Steven C. Cramer, MD, MMSc, FAAN, FAHA

Telerehabilitation After Stroke

Steven C. Cramer, MD, MMSc, FAAN, FAHA

Professor, Dept. NeurologyUniversity of California, Los Angeles

Director of Medical ResearchCalifornia Rehabilitation Institute

Disclosures

Dr. Cramer serves as a consultant for Abbvie, Constant Therapeutics, MicroTransponder, Neurolutions, SanBio, NeuExcell, Elevian, Medtronic, and TRCare.

DrugsSSRIs, stimulants, L-Dopa, niacin, memantine, maraviroc…Biological agentsGrowth factors: Erythropoietin, hCG, G-CSF, b-FGF, OP-1...Monoclonal antibodies: anti-MAG Ab, anti-Nogo A Ab...Cells: embryonic, induced pluripotent, adult cell therapies...Brain stimulationTranscranial magnetic stimulation, transcranial DC stim, epidural stim, deep brain stim; vagal nerve stimulation...Lesion bypassBrain-computer interface, brain-machine interface, nerve transferActivity-based therapiesOT/PT/SLT, constraint-induced therapy, robots, telerehabilitation...Cognitive-based therapiesMental imagery, environmental enrichment, prism adaptation…

Therapies for stroke recovery in humans

Neurology 2014;82:1277–1286

44/46 preclinical studies: better outcome with MSC vs. control

Effects of MSCs on functional recovery robust across • species, route, type of MSC (allogeneic vs. autologous),

time post-stroke, and dosage.

Stroke. 2019; 50:2835-2841

IV MSC, up to 1.5 M cells/kg, chronic stroke:

Stroke. 2019; 50:2835-2841

IV MSC, up to 1.5 M cells/kg, chronic stroke:• Safe• Significant gains over 12 months in NIHSS, Barthel Index,

MMSE, and Geriatric Depression Scale scores

Stroke. 2019; 50:2835-2841

IV MSC, up to 1.5 M cells/kg, chronic stroke:• Safe• Significant gains over 12 months in NIHSS, Barthel Index,

MMSE, and Geriatric Depression Scale scores• Excellent functional outcome (Barthel score ≥95) in 11.4% (baseline) 27.3% (6 mo) 35.5% (12 mo)


Activity-based therapies have double importance:--can improve outcomes--adjuvant to many other types of restorative therapy

(“experience-dependent neural plasticity”)


Animal studies showing favorable plasticity use high rehab doses.(600-700 repetitions/day, Nudo 1996; Jeffers 2018)

Unmet need: delivery of large doses of rehab therapy


In humans, higher rehab therapy doses may improve outcomes.





“A positive relationship between the time scheduled for therapy and therapy outcomes.”

Lohse et al. Stroke. 2014;45:2053-2058



Quantity of rehab therapy often low in humans, however:(1) financial constraints(2) access to rehab therapy providers(3) poor patient compliance with assignments(4) limited dose during stroke rehabilitation

(mean of 32 arm repetitions/session, Lang 2009)




Quantity of rehab therapy often low in humans, however:(1) financial constraints(2) access to rehab therapy providers(3) poor patient compliance with assignments(4) limited dose during stroke rehabilitation

(mean of 32 arm repetitions/session, Lang 2009)


Quality of rehab is also important; greater plasticity when a task is (1) challenging, interesting, motivating, goal-oriented, varied(2) accompanied by appropriate feedback(3) environmentally and ecologically relevant

Telerehabilitation has been defined as “Delivery of rehabilitation services via information and

communication technologies……encompasses a range of rehabilitation and habilitation

services that include assessment, monitoring, prevention, intervention, supervision, education, consultation, and counseling”

D Brennan et al. Int J Telerehab. 2010; 2:31-34.

Definition of telerehabilitation

‘Telerehabilitation’: a term applied to many different therapies

Telerehabilitation means very different things to different people

Wide variation in dose, content of therapy, device employed, etc



Asking “Does telerehabilitation work?” can be confusing


https://creativemarket.com/ananeirfy/3203007-Pile-of-pills

It’s like asking “Do pills work?”



