Effects of Telerehabilitation on Physical Function and
Disability for Stroke Patients
A Randomized, Controlled Trial
Neale R. Chumbler, PhD; Patricia Quigley, PhD, MPH, ARNP, CRRN; Xinli Li, PhD;
Miriam Morey, PhD; Dorian Rose, PhD, PT; Jon Sanford, MArch;
Patricia Griffiths, PhD; Helen Hoenig, MD, MPH
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Background and Purpose—To determine the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on
physical function, and secondarily on disability, in veterans poststroke.
Methods—We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans with stroke from 3
Veterans Affairs medical centers. Veterans with a stroke in the preceding 24 months were randomized to the STeleR
intervention or usual care. The STeleR intervention consisted of 3 home visits, 5 telephone calls, and an in-home
messaging device provided over 3 months to instruct patients in functionally based exercises and adaptive
strategies. Usual care participants received routine rehabilitation care as prescribed by their physicians. The
primary outcome measures were improvement in function at 6 months, measured by both the motor subscale of the
Telephone Version of Functional Independence Measure and by the function scales of the Late-Life Function and
Disability Instrument.
Results—The 2 complementary primary outcomes (Late-Life Function and Disability Instrument Function and Telephone
Version of Functional Independence Measure) improved at 6 months for the STeleR group and declined for the usual
care group, but the differences were not statistically significant (P⫽0.25, Late-Life Function and Disability Instrument;
P⫽0.316). Several of secondary outcomes were statistically significant. At 6 months, compared with the usual care
group, the STeleR group showed statistically significant improvements in 4 of the 5 Late-Life Function and Disability
Instrument disability component subscales (P⬍0.05), and approached significance in 1 of the 3 Function component
subscales (P⫽0.06).
Conclusions—The STeleR intervention significantly improved physical function, with improvements persisting up to 3
months after completing the intervention. STeleR could be a useful supplement to traditional poststroke rehabilitation
given the limited resources available for in-home rehabilitation for stroke survivors.
Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00384748.
(Stroke. 2012;43:2168-2174.)
Key Words: stroke recovery 䡲 rehabilitation 䡲 telemedicine
P
hysical function reaches its peak at around 6 months
poststroke and begins to decline as soon as 1 year after
stroke1; this suggests that increasing use of rehabilitation
postdischarge is likely to result in better functional recovery.
Indeed, supervised stroke rehabilitation in the community for
up to 1 year postdischarge was associated with faster recov-
ery and better functional status at 1 year than with unsupervised therapy.2 The main barriers cited by patients to participating in supervised rehabilitation postdischarge were
getting to the rehabilitation clinic and inconvenience.2 Providing rehabilitation in the home is limited by high costs and
rehabilitation provider availability, particularly in rural ar-
Received December 7, 2011; accepted April 18, 2012.
From the VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (N.R.C.), Richard L. Roudebush VAMC, Indianapolis, IN;
Department of Sociology (N.R.C.), Indiana University School of Liberal Arts, Indiana University-Purdue University Indianapolis, Indianapolis, IN; VA
HSR&D Stroke Quality Enhancement Research Initiative (QUERI) Program (N.R.C.), Richard L. Roudebush VAMC, Indianapolis, IN; Regenstrief
Institute (N.R.C.), Indianapolis, IN; VA HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes (P.Q.), James A. Haley VAMC,
Tampa, FL; VA National Surgery Office Deputy Undersecretary for Health for Operations and Management (X.L.), Denver, CO.; Geriatric Research
Education and Clinical Center (M.M.), Durham VAMC, Durham, NC; Department of Medicine (M.M., H.H.), Duke University Medical Center, Durham,
NC; Duke Claude D. Pepper OAIC (M.M., H.H.), Duke University Medical Center, Durham, NC; University of Florida (D.R.), Department of Physical
Therapy, College of Public Health and Health Professions, Gainesville, FL; Atlanta VA Rehab R&D Center (J.S., P.G.), Atlanta VAMC, Atlanta GA;
Emory University School of Medicine (P.G.), Division of Geriatrics and Gerontology, Atlanta, GA; Physical Medicine & Rehabilitation Service (H.H.),
Durham VAMC, Durham, NC.
