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NEW Stroke Rehabilitation Planning for Optimal Care Delivery
NEW Stroke Rehabilitation Planning for Optimal Care Delivery

6. Virtual Stroke Rehabilitation

Notes

In-person stroke rehabilitation should be prioritized when possible, and virtual stroke rehabilitation should be considered a viable option when appropriate for an individual situation, the goals of therapy, and current health and functional status. 

These recommendations are based on the premise that stroke rehabilitation can be provided through virtual technology at any stage along the care continuum, alone or in combination with in-person formats (i.e. hybrid) and for a range of intended goals. Virtual stroke rehabilitation has been shown to safely and effectively increase access to rehabilitation therapies and care providers, community reintegration, home monitoring, as well as support mental health and activities of daily living. Virtual healthcare delivery has been shown to enable timely and cost-efficient access to best-available stroke rehabilitation regardless of where the person with stroke is located. For the purposes of these recommendations, virtual stroke rehabilitation will include both fully virtual and hybrid formats.

Recommendations and/or Clinical Considerations
6.1 Access and Eligibility for Virtual Stroke Rehabilitation
6.1.1 Access to Stroke Rehabilitation through Virtual Care Modalities
  1. Virtual stroke rehabilitation should be considered as a reasonable alternative for eligible individuals with stroke when an in-person therapy session is not feasible or available, or as an adjunct when the goals of the session can be achieved virtually [Strong recommendation; Moderate quality of evidence].
  2. Virtual care modalities should be integrated into stroke rehabilitation planning and service delivery across the continuum (i.e., from acute care to stroke prevention, stroke rehabilitation, home-based therapy, and ambulatory care) to support optimal recovery of individuals with stroke, provide support for families, and ensure equitable access to care throughout Canada [Strong recommendation; Moderate quality of evidence].
  3. All rehabilitation disciplines should consider the use of virtual care technology for assessment of individuals with stroke and for delivery of clinical therapies (e.g., exercise monitoring and intensity adjustments, speech and language therapies for aphasia) where appropriate [Strong recommendation; Low quality of evidence].
  4. Home-based monitoring for outpatient stroke rehabilitation through web-based applications may be considered as an alternative or adjunct to in-person rehabilitation therapy sessions when frequent monitoring is necessary and access to in-person services is limited [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Stroke Systems of Care module for additional information.

Section 6.1.1 Clinical Considerations

  1. Clinicians should consider the current health status of the individual with stroke (e.g., cognitive, communication, physical, and sensory abilities), behavioural factors, and available resources, to determine the safety and appropriateness of virtual stroke rehabilitation. Refer to Heart & Stroke Virtual Care Decision Framework for additional information.
  2. Clinicians should consider individual preferences when an individual with stroke is eligible for both virtual and in-person stroke rehabilitation, and the clinician is able to offer either one or a combination of both options.
  3. Clinicians should develop a safety or adverse events plan with the individual with stroke prior to starting virtual stroke rehabilitation. This includes having the individual’s phone number, address, and emergency contact information, and asking them to have a family member or caregiver nearby and/or a phone at hand. Refer to CSBPR Virtual Stroke Care Toolkit for additional information.
  4. The benefits of virtual modalities may extend beyond therapy activities and could support other rehabilitation functions such as transitional planning, education and skills training, and peer support.
6.1.2 Eligibility for Virtual Rehabilitation
  1. All individuals with acute stroke admitted to hospital should be assessed to determine the severity of their stroke, their early rehabilitation needs, and the most appropriate mechanism to deliver timely and effective stroke rehabilitation, whether in-person, virtual, or a hybrid (a combination of in-person and virtual modalities) model [Strong recommendation; Moderate quality of evidence]. Refer to Section 1 for additional information.
  2. All individuals with acute stroke who are not admitted to hospital should be screened in-person or using virtual healthcare modalities for the need to undergo a comprehensive rehabilitation assessment to determine the scope of deficits from the index stroke event and any potential rehabilitation requirements [Strong recommendation; Low quality of evidence].
  3. Clearly defined criteria and protocols should be available to help referring sites determine when and how individuals with stroke can access virtually delivered services, including stroke rehabilitation, secondary stroke prevention, and ambulatory services [Strong recommendation; Low quality of evidence]. Refer to Heart & Stroke Virtual Care Decision Framework for additional information.
6.2 Assessment and Service Delivery for Virtual Stroke Rehabilitation
6.2.1 Assessment
  1. Where available, tools selected for assessment of impairments, activity limitations, participation restrictions, and environmental factors relevant to stroke rehabilitation should have evidence of validity for the method of virtual administration and be administered by trained personnel [Strong recommendation; Low quality of evidence]. 
    1. Assessment tools selected for use via videoconferencing should have evidence of validity for this administration method [Conditional recommendation; Low quality of evidence] 
    2. Assessment tools selected for use via telephone should have evidence of validity for this administration method [Conditional recommendation; Moderate quality of evidence].
  2. Screening for pre-stroke mental health and cognitive status and for changes in mood or cognition following stroke should be included as a routine component of virtual stroke rehabilitation [Strong recommendation; Moderate quality of evidence].
  3. For individuals with stroke who have cognitive, sensory or communication impairments (such as aphasia or vision loss), assessment tools should be adapted for use through virtual modalities, as required [Strong recommendation; Low quality of evidence].

