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

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<ul><li><p> of Telemedicine and Telecare</p><p> online version of this article can be found at:</p><p> DOI: 10.1258/1357633041424340</p><p> 2004 10: 199J Telemed TelecareJerry CK Lai, Jean Woo, Elsie Hui and WM Chan</p><p> a new model for community-based stroke rehabilitationTelerehabilitation </p><p>Published by:</p><p></p><p> can be found at:Journal of Telemedicine and TelecareAdditional services and information for </p><p> Alerts: </p><p> </p><p> </p><p> </p><p> What is This? </p><p>- Aug 1, 2004Version of Record &gt;&gt; </p><p> at GEORGE MASON UNIV on October 1, 2014jtt.sagepub.comDownloaded from at GEORGE MASON UNIV on October 1, 2014jtt.sagepub.comDownloaded from </p><p></p></li><li><p>Telerehabilitation a new model forcommunity-based stroke rehabilitation</p><p>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</p><p>Summary</p><p>Community resources for stroke clients are underdeveloped in Hong Kong and stroke survivors often face</p><p>difficulties in community reintegration. We have examined the feasibility of using videoconferencing for</p><p>community-based stroke rehabilitation. The sample comprised 21 stroke patients living at home. All the</p><p>subjects participated in an eight-week intervention programme at a community centre for seniors. The</p><p>intervention, which comprised educational talks, exercise and psychosocial support, was conducted by a</p><p>physiotherapist via a videoconference link. The Berg Balance Scale (BBS), State Self-Esteem Scale (SSES),</p><p>Medical Outcomes Study 36-item Short Form (SF-36) and a stroke knowledge test were administered at the</p><p>start and end of the programme. In addition, at the start of the study the Geriatric Depression Scale 15-item</p><p>Short Form, the Elderly Mobility Scale and the Lawton Instrumental Activities of Daily Living Scale were used to</p><p>assess subjects baseline status, and a focus group was also held at the end of the programme to gather</p><p>qualitative findings. Nineteen subjects completed the eight-week intervention. The baseline functional status</p><p>was high, although 52% had symptoms of depression. After the intervention, there were significant</p><p>improvements in BBS, SSES and knowledge test scores and scores on all subscales of the SF-36. All the subjects</p><p>accepted the use of videoconferencing for delivery of the intervention. The pilot study demonstrated the</p><p>feasibility, efficacy and high level of acceptance of telerehabilitation for community-dwelling stroke clients.</p><p>Introduction...............................................................................</p><p>Stroke, or cerebrovascular accident, is the third leading</p><p>cause of death in Hong Kong. According to the Hospital</p><p>Authority Statistical Report 20012002, there were 3130</p><p>deaths from stroke, of which 88% occurred in those</p><p>aged 65 years or above, and the number of patients</p><p>diagnosed with stroke doubled from 1981 to 20001.</p><p>Although the mortality rate has decreased in recent</p><p>decades, possibly due to advances in medical tech-</p><p>nology, stroke survivors still suffer from a variety of</p><p>disabilities and need costly long-term rehabilitation.</p><p>After the acute phase, stroke survivors usually undergo</p><p>three to six months of rehabilitation in extended-care,</p><p>day-care or outpatient units. This represents a</p><p>considerable economic burden and has societal</p><p>consequences.</p><p>Early-discharge rehabilitation programmes aim to</p><p>reduce the length of hospital stay. Such programmes</p><p>should be supplemented with well organized, post-</p><p>discharge, community-based rehabilitation in order to</p><p>provide additional rehabilitation and ensure a seamless</p><p>transfer of patients from hospital to community. In</p><p>some countries, community-based stroke rehabilitation</p><p>is well developed. Studies have found that community-</p><p>based stroke rehabilitation is cost-effective2,3 and can</p><p>significantly improve the mobility of stroke patients4.</p><p>Community-based stroke rehabilitation in Hong</p><p>Kong is underdeveloped. The current community-</p><p>based stroke rehabilitation services are mainly run by</p><p>the Hospital Authority, a non-governmental associ-</p><p>ation (the Community Rehabilitation Network) and a</p><p>self-help group (the Hong Kong Stroke Association).</p><p>The service run by the Hospital Authority mainly</p><p>involves home-based rehabilitation and so often lacks</p><p>the element of psychosocial support3. The Community</p><p>Rehabilitation Network offers educational talks, group</p><p>therapeutic classes and peer support, at community</p><p>centres, but this service is poorly utilized because of</p><p>insufficient promotion, poor access to services due to</p><p>Original article......................................................................................................................................................