Asking “Does telerehabilitation work?” can be confusing


Laver et al reviewed 22 randomized controlled trials of stroke telerehab; 1,937 patients

The Cochrane database of systematic reviews. 2020, Issue 1. Art. No.: CD010255.

Meta-analysis of telerehabilitation for stroke

Concerns included studies with inadequate reporting quality, selective outcome reporting, and incomplete outcome data

Therapy target varied: e.g., discharge support programs, upper limb training, mobility retraining, communication therapy...

Meta-analysis of telerehabilitation for stroke: concerns


Concerns included studies with inadequate reporting quality, selective outcome reporting, and incomplete outcome data

Therapy target varied: e.g., discharge support programs, upper limb training, mobility retraining, communication therapy...

Technology used varied (sometimes used in combinations):• Telephone• Videoconferencing• Desktop videophones• Video recordings

• Email• Online chat program• Online resource room• In-home messaging device

Meta-analysis of telerehabilitation for stroke: concerns


Core principles:• High intensity movement practice• Engage numerous brain circuits• Game-ification• Socialization

Dodakian et al, Neurorehab Neural Repair. 2017; 31:923-933

Telerehabilitation components

Cramer et al. JAMA Neurology. 2019; 76:1079-1087

Telerehabilitation components

“Among all the components of the system, all participants rated highly their experience using the videoconference…”

Chen et al. A qualitative study on a home-based stroke telerehabilitation system. Topics in Stroke Rehab. 2020; 27:81-92

Eligibility

Patients had to be 3-6 months post-stroke; could have mild, moderate, or severe arm weakness (FM score 22-55 out of 66)

Treatment

We delivered and assembled our system to their home.

Each subject received 28 days of telerehabilitation.

Each day consisted 1 hour that was required and structured, plus 1 optional hour of free play.

Plus 3 videoconferences per week

Pilot Study Of Home-Based Telerehabilitation After Stroke


Compliance was excellentSubjects engaged in therapy 329 of 336 (97.9%) assigned days.




Improved arm movementFM score started at 39±12 (range 23-55),increased by 4.8±3.8 points (p=0.0015); met clinically important difference in 6 of 12.





Findings not dependent on computer skillsComputer literacy scores declined with age (r = -0.92, p<0.0001), but were not related to arm motor gains or to home compliance.






Holistic care in parallel--Daily education increased stroke knowledge by 39% (p=0.001)--Videoconference screen detected depression in 3/12 patients--Home BP measurement validated (r = 0.99; p<0.0001)



Average of 879 arm repetitions/day





Holistic care in parallel--Daily education increased stroke knowledge by 39% (p=0.001)--Videoconference screen detected depression in 3/12 patients--Home BP measurement validated (r = 0.99; p<0.0001)


124 subjects, 4-36 wk post-stroke, arm paresis

36 sessions, each 70-min, over 6 wk: randomized to either[1] In-Clinic or [2] In-Home telerehabilitation

Assessor-blind, randomized, non-inferiority design


Key Inclusion criteria1. Age ≥18 years2. Stroke (ischemic or ICH) onset 4-36 weeks prior3. Arm motor Fugl-Meyer score = 22-56 (out of 66)

Key Exclusion criteria1. Major, active, coexistent neurological or psychiatric disease2. Other diagnosis substantially affecting paretic arm3. Severe depression (GDS Score >10)4. Significant cognitive impairment (MoCA <22)5. Communication deficits interfering with participation6. Life expectancy <6 months7. Non-English speaking


Results

Dropout10 subjects (8.1%) dropped out before the final visit:

No Therapy MD Withdrew Lost to follow-up Return to WorkTelerehab 3 0 0 0In-Clinic 1 2 (HTN, Fx) 2 2

Adverse eventsSAE Other adverse events

Telerehab 1 (all unrelated) 6 reasonably or definitely relatedIn-Clinic 6 (all unrelated) 5 reasonably or definitely related

ComplianceTelerehab 58/62 (98.3 %) subjects compliant with 36 sessions In-Clinic 57/62 (93.4 %) subjects compliant with 36 sessions


The adjusted difference* between groups in ΔFM is 0.06 points, the 95% CI for which is inside the non-inferiority margin.