Correspondence to Neale R. Chumbler, PhD, Richard L. Roudebush VAMC (11H), 1481 W. 10th Street, Indianapolis, IN 46202-2884. Email
[email protected]
© 2012 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.111.646943
2168
Chumbler et al
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eas.3 Thus, stroke survivors could benefit from a system that
enables therapists to deliver rehabilitation in the patient’s
home from a remote location.4
Home-based telerehabilitation (TR) is defined as use by a
clinician of telecommunication devices (eg, telephone, videophone) to provide evaluation and distance support of
disabled persons living at home.4 Many standardized instruments have been validated and recommended for use by
occupational therapy/physical therapy via high-quality videoconferencing system when an in-person assessment is impractical.4 A 2011 systematic review of TR interventions in
stroke care identified 9 studies; only 4 of these were randomized controlled trials (RCTs), the quality of which indicated
that methodological improvement is needed.5 Most of the TR
studies focused on upper extremity function. Lacking from
stroke TR studies were interventions directed toward broader
functional goals using traditional rehabilitation interventions
(eg, exercise, adaptive strategies).
To date, no RCT has been published evaluating the
efficacy of TR to provide training in lower extremity exercises and adaptive strategies for stroke survivors in a home
environment. The purpose of this RCT was to study the effect
of a multifaceted stroke telerehabilitation (STeleR) intervention, using functionally based exercises and adaptive strategies, on physical function, and secondarily on disability.
Methods
A complete description of our methods has been published.6 In brief,
the study was a 3-site, 2-arm, single-blinded RCT, with a fourth
Veterans Affairs (VA) facility serving as the coordinating center.
The institutional review boards at all 4 VA facilities reviewed and
approved the research protocol, and written consent was obtained
from all patients.
Settings and Participants
Participants were eligible for the study if they experienced an
ischemic or hemorrhagic stroke within the previous 24 months.
Other inclusion criteria included age 45 to 90 years, having been
discharged to the community, not cognitively impaired (no more
than 4 errors on the Short Portable Mental Status Questionnaire),
able to follow a 3-step command, discharge motor Functional
Independence Measure (FIM) score of 18 to 88 (ie, maximal
assistance on no more than 4 motor activities of daily living as the
most severe stroke included, and modified independence on at least
2 motor activities of daily living as the least severe), approval by the
patient’s physician, and signed medical media release form.6 The
FIM measures physical and cognitive disability with reference to
burden of care. It has been employed to check patient progress and
to measure rehabilitation outcomes.7
We employed 3 corresponding methods to identify potential study
participants. First, we used the Functional Status Outcomes Database
notification system, which utilizes administrative diagnoses to alert
clinicians that a patient with an acute stroke was admitted to the VA
facility. Second, prospective participants were identified by referrals
made to study staff by clinicians on the acute medical/surgical wards,
and stroke and/or rehabilitation units. Third, site-specific databases
were queried by analysts who used an analogous algorithm to the
Functional Status Outcomes Database automated search strategy.
The lists containing prospective participants were reviewed by study
staff for determination of study eligibility.6 Eligible study participants were randomized by centrally sealed allocation into the STeleR
or usual care (UC) groups.
Effects of Telerehabilitation for Stroke Patients
2169
STeleR Intervention
The SteleR intervention was guided by the Veterans Health Administration guidelines for the management of stroke rehabilitation care8
and by Verbrugge and Jette’s9 model for the disablement process,
which described how chronic and acute conditions, and personal and
environmental factors, influence the disablement process (ie, the
process by which people develop limitations in activities of daily
living and social role function). The STeleR intervention focused on
improving functional mobility. The intervention lasted 3 months and
included the following 3 components: 3 1-hour home visits (televisits) by a trained assistant to assess physical performance and help
communicate the instruction of exercises and use of assistive
technology and/or adaptive techniques recommended by a licensed
physical therapist or occupational therapist (teletherapist); participants’ daily use of an in-home messaging device (IHMD) that was
monitored weekly by the teletherapist; and 5 telephone intervention
calls between the teletherapist and the participant. During this
3-month period, all participants (intervention and UC) received
routine VA care as directed by their providers.
Home Televisits
The 3 home televisits transpired every 12 to 16 days and were
completed within 5 weeks of randomization. The first televisit was
devoted to the assessment of physical function and goal setting. A
research assistant used a camcorder to record both the home
environment and the participant carrying out standardized measures
of physical and functional performance. In Televisit 2, the assistant
presented the exercise prescription, demonstrating each exercise
before the participant performed for later review by the teletherapist.