</p><p>"</p><p>Journal of Telemedicine and Telecare 2004; 10: 199205</p><p>Accepted 13 April 2004</p><p>Correspondence: Professor Jean Woo, Department of Medicine and</p><p>Therapeutics, Prince of Wales Hospital, Shatin, NT, Hong Kong, China</p><p>(Fax: +852 2632 3141; Email:</p><p> at GEORGE MASON UNIV on October 1, 2014jtt.sagepub.comDownloaded from </p><p></p></li><li><p>transportation problems and inadequate collaboration</p><p>between hospital and community service providers.</p><p>Thus there is a need for a convenient, easily accessible</p><p>and cost-effective model of community-based stroke</p><p>rehabilitation.</p><p>Telerehabilitation is the provision of distance</p><p>support, assessment and intervention to individuals</p><p>with disabilities via telecommunication, and is a</p><p>subcomponent of the broader area of telemedicine5.</p><p>Telerehabilitation can be used to extend post-acute</p><p>care into a non-clinical setting6. For example, by</p><p>extending rehabilitation beyond the hospital and into</p><p>the community or the home, providers can continue to</p><p>monitor patients progress, identify areas in need of</p><p>improvement before complications set in, and</p><p>ultimately improve patient function and decrease</p><p>long-term disability and costs7.</p><p>Previously reported telerehabilitation projects have</p><p>shown that telemedicine is feasible and effective in the</p><p>management of pressure ulcers in patients with spinal</p><p>cord injuries and multiple sclerosis8,9, orthopaedic</p><p>injuries10 and brain injuries7,11. However, there have</p><p>been only a few studies on the application of</p><p>telemedicine in stroke. These examined the use of</p><p>telecommunication for the management of acute</p><p>stroke in rural areas1214, speechlanguage problems15,</p><p>support for the carers of stroke patients16 and post-stroke</p><p>follow-up care at home17.</p><p>There are several advantages of using telemedicine in</p><p>community-based rehabilitation. First, it allows</p><p>participants to access the service more readily if video-</p><p>conference systems can be installed at community</p><p>centres near their homes. Second, therapy conducted</p><p>as a group may enhance the atmosphere for learning.</p><p>Third, it allows realtime interaction between the</p><p>participants and medical professionals.</p><p>Multi-site links can increase the number of partici-</p><p>pants at any one time. However, traditional stroke</p><p>rehabilitation has always been conducted face to face</p><p>with the client. Therefore, the feasibility of tele-</p><p>rehabilitation in stroke patients is unknown. The aim</p><p>of the present study was to evaluate the feasibility,</p><p>efficacy and acceptability of a community-based stroke</p><p>rehabilitation programme conducted via video-</p><p>conferencing.</p><p>Methods...............................................................................</p><p>The subjects participated in an eight-week intervention</p><p>programme (1 session per week and 1.5 h per session) at</p><p>a community centre for seniors. The intervention was</p><p>conducted by a physiotherapist via a videoconference</p><p>link. The class size was about six to eight subjects. A</p><p>non-professional assistant was stationed at the</p><p>community centre to facilitate the smooth running of</p><p>the programme.</p><p>Equipment</p><p>The two videoconferencing sites were the Shatin</p><p>Hospital and a community centre for seniors in the</p><p>same district. The videoconferencing equipment at the</p><p>hospital (Model 880, Tandberg) and the community</p><p>centre (ViewStation FX, Polycom) had similar</p><p>capabilities. They were connected by a 10 Mbit/s</p><p>broadband line (Hutchison Global Crossing) and could</p><p>transmit images at 30 frames/s. Dual video output</p><p>allowed the subjects to see the physiotherapist and</p><p>slide presentation on two separate 86 cm television</p><p>screens.</p><p>Sampling method</p><p>Subjects were recruited by a physiotherapist either after</p><p>discharge from the geriatric day hospital (Shatin</p><p>Hospital) or from the community centre for seniors</p><p>(Evangelical Lutheran Church of Hong Kong). They</p><p>had had a stroke at least six months previously and</p><p>were able to walk independently, with or without</p><p>walking aids (Modified Functional Ambulatory</p><p>Categories VI and VII18). Those with Mini Mental State</p><p>Examination (MMSE) scores19 of less than 18</p><p>(indicating mild or worse impairment of cognitive</p><p>function) were excluded to ensure that all subjects</p><p>would be able to comprehend the instructions,</p><p>questionnaires and test procedures involved. Those</p><p>with significant communication barriers or uncom-</p><p>pensated cardiac or pulmonary insufficiency were also</p><p>excluded.</p><p>Intervention</p><p>The intervention consisted of education, exercise and</p><p>social support. The education component included</p><p>talks covering the pathophysiology of stroke, signs and</p><p>symptoms, medical management, rehabilitation</p><p>pathways, the identification and modification of risk</p><p>factors, psychosocial impact, community support, and</p><p>home and environmental safety.</p><p>The exercise programme was designed to improve</p><p>strength and balance. Each exercise session lasted for</p><p>about 30 min and was divided into three blocks. It</p><p>comprised a 5 min warm-up session of stretching and</p><p>flexibility exercise, a 20 min strength and balance</p><p>exercise, and a 5 min cool-down exercise. The strength</p><p>and balance exercise mainly involved leg muscles.