Section 6.2.1 Clinical Considerations

  1. There is limited published evidence on the safety, feasibility, reliability, and validity of approaches to administering standardized assessment tools post-stroke using virtual rehabilitation platforms or technologies. Safety precautions should be taken during virtual performance-based health assessments. Refer to Heart & Stroke Virtual Care Decision Framework for additional information.
    1. Healthcare professionals should receive training on the administration of virtual performance-based assessment tools to optimize validity and safety.
    2. Assessment considerations may include ensuring the individual with stroke has sufficient capacity to follow instructions, access to handholds to maintain balance, and a support person present to assist. 
    3. Healthcare professionals should provide instructions to individuals with stroke and their families and caregivers on how to prepare the home environment to ensure safe participation in assessment and therapy activities.
  2. When assessment tools cannot be fully administered virtually, a hybrid model that combines in-person and virtual assessment should be considered. 
    1. Where possible, timed assessment tools should be administered using a consistent method, either virtual or in-person. It is not advisable to directly compare timed data from assessment tools administered in-person and virtually, for the same individual, due to lag times.  
  3. Self-reported measures of rehabilitation outcomes, which are typically evaluated using performance-based assessment tools, may be feasible and useful to integrate when in-person assessment is not available. 
  4. Motivation and mood may influence engagement of the individual with stroke during virtual and in-person stroke rehabilitation sessions.
6.2.2 Service Delivery
  1. Outpatient stroke rehabilitation services, whether delivered using virtual modalities alone or a hybrid model, should offer the same elements as coordinated, in-person rehabilitation services [Strong recommendation; Moderate quality of evidence]. Refer to Section 4 for details. 

Refer to Stroke Systems of Care module for additional information on Virtual Care Principles.

Rationale +-

Virtual stroke rehabilitation refers to the use of information and communication technologies to deliver rehabilitation services from a distance, often using video or telephone conferencing. Virtual stroke rehabilitation supports equitable and timely access to optimal stroke services across geographic boundaries and improves communication and networking and enables better access to stroke expertise, regardless of the location of the individual with stroke or the treating hospital, facility or healthcare provider. The most familiar application of virtual stroke rehabilitation is the provision of therapies provided by physiotherapists, occupational therapists and speech-language therapists or their assistants that mimic in-person interactions and are provided synchronously (real time) over weeks or months, as required. Virtual stroke rehabilitation can also be used for other purposes including assessment, counselling and support, and education. One of the key advantages of virtual stroke rehabilitation is that it provides opportunities for individuals who live in isolated or rural communities across Canada to access specialized rehabilitation services reducing or eliminating transportation challenges that are commonly encountered by individuals who have had a stroke and their caregivers. 