The exercise component of the intervention included 3 to 4 exercises
that focused on strength and balance, selected by the therapist based
on the physical performance measures. For Televisit 3, the teletherapist reviewed the videotape of the participant’s functional performance and home environment with the participant, identified any
problems and obstacles, and then jointly developed a treatment plan
(eg, modifying the home environment, new adaptive equipment or
techniques). The research assistant reviewed the adaptive prescription with the participant. A fourth televisit was requested by the
teletherapist in the event of interval problems that could not be
addressed via telephone. For all of the home visits, the research
assistant was at the home; the therapist only communicated with the
patient via telephone messaging. The therapist maintained contact
throughout the study with the same group of patients.
IHMD
The IHMD was connected to a standard telephone line in the
participant’s home. Participants answered questions consisting of a
series of validated self-report measurement instruments regarding
common poststroke complications of depression, self-care/mobility,
and falls. The teletherapist viewed the participant’s answers. If any
answers were of concern, the teletherapist called the participant. The
IHMD used the Patient Health Questionnaire (PHQ-9)10 to screen for
depression at baseline (week 1–2) and 3 months, the 16-item version
of the Stroke Impact Scale (SIS-16)11 to assess self-care/mobility
every 2 weeks, and once weekly to ask 3 questions related to falls.
The IHMD also provided instant feedback to the participant in the
form of positive encouragement to enhance exercise adherence.
Telephone Intervention
Five telephone calls were made from the teletherapist to the participant.
Calls occurred approximately every 14 days, with the first occurring 7
to 10 days after Televisit 1. In the first call, the teletherapist
established rapport and reviewed the participant’s current exercise
regimen and current assistive technology. The teletherapist explored
any potential barriers and identified solutions to overcome these
barriers. Telephone calls 2 to 5 focused on reassessment and
advancement of the exercise program, along with reviewing participant concerns relating to their functional mobility (eg, toilet and
tub/shower transfers).
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Stroke
August 2012
UC Group
Participants randomized to the UC group were not contacted by
study personnel other than for the initial recruitment and consent,
and to obtain baseline and outcome measures. The UC participants
could receive any services provided as part of their usual VA or
non-VA care, such as home health care.
Study Measures
Dependent variables were measured at baseline, 3 months, and 6
months (3 months after the completion of the intervention) through
telephone interview by a research assistant blinded to randomization,
and through the medical record.
Primary Outcome
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The primary outcome focused on the aspects of physical function (ie,
basic activities of daily living) most directly affected by the lower
extremity exercise and adaptive strategies used in our study. We used
2 complementary primary outcome measures:
(1) The motor subscale of the Telephone Version of the Functional
Independence Measure (FONEFIM).12 The FONEFIM was developed as a telephonic alternative and yields good concordance to the
in-person, performance-based FIM.12 The motor subscale of the
FONEFIM (Motor FONEFIM) consists of 13 items encompassing 4
categories: self-care, sphincter control, transfers, and locomotion.
Each item is scored on an ordinal scale from 1 being total dependence to 7 being total independence. Possible scores range from 13
to 91, with higher scores indicating greater independence. The
scoring considers the use of adaptive equipment and/or the extent of
personal assistance or supervision required to complete the task.
(2) The Overall Function Component of the Late-Life Function
and Disability Instrument (LLFDI).13 The LLFDI is a comprehensive
measure of functioning and participation and includes 2 disablement
constructs: function and disability. In contrast to the Motor
FONEFIM, which measures independence in task performance, the
LLFDI Function Component measures difficulty with task performance. For all components and subscales (domains), the LLFDI
transforms raw scores into linear scaled scores (0 –100), where a
higher score represents better functioning.14,15
Secondary Outcomes
Secondary outcomes included the 3 subscales of the LLFDI Function
Component: upper extremity function (7 items reflecting ability to
perform activities with the hands and arms, eg, holding a full glass
of water), basic lower extremity function (14 items reflecting
activities involving standing and use of the legs, eg, stepping up and
down from a curb), and advanced lower extremity function (11 items
reflecting activities that involve a high level of physical ability and
endurance, eg, walking on a slippery surface outdoors).
Other secondary outcomes included the LLFDI Disability Component, which evaluates social roles (eg, visiting friends) and
personal roles (eg, meal preparation), and evaluates difficulty with
task performance and frequency of performance. The disability
section provides an overall score and 5 subscores (frequency of
social and personal roles, and difficulty with instrumental and
management roles). All items are scored on a 5-point ordinal scale.
