Telemedicine for Stroke Care and Rehabilitation
While the COVID-19 pandemic increased the use of telemedicine in stroke care, a version of it, known as telestroke, has been around for decades.
The COVID-19 pandemic changed how much of healthcare was delivered in the United States, including some aspects of stroke care. Telemedicine, in which doctor and patient communicate via telephone or video conference, allowed stroke patients and their doctors to continue meeting for post-stroke rehabilitative and preventive treatment visits.
According to Lee Schwamm, MD, director of the Massachusetts General Hospital (MGH) Center for TeleHealth and vice president of virtual care for Mass General Brigham in Boston, "Telehealth was predominantly a small or boutique practice for most hospitals prior to COVID-19, but once the pandemic hit, we pretty much shut the door to most patients. Telehealth was an amazing opportunity to continue patient care virtually.”
Dr. Schwamm reports that the MGH neurology department went from seeing less than 1 percent of their patients via telehealth visits before the COVID-19 pandemic, to 90 percent in the first two months of stay-at-home orders. The department is still seeing around 60 percent of patients, many of them stroke survivors, virtually.
But even before the pandemic, one type of remote stroke care was already well-established: In-hospital telemedicine for stroke care, called telestroke, has been around since the late 1990s, and according to Schwaam, the practice has remained relatively unchanged for decades.
Telestroke describes an arrangement by which remote stroke experts help local emergency physicians assess patients with suspected stroke and decide how to manage their care. The practice raises the likelihood that people experiencing stroke will receive appropriate care, even if they don’t go to a hospital with its own on-call stroke team.
According to a study published in May 2020 in JAMA Neurology, around 27 percent of short-term acute hospitals and critical access hospitals in the United States had adopted a telestroke program by 2017.
Telestroke Brings Experts Into Hospitals That Need Them
Telestroke was originally developed as a way to bring stroke experts into acute care hospitals, often in rural and low-income areas, that otherwise wouldn’t have access to specialists on site. This is still a primary focus of telestroke programs today.
A report published in July 2019 in JAMA Neurology found that less than 40 percent of the roughly 4,500 U.S. hospitals included in the study were stroke-certified between 2009 and 2017. Hospitals in low-income communities were the least likely to be certified.
Video telestroke assistance can start in the ambulance, which allows teams of specialists to start evaluating a patient before they have reached the hospital. Starting the evaluation as soon as possible is important, because acting fast to treat the cause of the stroke — most commonly a blood clot that has traveled to the brain — is a crucial factor that determines how badly a person will be impacted by the stroke, says Bart Demaerschalk, MD, a professor of neurology at Mayo Clinic College of Medicine and medical director of Mayo Clinic Telestroke in Rochester, Minnesota.
Once a patient arrives at the hospital, an emergency department team can virtually access an on-call stroke expert who directs the care team in the assessment, which often includes analyzing images of the affected area and recommending a treatment, such as clot-busting medication or surgery.
“At the end of our call, we discuss the level of care necessary for the patient beyond that consultation. If the patient needs care beyond what the hospital can provide with their resources, we make recommendations for transfer for the nearest stroke center,” says Dr. Demaerschalk.
In a 2016 scientific statement on telemedicine for stroke, published by the American Heart Association (AHA), Demaerschalk and his colleagues note that while telestroke experts can usually walk a healthcare professional through administering clot-busting drugs, telestroke does not provide ongoing patient care. In-hospital telestroke assistance is only for helping the medical team treat acute stroke. Patients who suffered a severe stroke will usually still need to be transported to a stroke center, says Demaerschalk.
Still, the Mayo Clinic’s telestroke program has reduced unnecessary ground and air transfers of stroke patients to stroke centers by 60 percent, something Demaerschalk says cuts back on healthcare costs, supports community hospitals, and allows many patients to remain close to their support network during recovery.