</p><p>Blood pressure and heart rate were recorded before and</p><p>after the exercise. The participants were encouraged to</p><p>J C K Lai et al. New model for stroke rehabilitation</p><p>200 Journal of Telemedicine and Telecare Volume 10 Number 4 2004 at GEORGE MASON UNIV on October 1, 2014jtt.sagepub.comDownloaded from </p><p></p></li><li><p>do the same exercise at home at least three times a</p><p>week. An exercise logbook was given to each subject to</p><p>record exercise compliance.</p><p>Subject assessment</p><p>At initial assessment, the following data were recorded:</p><p>age, sex, education level, smoking and drinking</p><p>history, exercise habit, disease duration, type of stroke,</p><p>side of hemiparesis, number of recurrent strokes, co-</p><p>morbidity, body mass index, fall history in previous</p><p>year, and scores on the Elderly Mobility Scale (EMS)20,</p><p>the Lawton Instrumental Activities of Daily Living</p><p>Scale (IADL)21 and the Geriatric Depression Scale</p><p>15-item Short Form (GDS-15)22. Assessment of the</p><p>subjects balance was conducted by a physiotherapist</p><p>using the Berg Balance Scale (BBS)23. The Medical</p><p>Outcomes Study 36-item Short Form (SF-36)24, State</p><p>Self-Esteem Scale (SSES)25 and a stroke knowledge test26</p><p>were administered by another research assistant. After</p><p>completion of the programme, evaluation of the</p><p>primary outcome measures but not of the secondary</p><p>measures (see below) was repeated.</p><p>Primary outcome measures</p><p>Berg Balance Scale (BBS)</p><p>The BBS records a subjects ability to perform 14</p><p>activities, each of which is rated on a five-point Likert</p><p>scale (0worst, 4best, to give a highest possible scoreof 56). A score of 45 or below represents a risk factor for</p><p>a fall. This tool has good levels of reliability, validity</p><p>and responsiveness for patients at different stages of</p><p>recovery after stroke23,27.</p><p>Medical Outcomes Study 36-item Short Form(SF-36)</p><p>The SF-36 questionnaire is a multidimensional generic</p><p>quality-of-life measure that is widely used to measure</p><p>health status after stroke24,28. It consists of 36 items in</p><p>eight subscales: physical functioning, limitations due</p><p>to physical health problems (role, physical), bodily</p><p>pain, general health, vitality, social functioning,</p><p>limitations due to emotional health problems (role,</p><p>emotional) and mental health. Subscores are</p><p>transformed to a scale of 0100, with higher scores</p><p>representing better health status. In this study, the</p><p>Chinese (Hong Kong) version was used29.</p><p>State Self-Esteem Scale (SSES)</p><p>Self-esteem can affect a persons response to illness30,31.</p><p>It is viewed both as a symptom of depression32 and as a</p><p>causal factor in reactive depression33. The SSES consists</p><p>of 20 statements that describe a subjects feelings. Each</p><p>item is scored on a five-point scale (1not at all, to5extremely). The highest possible score is therefore100, and higher scores indicate more self-esteem. The</p><p>SSES Chinese version has been examined for its validity</p><p>with stroke patients34.</p><p>Stroke knowledge test</p><p>The knowledge test comprised 10 questions on the</p><p>signs, symptoms and risk factors of stroke, precautions</p><p>on taking medication and during exercise, and sources</p><p>of community support26.</p><p>Client satisfaction and feedback</p><p>A questionnaire adapted from a previous telemedicine</p><p>study conducted with Chinese residents of a nursing</p><p>home35 was used to evaluate the satisfaction of the</p><p>subjects after completion of the programme. The</p><p>questions covered visual and audio quality, class</p><p>frequency and duration, and the acceptance of</p><p>provision of services via videoconferencing. A focus</p><p>group was conducted by a social worker after the eight-</p><p>week intervention to collect feedback from subjects.</p><p>The dialogue was recorded and analysed.</p><p>Secondary outcome measures</p><p>The three secondary outcome measures, described</p><p>below, were assessed only upon recruitment into the</p><p>study, to define the baseline functional and clinical</p><p>status of the subjects.</p><p>Geriatric Depression Scale 15-item Short Form(GDS-15)</p><p>The GDS-15 is used to assess symptoms of depression. It</p><p>covers domains of mood and outlook, energy, agitation</p><p>or restlessness, and social withdrawal. Scores range</p><p>from 0 to 15; a score of 8 points or higher indicates</p><p>depression22.</p><p>Elderly Mobility Scale (EMS)</p><p>The EMS tests the following functions: lying to sitting,</p><p>sitting to lying, sitting to standing, standing, gait,</p><p>walking speed and functional reach. It is an assessment</p><p>of locomotion, balance and key position changes,</p><p>which are prerequisites to more complex activities of</p><p>daily living. The maximum possible score, which</p><p>represents independent mobility, is 2020.</p><p>J C K Lai et al. New model for stroke rehabilitation</p><p>Journal of Telemedicine and Telecare Vol...</p></li></ul>