Covariates
The following demographic variables were collected by patient
self-report: age, sex, race, marital status, and education. The Canadian Neurological Scale was employed to assess initial stroke
severity,16 based on review of the medical record, using Goldstein
and Chilukuri’s algorithm.17
Statistical Analyses and Sample Size
All analyses were conducted using SAS version 9.2 (SAS Institute).
Intention-to-treat analyses were used for all outcomes. Mean differences between variables at baseline were assessed using unpaired t
tests and ␹2 tests. All outcome variables were analyzed using a
mixed-model with a mixed-model analysis of variance procedure
using maximum likelihood estimation. This model presumes that the
groups have equal baseline means, which is appropriate for a RCT,
and is comparable in efficiency to an analysis of covariance model.18
This method permits estimation in the presence of missing values,19
which means that all available data are used. All participants with at
least 1 follow-up were included in the mixed-model analyses. Group,
time (month of follow-up), the group-by-time interaction, participant
age, stroke severity, and whether a participant was in a rehabilitation
bed unit, were included as predictors in each model. (Because of the
small sample size, we were not able to add other covariates to the
model.) To adjust for type 1 error and assess the overall differences
between the STeleR and UC groups during and at the end of the
study, the statistical significance for group and the group-by-time
interaction was assessed according to the change in log-likelihood.
The overall effect of group (STeleR versus UC) was evaluated by
comparing the maximum likelihood fit of the full (covariates plus
group and group-by-time interaction) models. With reference to the
total Function score of the LLFDI, with 20 subjects per group, we
projected 80% power to detect an effect size of 0.50 (translating to
an approximately 14.1% absolute difference in response rates between the groups) using a 2-sided ␹2 test with á⫽0.05. For the FIM,
given the standard deviation in our population, this would equate to
changing from using a tool or extra time rather than human help for
ⱖ2 items. Significance was accepted at P⬍0.05. A Bonferroni
correction was applied to all of the comparisons (ie, all of the
primary and secondary outcomes), which would be P⫽0.025. All the
probability values were for testing the interaction term only.
Results
Participants
Fifty-two participants met the inclusion criteria, gave written
informed consent, and were randomized. Of those 52 participants, 48 participants completed baseline assessments. The 4
participants who failed to complete the baseline assessment
(2 participants each in the STeleR and UC groups) could not
be reached via telephone to complete the baseline assessment.
Of the 48 participants who completed baseline assessments
(25 STeleR and 23 UC), 44 participants (22 participants in
each group) completed 3-month surveys (92% completion
rate), and 43 participants (24 STeleR and 19 UC) completed
6-month surveys (90% completion rate). Five participants
dropped out for the following reasons: lost to contact,
reported being too busy to complete the final outcome
assessment, or were unable to reach participant at the specified time point. One participant died before completing the
follow-up interviews. There were no differences between
dropouts and participants completing the trial. Intervention
group membership was unrelated to loss to follow-up, and
drop-outs did not differ for any of the participant characteristics in Table 1 at any of the follow-up time points. No
serious study-related adverse events occurred.
There were no significant differences between the STeleR
and UC groups at baseline (Table 1). With reference to race
or ethnicity and marital status, participants were nearly
evenly split between white (42%) and nonwhite (58%), and
married (42%) and not-married (58%). Most nonwhite participants (79%) were black, and most not-married participants
(50%) were divorced.
Change in Self-Reported Function and Disability
Primary Outcomes
At baseline, there were no differences between the 2 groups
in Motor FONEFIM and LLFDI Function scores (statistical
results not shown). The Motor FONEFIM increased some-
Chumbler et al
Table 1.
Baseline Characteristics
Variable
Men
STeleR
Intervention
n⫽25
24 (96.0%)
Usual Care
n⫽23
P Value
0.99
0.26
Race
11 (41.7%)
9 (39.1%)
Black
12 (45.8%)
10 (43.5%)
Other
6 (12.6%)
4 (17.3%)
Age (y), mean (SD)
67.1 (9.5)
67.7 (10.0)
0.84
⬍High school graduate
12 (48.0%)
6 (26.0%)
Married
10 (40.0%)
10 (43.5%)
0.98
8 (32.0%)
5 (21.7%)
0.66
Lives alone
Rehabilitation bed unit
Days since stroke, med (IQR)
Stroke severity* mean, (SD)
2 (8.0%)
26 (4150)
4 (17.4%)
2171
measures, most of the improvement occurred during the
3-month intervention period and was maintained during the
subsequent 3 months.