Pandemic Lowering Barriers to At-Home, Post-Stroke Care
A person who survives a stroke typically needs ongoing care for some period of time following the initial hospitalization. Such care might include treating the underlying conditions that led to the stroke, such as high blood pressure, high cholesterol, cigarette smoking, and heavy alcohol or drug use. It will also likely include various forms of rehabilitation, such as physical therapy and speech therapy. And it may include psychotherapy to deal with depression following a stroke.
"Having a stroke means different things to different patients, and people have different needs based on the type and severity of their stroke,” says Steven C. Cramer, MD, a professor of neurology at UCLA and director of research at California Rehabilitation Institute in Los Angeles, who notes that the healthcare system should provide a more tailored approach that considers factors such as a patient’s mobility when deciding the best way to carry out aftercare.
Dr. Cramer is also a consultant for TR Care, a private company working on ways to improve stroke recovery through telerehabilitation.
Telemedicine is one way to more easily get care to people with compromised mobility following a stroke. Telemedicine also allows stroke survivors to access experts from across the world who are best suited to address their medical concerns, which may change throughout the recovery process.
According to Schwamm, a combination of in-person and virtual aftercare visits may be the best option for some patients. He says that, altered by the pandemic, the current mixed model is serving as an experiment for how stroke aftercare could look moving forward.
However, up until the past year, health insurance coverage has been one of the biggest hurdles in making telemedicine for stroke care widely available throughout all phases of stroke treatment and recovery. According to Demaerschalk and the 2016 AHA statement, insurance companies have traditionally rarely covered telemedicine.
The COVID-19 pandemic has temporarily changed this, and some stroke experts say that making this change permanent is a key factor in expanding access to remote stroke care.
"That is the vision that we ought to embrace here — how can we make the routine care that requires a lot of commitment and patient engagement much easier to access,” says Schwamm. "Our system needs to become more adaptable to variation across patients."
Telerehabilitation as Good as In-Person Rehab
Some recent studies support the use of virtually delivered, home-based rehabilitation therapy.
A small study published in September 2020 in the journal Neurology compared two methods of delivering physical therapy to stroke survivors in China. For 12 weeks, half of the 52 participants did motor skills training through a telerehabilitation program, while the other half did in-person group physical therapy. All patients had hemiplegia, meaning they were paralyzed on one side of their body. The researchers found that participants in the at-home group had a greater increase in motor function when compared with those who were seen in-person.
According to Cramer, this could be due to the fact that at-home programs allow patients to spend more time repeating a movement throughout the day than they would during an hour-long, in-person session.
In his randomized clinical trial, published in June 2019 in JAMA Neurology, Cramer evaluated the efficacy of a telerehabilitation system when compared with traditional in-person stroke rehabilitation. The gamified system focused on regaining arm movement in stroke survivors who had developed motor skills deficits, an occurrence that affects 80 percent of people who have had a stroke. His team found that people who trained via the telerehabilitation program for 30 days were able to achieve the same results as those who trained in person.
In addition, patients who participated in telerehabilitation therapy attended 5 percent more sessions than those assigned to attend out-of-home sessions.
“Animal studies say you need at least 700 practice movements per day to really change how the brain works. Our primary focus was getting people to do hundreds of movements per day, whereas research suggests they’re likely to only be getting 32 per day during in-person therapy,” says Cramer. "If we can build brain plasticity, we can get a higher level of function in the areas that suffered the stroke.”
TeleRehab Can Deliver Multiple Types of Therapy
In addition to gamified exercises meant to help stroke survivors regain physical and mental functioning, the system tested by Cramer’s team provided stroke education, video conferencing with medical professionals from different specialties, and data collection that can be customized for each person.
"We think of rehab involving occupational, speech, and physical therapy, but it’s a complicated affair. There are all kinds of things that a rehabilitation doctor cares about other than regaining mobility. That's why with telerehab, our aim is to take a holistic approach,” says Cramer, who notes that nutritionists, cardiologists, psychologists, physical, speech and occupational therapists, and neurologists all play an important role in a person’s post-stroke health.
"Aftercare also focuses on preventing another stroke, because no matter how bad a patient's situation is, it will always be worse if they have another stroke," Cramer says.