at 0.05.

Results...............................................................................

Between May and November 2003, 21 subjects were

recruited, but only 19 completed the eight-week

intervention — one subject dropped out due to

recurrent stroke and another moved back to mainland

China. The overall attendance rate was high (87%). The

subjects’ mean age was 69.5 years (SD 6.1). Nine of the

21 subjects (43%) were women. The subjects’ mean

body mass index was 22.9 (SD 2.4) kg/m2. Eleven of the

subjects (52%) had suffered a stroke within the past

year; the mean time since the onset of stroke was 3 years

(SD 2, range 1–7 years). Sixteen (76%) had suffered

ischaemic stroke and the other five (24%) a haemor-

rhagic stroke. The commonest risk factors were hyper-

tension (67%), smoking history (52%) and diabetes

(33%). The demographic and clinical profiles are

summarized in Table 1.

At the baseline functional assessment, the mean

scores on the EMS and Lawton IADL were 15.3 (SD 2.4)

and 9.7 (SD 3.0), respectively. Eleven subjects (52%)

had symptoms of depression (GDS-15 score 58).

Following the eight-week intervention, significant

improvement was observed in the scores on the BBS,

SSES, knowledge test and all subscales of the SF-36,

compared with baseline (Table 2).

In the present study, all eight SF-36 subscale scores at

baseline were lower than the age-equivalent (age 565

years) population norms36, especially those for physical

functioning, role, physical, social functioning and role,

emotional. After the intervention, the subjects showed

similar and even higher subscale scores than the

population norms (Fig 1).

Regarding satisfaction and feedback from the

subjects, 63% and 37% rated the clinical effectiveness

of telerehabilitation as good or excellent. All the

subjects rated the visual and audio quality as good.

They expressed no preference between



Table 1 Baseline demographic and clinical profiles of subjects

(n¼21)

No. (%) of subjects

Gender

Female 9 (43)

Male 12 (57)

Education level

University 2 (10)

Secondary 2 (10)

Primary 11 (52)

No formal education 4 (19)

Illiterate 2 (10)

Type of stroke

Ischaemic 16 (76)

Haemorrhagic 5 (24)

Smoking history 11 (52)

Co-morbidity

Hypertension 14 (67)

Diabetes 7 (33)

Heart disease 4 (19)

GDS-15 score 58a 11 (52)

aGDS-15¼Geriatric Depression Scale 15-item Short Form, on which scores of 8 or

over indicate the presence of depression.

Table 2 Comparison (paired t-tests) of the pre- and post-

intervention mean (SD) scores on the four primary outcomemeasures: BBSa, SSESb, SF-36c and stroke knowledge testd

Pre-

intervention

Post-

intervention

Population

norms

BBS 42.2 (6.7) 49.0 (6.5)*** —

SSES 64.8 (12.3) 79.8 (12.8)*** —

SF-36

physical functioning 49.0 (15.7) 71.6 (21.7)*** 79.2 (19.7)

role, physical 18.4 (32.1) 79.0 (41.9)*** 73.7 (37.2)

bodily pain 57.4 (29.3) 86.0 (24.3)*** 77.4 (26.7)

general health 35.0 (20.3) 53.2 (17.7)*** 49.2 (21.2)

vitality 40.8 (16.3) 66.3 (17.7)*** 59.9 (19.8)

social functioning 68.4 (22.2) 88.8 (19.5)*** 92.1 (17.3)

role, emotional 45.6 (38.8) 93.0 (23.8)*** 78.1 (37.2)

mental health 65.3 (22.2) 77.7 (17.4)* 75.7 (18.1)

Knowledge test 4.8 (1.7) 8.7 (1.5)*** —

aBBS, Berg Balance Scale, on which a score of 45 or below represents a risk factor for

a fall.bSSES, State Self-Esteem Scale, on which the highest possible score is 100, with

higher scores indicating greater self-esteem.cSF-36, Medical Outcomes Study 36-item Short Form, on which subscores are

transformed to a scale of 0–100, with higher scores representing better health status.dStroke knowledge test, comprising 10 questions (one mark awarded for each

correct answer).

*P50.05, ***P50.001.



telerehabilitation and face-to-face treatment. All the

subjects accepted the use of videoconferencing for

delivery of the intervention.