23 (100.0%)
White
Effects of Telerehabilitation for Stroke Patients
0.64
0.33
74 (3149)
0.52
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6.7 (1.3)
6.8 (1.4)
0.81
SIS†, mean (SD)
56.9 (10.5)
56.9 (14.8)
0.99
GDS‡, mean (SD)
8.2 (6.7)
9.4 (9.5)
0.59
STeleR indicates stroke telerehabilitation; IQR, interquartile range; SIS,
Stroke Impact Scale; GDS, Geriatric Depression Scale.
*Stroke severity is measured by the Goldstein and Chilukuri algorithm of the
Canadian Neurological Scale. A higher score indicates greater initial severity.
†SIS indicates Stroke Impact Scale 2.0, which is used at baseline to assess
self-care/mobility.
‡GDS indicates Geriatric Depression Scale; higher scores equal greater
depression.
what over time (83.5– 83.7) in the STeleR group, and it
decreased slightly (81.5– 80.9) in the UC group. This difference was not statistically significant. The LLFDI Function
total score, which focuses on difficulty with basic activities of
daily living tasks, increased from 49.5 to 54.6 in the STeleR
group, and declined from 51.7 to 50.6 in the UC group (Table
2); this difference was not statistically significant. As can be
seen in Figures 1 and 2, most of the improvement occurred
during the 3-month STeleR intervention period, and essentially was maintained during the subsequent 3 months.
Secondary Outcomes
Examination of the LLFDI Function subscales showed an
apparent treatment effect on all 3 domains, with ⱖ10%
improvement in all subscales for the STeleR group, and a
decline in function on all subscales for the UC group. One of
the 3 domains approached significance. The Basic Lower
Extremity score (items that involve the use of legs and
standing) increased from 59.0 to 64.9 in the STeleR group
and essentially remained unchanged from 61.3 to 61.1 in the
UC group (P⫽0.06). Four of the 6 LLFDI Disability subscales demonstrated a treatment effect and significantly
improved over the 6-month study period. Table 2 shows that
the STeleR intervention resulted in improvement in LLFDI
Disability measures of all measures of task difficulty (ie,
instrumental role domain, management role domain, and total
role domain), and also in 1 of the 2 measures of task
frequency (personal role frequencies). For instance, the total
role domain that considers all elements of task difficulty
increased from 53.9 to 68.0 in the STeleR group, and declined
from 62.2 to 59.5 in the UC group (P⫽0.025). For all
Discussion
Motor weakness in the lower extremities adversely affects
functional mobility, including sit-to-stand ability and the
ability to walk,15 and thereby affects mobility-related daily
tasks and social roles. Exercise and use of adaptive strategies,
such as assistive technology (eg, gait aids, bathroom aids) and
environmental modifications (eg, rails), have been found to
improve physical functioning; these are the main focus of
traditional physical rehabilitation. In fact, locomotor training,
including the use of body-weight support in stepping on a
treadmill, was not shown to be superior to physical therapistsupervised progressive exercise for stroke patients at home.20
Thus, providing home-based, exercise-oriented interventions
is very efficacious. Dovetailing with this literature, we
demonstrated that a telehealth program that taught stroke
patients how to perform functionally based exercises and
improve the interface with their environment resulted in
greater improvements in the ability to perform both self-care
and social role tasks than did UC alone. To our knowledge,
this is the largest RCT to date employing telerehabilitation
technology to improve functional outcomes for communitydwelling individuals who experienced a stroke within the past
2 years.
The LLFDI Function total score declined in the UC group,
but improved 5.1 points between baseline to 6 months in the
STeleR group. However, the time-by-treatment interaction
was not statistically significant. In addition, the Motor
FONEFIM did not significantly improve over time in the
STeleR group compared with in the UC group.21 The LLFDI
Function score measures some of the same basic functional
skills as does the Motor FONEFIM (eg, climbing stairs).
However, in contrast to the Motor FONEFIM, the LLFDI
measures self-reported difficulty performing life tasks (instrumental and management roles), so it is an excellent
complement to the Motor FONEFIM. Also, in contrast to
performance-based functional measures like the Motor
FONEFIM, the LLFDI is able to capture self-perceived
changes in physical functioning ability.