Individuals with stroke have emphasized that virtual stroke rehabilitation enables increased and more equitable access to care and resources, especially when access to in-person services may not be available or feasible. The decisions surrounding the use of virtual stroke rehabilitation may depend on the type of therapy being provided, comfort level of the individual receiving care with virtual modalities, familiarity and skill level of the healthcare provider with virtual modalities, and safety cautions that need to be considered. Equitable access to necessary infrastructure, such as internet connections and technology is also a factor. The potential challenges for those engaging in virtual stroke rehabilitation have been identified as discomfort with use of technology and low digital literacy, being unfamiliar with what virtual care is and how it can be used, as well as cognitive and/or visual changes that may increase difficulty of participating in virtual rehabilitation. These recommendations emphasize the need for education about virtual care and training on the use of technology for both individuals with stroke, family and caregivers as well as healthcare providers delivering their care. 

There is value in having a support person with individuals when participating in virtual stroke rehabilitation to help with technology, remember information, support and enhance safety, aid movements, and provide encouragement. While having a support person may not be possible for everyone, healthcare professionals are encouraged to consider the impact this may have on those participating in a virtual visit. 

It is recognized that, for a variety of reasons, virtual care may not be appropriate for some individuals or certain session goals.  There is a need for joint decision-making between the individual with stroke and their healthcare team to determine the most appropriate way forward, whether that be virtual, in-person, or a hybrid model, which also considers issues of safety and privacy, and use of secure systems for teleconferencing and information storing.

Performance Measures +-

System indicators:

Virtual stroke rehabilitation is an emerging field. It is critically important that mechanisms be established to collect consistent high-quality data to inform planning and improvement and provide evidence for quality and sustainability. Virtual care should be considered as one modality in the delivery of stroke care.

Jurisdictions may consider using one or more of the following indicators to monitor virtual care services:

Health system and clinical indicators (please refer to Quality of Stroke Care in Canada Key Quality Indicators and Stroke Case Definitions for more details)

  1. Proportion of individuals with stroke who receive access to stroke rehabilitation through virtual healthcare modalities for assessment and/or management.
  2. Number of scheduled rehabilitation appointments for individuals with stroke accessing rehabilitation services through virtual healthcare modalities, with values reported separately for each service accessed (e.g., physiotherapy, speech therapy).
  3. Cost effectiveness of virtual stroke rehabilitation compared to in-person stroke rehabilitation.
  4. Rural and remote settings increased access to stroke rehabilitation services through virtual modalities.

Process indicators:

  1. Median time from referral for virtual stroke rehabilitation to first virtual stroke rehabilitation encounter.
  2. Median time from stroke onset to rehabilitation referral for: 
    1. Inpatient stroke rehabilitation
    2. Ambulatory stroke rehabilitation
    3. Virtual stroke rehabilitation 
  3. Proportion of individuals with stroke who underwent a virtual care session indicated by the presence of the virtual care consultant’s note in the person’s health record.
  4. Median duration of scheduled virtual stroke rehabilitation encounters, with values reported separately for each service (e.g., physiotherapy, speech therapy). 
  5. Proportion of virtual stroke rehabilitation encounters requiring urgent transfer of individual with stroke to an in-person healthcare visit.
  6. Proportion of virtual stroke rehabilitation encounters disrupted by technical difficulties by the healthcare provider.
  7. Proportion of virtual stroke rehabilitation appointments provided using synchronous two-way video conferencing compared to by telephone only.

Patient-oriented indicators:

  1. Patient-reported experience with virtual stroke rehabilitation related to attributes such as feasibility, satisfaction, quality, sound, visual clarity, reliability of technology, and ease of use.
  2. Patient-reported experience of their safety during virtual stroke rehabilitation encounters, including prevention of risks associated with virtual stroke rehabilitation.
  3. Proportion of virtual stroke rehabilitation encounters that included family members and/or caregivers who were in a different location from the individual with stroke. 
  4. Changes in functional status from start of virtual stroke rehabilitation compared at 3 months, 6 months and one year post start.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List

Virtual stroke rehabilitation, also known as telerehabilitation, refers to the use of information and communication technologies to deliver rehabilitation services from a distance, often using video or telephone conferencing. The most familiar application of stroke telerehabilitation is the provision of therapies that mimic face-to-face interactions, which are provided synchronously over weeks or months, as required. Remote interventions, monitoring, evaluation and education can also be provided in asynchronous forms, using a variety of technologies. One of the key advantages of telerehabilitation is that it provides the opportunity for individuals who live in isolated or rural communities access to specialized rehabilitation services, which would otherwise be unavailable to them. Furthermore, telerehabilitation reduces or eliminates transportation problems that are commonly encountered by stroke survivors and their caregivers.

