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Original Investigation
June 24, 2019

Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Neurology, University of California, Irvine
  • 2Sue & Bill Gross Stem Cell Research Center, University of California, Irvine
  • 3Department of Physical Therapy, Chapman University, Irvine, California
  • 4Department of Psychological Science, University of California, Irvine
  • 5Institute for Software Research, University of California, Irvine
  • 6Department of Statistics, University of California, Irvine
  • 7Department of Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey
  • 8Department of Stroke Rehabilitation, Kessler Institute for Rehabilitation, West Orange, New Jersey
  • 9Department of Physical Medicine and Rehabilitation, MetroHealth System, Case Western Reserve University, Cleveland, Ohio
  • 10Brain Stimulation and Robotics Laboratory, Burke Neurological Institute, White Plains, New York
  • 11Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
  • 12Department of Clinical Neurosciences, University of California, San Diego, La Jolla
  • 13Brooks Rehabilitation Clinical Research Center, Brooks Rehabilitation, Jacksonville, Florida
  • 14Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
  • 15Department of Neurology, University of Washington, Seattle
  • 16Department of Health Science and Research, Medical University of South Carolina, Charleston
  • 17Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts
  • 18Massachusetts General Hospital, Boston
  • 19Brigham and Women’s Hospital, Boston, Massachusetts
  • 20Harvard Medical School, Boston, Massachusetts
  • 21Department of Public Health Sciences, Medical University of South Carolina, Charleston
  • 22Department of Neurology, University of Cincinnati, Cincinnati, Ohio
  • 23Division of Physical Therapy Education, Department of Rehabilitation Medicine, Emory University, Atlanta, Georgia
  • 24Atlanta Veterans Affairs Health Care System, Center for Visual and Neurocognitive Rehabilitation, Decatur, Georgia
  • 25National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
JAMA Neurol. 2019;76(9):1079-1087. doi:10.1001/jamaneurol.2019.1604
Key Points

Question  Does a 6-week course of intensive home-based telehealth targeting arm movements after stroke provide rehabilitation benefits that are comparable with those derived from dose-matched traditional in-clinic rehabilitation therapy?

Findings  In this randomized, assessor-blinded, noninferiority clinical trial of 124 adults following stroke, telerehabilitation showed comparable efficacy to traditional in-clinic rehabilitation for improving motor status (Fugl-Meyer arm motor scale) and for improving patient knowledge about stroke.

Meaning  Telehealth is an effective means to provide rehabilitation therapy and improve patient outcomes after stroke and may be useful for improving access to rehabilitation therapy.

Abstract

Importance  Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues.

Objectives  To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education.

Design, Setting, and Participants  In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population.

Interventions  Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups.

Main Outcomes and Measures  Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy.

Results  A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, –2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately.

Conclusions and Relevance  Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale.

Trial Registration  ClinicalTrials.gov identifier: NCT02360488

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