Primary Study Results

In-Clinic TelerehabBaseline Fugl-Meyer 42.7 ± 8.7 42.8 ± 7.8Fugl-Meyer change to d30 8.36 ±

7.07.86 ±

6.7

*Adjusted for age, baseline FM, time post-stroke, enrollment site, and stroke subtype





7.07.86 ±

6.7



Arm motor gains did not differ among subjects with (n=39) vs. without (n=75) aphasia.




7.07.86 ±

6.7



Arm motor gains did not differ among subjects with (n=39) vs. without (n=75) aphasia.

The number of TR arm movement repetitions averaged 1,031/day.

Home-based telerehabilitation: clinically and statistically significant gains in arm movement in patients with stroke.

Home-based telerehabilitation: comparably efficacious compared to in-clinic therapy.

Conclusions


Conclusions

Among patients randomized >90 days post-stroke:

• The mRS score decreased in 39.5% of TR patients

Cramer et al. Neurology. 2021;96:1812-1822





Conclusions

Among patients randomized >90 days post-stroke:

• The mRS score decreased in 39.5% of TR patients

• Overall, % patients with mRS score 0-2 was 46.8% at baseline66.2% at 30 days post-therapy (*p = 0.015)

Cramer et al. Neurology. 2021;96:1812-1822

Winstein et al. JAMA. 2016;315:571-581

In 361 patients who were an average of 46 days post-stroke, adding 30 hours of arm motor rehab did not significantly improve arm function at 12 months post-stroke

Lang CE et al. Ann Neurol.2016;80:342-354

In 85 patients who were an average of 12 months post-stroke, adding up to 32 hours of arm motor rehab did not significantly improve arm function at end of therapy.

Rodgers H et al. Lancet. 2019;394:51-62

In 669 patients who were between 1 week and 5 years post-stroke, 27 hours of arm motor therapy did not significantly improve arm function.

Might be

• Earlier time post-stroke (4.4 months vs. 8 or 12 months)• Less severe stroke (FM score 42.8 vs. 18)• More arm movements/day (1,031 vs. ≤300 in-clinic)• Higher therapy dose (42 hours vs. 27-32 hours)• Type of comparison (within-subject vs. inactive control)

Why did the telerehabilitation trial show significant benefit but these 3 trials of activity-based therapy in-clinic did not?

• Combine telerehab with a drug (experience-dependent plasticity)

Future directions for telerehabilitation

• Combine telerehab with a drug (experience-dependent plasticity)


Cramer et al. Front Neurol. 2021 Feb 3;11:611453

• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home• Improve access to telerehabilitation***

***www.trcare.net


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home• Improve access to telerehabilitation***• Very long-term treatment to prevent functional decline

***www.trcare.net


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home• Improve access to telerehabilitation***• Very long-term treatment to prevent functional decline• Generate actionable reports to health care professionals

***www.trcare.net


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home• Improve access to telerehabilitation***• Very long-term treatment to prevent functional decline• Generate actionable reports to health care professionals• Expanded prevention: meds, BP, glucose, activity, diet, etc

***www.trcare.net


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home• Improve access to telerehabilitation***• Very long-term treatment to prevent functional decline• Generate actionable reports to health care professionals• Expanded prevention: meds, BP, glucose, activity, diet, etc• Connect to electronic health record

***www.trcare.net


• Combine telerehab with a drug (experience-dependent plasticity)• Treat multiple neurological deficits in parallel• Practice real functional tasks in the home• Obtain detailed measurements from the home• Improve access to telerehabilitation***• Very long-term treatment to prevent functional decline• Generate actionable reports to health care professionals• Expanded prevention: meds, BP, glucose, activity, diet, etc• Connect to electronic health record• Ease transitions of care

***www.trcare.net


Telerehabilitation After Stroke

Steven C. Cramer, MD, MMSc, FAAN, FAHA

Professor, Dept. NeurologyUniversity of California, Los Angeles

Director of Medical ResearchCalifornia Rehabilitation Institute

Steven C. Cramer, MD, MMSc, FAAN, FAHA

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