Even though the primary outcomes were not supported by
the data, the study offered substantial support for many of the
secondary outcomes. An examination of the LLFDI Disability subscales demonstrated a significant treatment effect on
all 3 task difficulty domains (total difficulty dimension,
instrumental role difficulty, and management role difficulty),
with ⱖ19% improvement in all of the LLFDI subscales in the
STeleR group, and a decline in function on all of the
subscales in the UC group. In other words, the STeleR
intervention improved participants’ ability to perform life
tasks, such as limitation in activities at home (instrumental
role domain with an example item, such as take part in a
regular fitness program) and management of social tasks that
involve minimal mobility or physical activity (management
role domain with an example item, such as take care of own
health) more than did UC. These statistically significant
improvements were similar to some of the findings from
2172
Stroke
August 2012
Table 2.
Study Outcomes Over Time By Group
Mean STeleR Group⫾SD
n
Usual Care Group⫾SD
Baseline
3 Months
6 Months
Baseline
3 Months
6 Months
P Value*
25
22
24
23
22
19
83.5⫾9.5
82.7⫾9.7
83.7⫾9.9
81.5⫾12.1
79.0⫾15.0
80.9⫾12.0
0.306
49.5⫾10.1
54.6⫾13.6
54.6⫾12.0
51.7⫾12.8
49.6⫾12.0
50.6⫾11.7
0.248
Measure
Primary outcomes
FONEFIM
Motor domain
LLFDI: function component
Overall function total†
Secondary outcomes
LLFDI: function component
Upper extremity†
64.7⫾21.2
70.1⫾19.4
72.2⫾20.6
65.6⫾17.2
64.1⫾17.8
64.3⫾19.3
0.426
Basic lower extremity†
59.0⫾13.4
65.8⫾17.2
64.9⫾13.6
61.3⫾16.8
59.1⫾18.9
61.1⫾16.8
0.062
Advanced lower extremity†
32.5⫾19.0
40.7⫾20.6
38.5⫾20.3
37.9⫾17.4
35.2⫾17.8
34.2⫾20.0
0.204
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LLFDI: disability component
Frequency dimension total†
45.9⫾8.0
45.7⫾9.0
46.9⫾8.6
46.1⫾9.2
44.8⫾9.5
45.0⫾7.8
0.248
Social role frequency†
42.0⫾12.9
43.1⫾10.6
42.1⫾9.7
43.0⫾8.0
41.7⫾11.3
41.4⫾10.3
0.224
Personal role frequency†
47.6⫾10.8
50.2⫾15.3
49.6⫾18.1
49.2⫾14.8
45.8⫾14.2
47.2⫾11.9
0.025
Difficulty dimension total†
53.9⫾21.5
67.9⫾22.3
68.0⫾16.6
62.2⫾15.3
58.8⫾22.3
59.5⫾17.7
0.025
Instrumental role difficulty†
52.5⫾21.5
66.6⫾24.0
68.1⫾13.2
61.2⫾15.9
56.0⫾20.0
58.0⫾18.7
0.031
Management role difficulty†
64.1⫾24.4
76.4⫾21.1
79.3⫾19.1
73.3⫾22.6
74.3⫾25.8
69.4⫾19.9
0.024
FONEFIM indicates Telephone Version of Functional Independence Measure; LLFDI, Late-Life Function and Disability Instrument.
*Omnibus P value provides the overall differences between groups at the end of the study for group and group-by-time interaction assessed according to the change
in log-likelihood on 2 degrees of freedom. The intercepts were the random effects in the mixed model. The baseline values were not added to the models and the
likelihood ratio test includes only the interaction term. The P values are corrected with the Bonferroni criterion.
†Higher scores indicate higher levels of functioning and/or fewer limitations.
Ouellette et al,15 who used the LLFDI to evaluate the efficacy
of supervised, high-intensity progressive resistance training
on function and disability for long-term stroke survivors. The
changes in the intervention on the measures pertaining to task
difficulty were not only statistically significant, but were
clinically meaningful as well. The LLFDI change scores
associated with minimal clinically important difference were
7.8 for Disability difficulty (limitation) domains; the study
exceeded both for the total score and the subscales.14 We note
that 1 of the 2 Disability frequency of performance scores
(frequency for activities such as meal preparation and money
management) significantly improved in the SteleR group
compared with in the UC group, but the amount of change
was modest and may not be clinically meaningful. There was
no significant change seen in the Disability score of frequency of performance for social roles (eg, visiting friends).