The results from a rapidly expanding volume of literature suggests that virtual stroke rehabilitation can be both feasible and effective compared with in-persons encounters.  The authors of recently published systematic reviews examining remotely delivered therapy reported that measures of balance, upper and lower extremity motor function, mobility, and performance of activities of daily living, were not significantly different compared to those of persons receiving conventional rehabilitation, and in some cases, were superior.59-64 In the 2020 Cochrane review,60 virtual care was also used successfully to treat persons with speech and language impairments and low mood post stroke. Knepley et al.65 reported that functional outcomes among those that received virtual stroke rehabilitation were equivalent or better compared with those that received in-person therapy, as was patient satisfaction. Additionally, some virtually provided therapies were less costly than in-person therapy.  

Several recent RCTs have examined virtual therapies for both upper and lower-limb rehabilitation. Late-Life Function and Disability Instrument scores were improved in both the virtual care group and the usual care group that received standard rehabilitation therapies, following hospital discharge in the Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial in which 124 patients were randomized to receive 3 months of physiotherapy (PT) and occupational therapy (OT) via a tele-rehabilitation system using an iPad based system to provide exercises 5 days a week.66 In the Augmented Community Telerehabilitation Intervention (ACTIV) trial, 67 a structured 6-month program using face-to-face sessions, telephone contact, and text messages to augment stroke rehabilitation was compared with usual care. The ACTIV focused on two functional categories: “staying upright” and “using your arm” and was provided to patients with a stroke occurring an average of 6 months previously, by physical therapists. There were improvements in both groups in the physical subcomponent of the Stroke Impact Scale (SIS 3.0), the primary outcome at 6 months, and the SIS subcomponents, with no significant differences between groups. The outcomes of patients who received virtual rehabilitation services have also been shown to be better than those who received conventional outpatient therapy. The Fugl-Meyer Assessment scores of patients who received a 12-week telerehabilitation program were significantly higher compared to those who received the same duration of outpatient therapy. 68 In the same study, telerehabilitation was found to be non-inferior for the modified Barthel index.

Adaptation of existing rehabilitation programs may offer alternative solutions to in-person therapy. Yang et al. 69 provided a virtual version of the Graded Repetitive Arm Supplementary Program (GRASP) over 10 weeks, to 9 persons with residual difficulty using their affected upper extremity following remote stroke. There were significant improvements over time for all outcome measures, which included the Arm Capacity and Movement test (ArmCAM), a new assessment tool developed for online use.

Assessment of performance-based measures in a virtual setting has not been well studied and poses challenges. Some previously validated outcome measures may not be appropriate, feasible or valid for virtual use. It remains to be determined whether new assessment tools will need to be developed and validated for virtual use. In some cases, adaptation of an existing measure may be sufficient. For example, Peters et al.70 developed a version of the Fugl-Meyer (FM) assessment, suitable for virtual care use (FM-tele) and demonstrated its feasibility. In addition, although the sample size was small (n=5), the proportional agreement between the FM-tele conducted in person and conducted remotely by the same assessor, one week apart, was good. Both individuals with stroke and assessors reported some issues with technical difficulties, a common complaint when using virtual platforms. Inter-rater reliability of the Balance Scale, Fugl-Meyer Assessment and the Action Research Arm Test has been shown to be good to excellent when comparing in-person assessments with those conducted virtually through videoconference.71, 72

Sex & Gender considerations

Research in this area is sparse. Older women may have less experience with technology or feel less comfortable using digital platforms for rehabilitation, which can hinder their participation in virtual programs. Men may potentially be less likely to seek out virtual rehabilitation support, leading to underutilization of digital resources. Additionally, men may experience challenges with technology due to lower levels of digital literacy and may be less likely to ask for help when they encounter difficulties. Virtual rehabilitation may not address gender-specific needs such as emotional or psychological support, often more prevalent in women, who may experience higher levels of post-stroke depression and anxiety. Virtual platforms that don’t incorporate an interactive element, thereby decreasing social interaction, may negatively affect women to a greater extent, since they generally place a high value on community and relational support.

Stroke Resources
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