Telehealth for Stroke Care:
Is Virtual Rehab Coming?
Blaire Chandler
VCU Physical Therapy – Class of 2016
AHA Stroke Stats
 Every 40 seconds, someone in
the U.S. has a stroke
 87% - ischemic, 10% - ICH, 3% - SAH
 Each year, ~795,000 people
suffer a stroke (new or recurrent)
 Annual direct and indirect cost
$33.6 billion
 In 2011, someone died every 4
minutes from a stroke
Age-Adjusted Average
Annual Rates per 100,000
Medium Purple: 89.0-100.1
Dark Purple: 100.2-300.1
Telemedicine
 “The remote delivery of
healthcare services and
clinical information using
telecommunications
technology.”
 2-way video
 Email
 Smart phones
 Wireless tools
 Online portals!
 Benefits:
 Improved access
 Cost efficiencies
 Improved quality
 Patient demand
What about reimbursement?
 Medicare:
 Sometimes
 Remote radiology, pathology &
some cardiology 
 Medicare Advantage
beneficiaries 
 ATA is working to get telehealth
covered for all Medicare
members
 Medicaid:
 Varies state-to-state but
most states have some
sort of telemedicine
coverage
 Private insurance:
 24 states and DC require
private insurance to
cover telehealth services
the same as in-person
services
MUSC’s Telestroke Program
 Provides urgent
consultations at select
hospitals in South Carolina
through a web-based
outreach initiative
 Almost 100% of the South
Carolina population is
within an hour of expert
stroke care
 MUSC has been a JCAHO
Primary Stroke Center since
2008
 1000 inpatient strokes/year
 18 hospitals in the
Telestroke system
 1247 calls per year
MUSC REACH Network
 1-843-792-FAST
 Available 24/7
 REACH Team









Dr. Robert Adams
Dr. Charles Andrews
Dr. Julio Chalela
Dr. Marc Chimowitz
Dr. Wuwei Feng
Dr. Christine Holmstedt
Dr. Edward Jauch
Dr. Shelly Ozark
Dr. Tanya Turan
MUSC REACH Locations
Hospital
City
Hospital
City
Allendale County
Hospital
Fairfax
McLeod Medical
Center Dillon
Dillon
Beaufort Memorial
Hospital
Beaufort
McLeod Medical
Center Loris
Loris
Carolina Pines Regional
Medical Center
Hartsville
McLeod Regional
Medical Center
Florence
Carolinas Hospital
System – Marion
Marion
McLeod-Seacoast
Medical Center
Little River
Coastal Carolina
Hospital
Hardeeville
Self Regional
Healthcare
Greenwood
Georgetown Memorial
Hospital
Georgetown
The Regional Medical
Center
Orangeburg
Kershaw Medical
Center
Camden
Tuomey Regional
Medical Center
Sumter
Waccamaw
Community Hospital
Murrells Inlet
Williamsburg Regional
Hospital
Kingstree
So what about…
Telerehabilitation services for stroke
(Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
Background
 “Stroke is one of the most
common causes of death
and acquired disability
worldwide.”
 ~1/2 of stroke survivors
participate in some sort of
rehab after acute care
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
Description of Intervention
 May include assessment,
diagnosis, goal setting,
therapy, education and
monitoring
 Some position statements by
certain organizations
 Treated as an alternative to
conventional treatment
rather than a subspecialty
 Ensure quality, ethical and
legal standards are met with
telerehab services
 Telerehab interventions
should mimic conventional
interventions
 Examples of scope: home
assessments, TKR rehab,
speech therapy
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 No statement by the APTA to
date
Advantages
Challenges
Key point = ACCESS!
How to do a “hands-on” job
without hands present
Complement and enhance
quality of current services
Lack of technical experience
Transition periods
Initial start-up costs
Cost savings
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
Systematic Review Objectives
 “To determine whether the
use of telerehabilitation
leads to improves ability to
perform ADLs amongst
stroke survivors when
compared with:”
 In-person rehabilitation
 No rehabilitation
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 Secondary Objectives:
 Greater independence in
self-care
 Improved mobility
 Health-related QoL
 Upper limb function
 Cognitive function
 Functional communication
Characteristics of Included Studies
Randomized Controlled Trials
Clinical diagnosis of stroke
All etiologies of stroke (SAH included)
All levels of severity
All stages of rehab (acute, subacute, chronic)
Interventions lasted more than 1 session
Interventions could be a combination of in-person, but “tele-” part had to
be greater
Included Studies
 10 RCTs
 933 participants
 Most studies <50 participants
 United States (5),
Netherlands (2), Italy (2), &
Canada (1)
 Between 2004-2012
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 Ages – 50s, 60s, 70s
 Male=female
 2 studies recruited in acute
stage
 5 studies excluded those
with significant cognitive
impairment
Independence in ADLs – Forducey, 2012
 Participants
 Interventions
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
Specific Studies
Independence in ADLs – Forducey, 2012
 Participants:
 1st stroke diagnosis within last
6 months
 Moderate deficits in selfcare, functional mobility,
and transfers
 Not included if aphasic
 Control:
 Same services delivered in
person
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 Intervention:
 12 treatment sessions (6 OT, 6
PT)
 Education, retraining of selfcare, functional mobility and
posture, home modifications,
and therapy to improve
function in impaired limbs
 Delivered over videophone
Independence in ADLs – Chumbler, 2012
 Participants:
 Stroke within last 24 months
 Discharged to community
 Able to follow 3-step
command
 FIM: 18-88
 Control:
 “Usual care”
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 Intervention:
 Purpose: improve functional
mobility
 3 televisits, in-home
messaging system, & 5
phone calls over 3 months
 Televisits=assessment of
mobility, goal-setting, &
exercise demonstrations
Independence in ADLs – Results
 Study 1:
 Both groups showed
significant improvement
 No difference between
groups
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 Study 2:
 No significant difference
between groups
Secondary Outcomes
 Mobility: no significant
difference
 Participant satisfaction: no
significant difference
 HR-QoL: no significant
difference
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
 UE function:
 Telerehab vs. usual care
 No significant difference
Overall Results
Telerehab isn’t bad…
… but it isn’t “GOLD” in
stroke care outcomes.
Author’s Conclusions: “evidence is currently insufficient to guide
practice.”
More research, more technology, more use is coming….
Telerehabilitation services for stroke (Review)
Laver KE, Schoene D, Crotty M, George S, Lannin NA, Sherrington C
2013
References
 Laver KE, Shoene D, Crotty M, George S, Lannin NA, Sherrington C. Telerehabilitation services for stroke.
Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD010255. DOI:
10.1002/14651858.CD010255.pub2.
 Mozaffarian, D, et al. (2014). Heart Disease and Stroke Statistics—2015 Update. Circulation. Retrieved May
28, 2015, from http://circ.ahajournals.org/content/early/2014/12/18/CIR.0000000000000152.citation
 www.americantelemed.org
 www.apta.org
http://www.muschealth.com/video/default.aspx?videoId
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