This is not surprising, as our intervention focused on physical
skills and activities inside the home. Moreover, it seems
self-evident that frequency of activities in general, and social
and personal activities in particular, would be strongly
influenced by factors other than physical ability alone (eg,
routines for meal preparation, financial needs, personal preferences for social contact).15 Indeed, Keysor and Jette22
suggested that both psychosocial and environmental factors
may drive the positive consequences of improved physical
abilities on Disability outcomes.
Figure 1. Change in Motor FONEFIM Score
over time. FONEFIM indicates Telephone Version of Functional Independence Measure;
STeleR, stroke telerehabilitation.
Chumbler et al
Effects of Telerehabilitation for Stroke Patients
2173
Figure 2. Change in LLFDI Function Score
over time. LLFDI indicates Late-Life Function
and Disability Instrument; STeleR, stroke
telerehabilitation.
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The present study had some limitations. First, our study
was conducted at 3 VA medical centers. Given that VA
patients are mainly men, older, and have more comorbid
conditions than does the general US population, our findings
may not be generalizable. For instance, women have frequently more difficult social circumstances after a stroke
because they are more likely to be living alone. However, the
present study did include a sizable proportion of unmarried
men that could help balance this potential sex bias. All study
participants had to be deemed competent to provide informed
consent, and we excluded stroke survivors who could not
successfully follow a 3-step command; this, in effect, excluded patients with significant receptive aphasia. Thus, we
do not know what added challenges might be present in
applying the intervention to stroke survivors with receptive
aphasia or other cognitive deficits. Although stroke rehabilitation services provided by the Veterans Health Administration are similar to those supported by Medicare, translation to
a non-VA medical center setting may present new challenges
for successful implementation, given the VA medical center’s
strong telehealth infrastructure and presence of a seamless
medical care continuum; this is well-supported by electronic
medical records. Some of the challenges related to the
implementation of this intervention pertained to variable
infrastructure of technology in the home (eg, availability of
high-speed internet), issues pertaining to information security
when using the internet for telecommunication, and technological needs for accurate real-time televideo imaging of
movement. These challenges are directions for future research. To compensate for some of these issues, we employed
a combination of store & forward technology (ie, videotaping
all encounters) in the event of technological issues affecting
the accuracy with the live 2-way video. This approach
ensures patient confidentiality and can be employed irrespective of the technology infrastructure.23
In sum, with reference to this group of predominantly
older, veteran stroke survivors who were men, the STeleR
intervention significantly improved physical function. Most
of the improvement on the measures occurred during the
3-month intervention window and essentially were maintained during the subsequent 3 months. STeleR has potential
to be a useful supplement to traditional poststroke rehabilitation, given the limited resources available for in-home
rehabilitation for stroke survivors. Many individuals with
stroke have serious challenges traveling to a facility for their
care because either they cannot drive or their informal
caregiver cannot take extended time off work to travel to the
main hospital.24 Telehealth-based programs similar to STeleR
could be an important way to overcome these access barriers
and may be particularly useful for reaching vulnerable patient
groups, such as individuals from a lower socioeconomic
status and those who live in a rural area. STeleR may also be
more readily integrated into clinical practice than are faceto-face programs. Findings from this study could lead to
improved methods for functional assessment and more effective and efficient rehabilitation strategies, and could support
the implementation of more efficient and effective approaches to coordination of care when transitioning from
hospital to home. Even though our novel intervention employed research staff for the home visits, we believe that it
has ready application to real-world scenarios. For example,
home health personnel already in the home, such as skilled
nurses or even certified nurse aids, might use the technology
to communicate efficiently with centrally located rehabilitation personnel. Within the Veterans Health Administration,
telehealth technologists are now employed in peripheral
clinics to facilitate telehealth clinics. In addition, the telehealth technologists may be able to facilitate home telehealth
visits.
Acknowledgments
The opinions contained in this article are those of the authors and do
not necessarily reflect those of the US Department of
Veterans Affairs.
Sources of Funding
This research was supported by the Department of Veteran Affairs
Rehabilitation Research and Development Service (B4492R).
Disclosures
N.R.C. discloses a research grant from the VA Office of Rural
Health for ⬎$10 000. No potential conflicts of interest exist for the
remaining authors.
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Stroke. 2012;43:2168-2174; originally published online May 24, 2012;
doi: 10.1161/STROKEAHA.111.646943
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