In the focus group, most of the subjects felt that the

programme had been very useful. The main reason was

that there was insufficient patient education when

they had been in hospital. Education would help to

decrease their fear of recurrent stroke. They also felt

that the programme provided for continuation of their

rehabilitation. Some felt that it had psychosocial

benefits for them. For example, subject 8 said ‘in the

past, I didn’t go out much and didn’t interact with

others. . . . I have poor self-image . . . after joining the

programme I feel happier and open to talk more and

more. I treat my co-participants as friends.’ Subject 11

said ‘it helps to increase my social network, it provides

a place for love, friendship and happiness . . . ’.

Discussion...............................................................................

The baseline data showed that the subjects had poor

psychosocial status, although their functional status

and balance were reasonable. The mean initial score on

the BBS was 42.2, which indicates that the subjects had

a high risk of falling. More than half the subjects had

symptoms of depression. The baseline SF-36 subscale

scores of the subjects were lower than the population

norms. These findings in the psychosocial domains

suggest that, following rehabilitation in the acute

phase of stroke, even though most survivors were able

to function physically at a reasonable level, their

perceived health and quality of life were being

overlooked.

The mean initial knowledge test score was 4.8, which

means the subjects were on average able to answer only

half the questions correctly. This is related to insuf-

ficient public health education on stroke prevention

and patient education targeted at stroke survivors, as

well as the low level of education among older Chinese

persons.

In Hong Kong, although hospital-based stroke

rehabilitation is fairly well developed, there is a service

gap between the hospital and community. Most of the

patients did not know how to seek support following

discharge home. On the other hand, costly inpatient

rehabilitation is a very significant socio-economic

burden, and there is pressure to discharge stroke

patients early. Therefore, it is important to develop a

low-cost, accessible and seamless rehabilitation service

by exploring collaboration between hospital and

community service providers.

The present study suffered certain limitations. First,

subjects were recruited through convenience sampling.

The major drawback of using this method is the

possibility of selection bias. Since all the subjects joined

the programme voluntarily, they were more motivated

than those who declined to do so. The sample size was

also small and there was no control group. The results,

therefore, cannot be generalized to the whole stroke

population. A randomized controlled trial comparing

telerehabilitation with conventional treatments, such

as domiciliary stroke rehabilitation, will now be

required.

Second, the SF-36 was used to assess quality of life in

the present study. Since it is a generic measure of

quality of life, some areas of potential dysfunction

might not have been addressed, such as hand function.

Anderson et al. found poor performance of the SF-36

social functioning subscale in stroke patients and

suggested its supplementation by other measures37.

Although there are several disease-specific quality-of-

life scales38, they have not been translated into Chinese

and have not been validated for a Chinese population.

Third, the length, frequency and duration of the

intervention may not be ideal. Feedback from the

subjects suggested that the frequency of the

intervention could be twice or three times per week

instead of once. They felt that a more intensive

programme would be of more benefit, in terms of both

exercise compliance and knowledge gained.

Fourth, there could be a longer follow-up period to

investigate the carry-over effect of the intervention, for

example three and six months after completion of the



SF-36 subscales

SF-

36 s

core

0

20

40

60

80

100

Pre Post Norm

Bo

dily

pai

n

Phy

sica

lfu

nctio

ning

Ro

le,

phy

sica

l

Gen

eral

heal

th

So

cial

func

tioni

ng

Vita

lity

Ro

le,

emo

tiona

l

Men

tal

heal

th

Fig 1 Pre- and post-intervention scores for the study sample on

the subscales of the Medical Outcomes Study 36-item ShortForm (SF-36), and the Hong Kong population-based norms.



programme. The numbers of falls during this period

could also be documented, as only short-term

improvements in balance have been demonstrated and

the long-term effects are unknown.

Finally, this study examined the use of video-

conferencing with a single community centre for

seniors. Further studies should address the effects of

multi-site application, as this would be more cost-

effective.

Although the present study demonstrated the

feasibility of using telecommunication technology to

run a community-based rehabilitation programme for

stroke clients, it was confined to rehabilitation through

advanced exercise training and psychosocial inter-

vention in chronic stroke survivors. Nonetheless, it

showed the feasibility, efficacy and acceptability of

telerehabilitation in community-dwelling stroke

clients. The intervention improved both physical

functioning and psychosocial wellbeing in the subjects.

It also demonstrated that such collaboration between

hospital and community service sectors was able to fill

an important service gap. Further studies with a larger

sample, multi-site application and clients at different

stages of disease and with different levels of function-

ing should be conducted.

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telerehabilitation -- a new model for community-based stroke rehabilitation

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