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The present and future of telemedicine in stroke care and rehabilitation Content Outline

Introduction

Stroke care, current therapies and access to neurological expertise

Stroke care in remote areas

Telemedicine and stroke care (Telestroke)

Case Study of Video Teleconferencing Communication (VTC)

Telemedicine and neurorehabilitation

Cost Effectiveness of Telestroke

Conclusions

The present and future of telemedicine in stroke care and rehabilitation Remote telemedicine consulting via real-time audio-visual streaming is gaining popularity in areas with populations deprived of enhanced clinical medical care expertise. Benefits of telemedicine include diagnosis and management of an array of neurologic disorders particularly stroke. Remote teleconferencing is also beneficial in rehabilitation of patients recovering from stroke following discharge from the acute care hospital. Stroke Care The past decades witnessed remarkable developments in the diagnosis and management of stroke. Major breakthroughs have been achieved in our

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understanding and management of stroke risk factors, the introduction of intravenous tissue plasminogen activator (tPA) for management of selective patients with acute ischemic stroke, and modern acute stroke care units1. With further improvements in technology, selected stroke patients have also benefited from advanced interventions such as angioplasty, stenting, carotid endarterectomy, and enabled increased access to acute stroke services through video teleconferencing (VTC) programs. Levine and Gorman2 were the first to introduce the term telestroke using telemedicine in the form of VTC to support acute stroke intervention. Specialists employ dedicated, high-quality, interactive, bidirectional audiovisual systems through this kind of VTC, also known as high-quality videoconferencing (HQ-VTC) techniques to assess patients remotely and review imaging. Our improved understanding of mechanisms of brain injury, repair, plasticity, and recovery has translated in improved stroke treatments and evolution of stroke care systems has led to better hospital preparedness. From 1997 to 2007, These developments may have contributed to a 44.8% decrease in the stroke death and 14.7% decline in absolute stroke deaths in United States from 1997 to 20073. In 1996, the Food and Drug Administration (FDA) approved the use of intravenous rtPA for the treatment of acute ischemic stroke (AIS) patients within 3 hours of last known well time. This resulted in a reduction of long term stroke morbidity in treated patients4. However, the need to administer intravenous rtPA within a narrow time window still hampers its widespread use 5, 6. Moreover, many hospitals, particularly in rural or remote areas, do not yet meet required standards in terms of available stroke resources, protocols and expertise for effective treatment of AIS with intravenous rtPA 7. In fact, the number of AIS patients receiving intravenous rtPA is still reported to be fewer than 5% in even after the US FDA approval8. Factors influencing patient access to stroke care and rtPA administration relate mainly to geography and available resources 9, 10. Furthermore, risk factors for stroke are more prevalent in these rural and remote areas of the United States rendering these regions particularly vulnerable 11, 12. Despite that several key organizations, including The Joint Commision (TJC), the Brain Attack Coalition (BAC) and the American Stroke Association (ASA), have thus provided guidelines for the development of Primary Stroke Centers (PSCs), it is estimated that nearly 135 million Americans live more than 1 hour away from the nearest PSC13. The remaining 40% live in counties with hospitals that have given rtPA to less than 2.4% of AIS patients14. Administering intravenous rtPA within 3 hours from onset of stroke symptoms has other limitations as well. Not all stroke patients can be seen by a neurologist within this timeframe, as most patients arrive with less than 60 minutes remaining in the 3-hour treatment window. Even though it is not mandatory that every stroke patient be seen by a neurologist, guidance from experienced stroke physicians has been associated with more appropriate rtPA use as decisions influencing selection criteria and neuroimaging interpretation may be complex15,

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16. There is evidence to suggest that optimal administration of intravenous rtPA for stroke patients can be much improved if hospitals comply with required PSC standards and treatment protocols that include appropriate stroke expertise17. However, wake-up strokes account for about 14% of ischemic strokes and are typically ineligible for thrombolytic therapy due to the current time-window restrictions18. However, ongoing research protocols are evaluating patients up to 12-hours (or even 24 hours in selective cases of basilar artery occlusive disease), post stroke symptom onset. These efforts may benefit patients with wake-up stroke. Telestroke Care in Remote Areas South Carolina tops the list of States for stroke incidence and mortality rates, particularly among African-American patients and has been labeled as the epicenter of the “Stroke Belt.” 19-23. Given this background, the Department of Health and Environmental Control was asked by the South Carolina legislature to develop an organized stroke system of care (South Carolina Legislature1). This initiative was influential in developing and establishing a system to treat stroke acutely with appropriate use of intravenous rtPA and moreover, it extended its support for further development the Remote Evaluation of Acute Ischemic Stroke-Medical University of South Carolina (REACH MUSC). The REACH MUSC has improved access to acute stroke care for the general population and specific vulnerable segments of the population of South Carolina19-23. A second stroke telemedicine network is the Remote Presence (RP) system (InTouch Health, Santa Barbara, California, USA) whereof staff at emergency department calls a toll-free number to activate the network, thus alerting the on-call hub stroke expert who connects via the Internet to a RP robot that is completely controlled remotely24. The on-call hub stroke expert utilizes a two-way audio/video device that has the capability to conduct a neurological assessment of the patient. The device can also be used to zoom in on the information that is displayed on monitors and allows direct interaction with the family and the medical staff 25, 26. Similar research has been conducted by the tri-state (North Carolina, South Carolina and Georgia) stroke network (TSSN) and the Centers for Disease Control and Prevention (CDC) in Atlanta. The TSSN and CDC previously determined that access to rtPA treatment was inadequate in the rural coastal plains. Estimates indicated that the population in the tri-state region had access to rtPA treatment within 30 min to 1 hour of stroke symptom onset. Therefore, access to a PSC was 30-minute drive for only a half of the population of NC, SC, and GA, while only 23% of rural residents had any access to a PSC27. Telehealth, Telemedicine, and Telestroke Telehealth is a general term applied to all forms of health information exchange and interaction that utilize advanced technology and communication systems such as the internet and cellular broadband. This includes long-distance learning and healthcare provision. Telemedicine is not a treatment modality, but rather a subdivision of telehealth methodology used to facilitate healthcare. Telemedicine allows providers to perform medical procedures or examinations and review

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data remotely including facilitating interactions between patient and provider and multiple providers. Telemedicine can be an especially helpful tool in time-sensitive medical emergencies such as acute ischemic stroke whereby video-conferencing equipment can be used to perform a real-time teleconsultation. Without much proficiency required on-site, telestroke has emerged as an effective delivery model for stroke specialist care to remote hospitals. However there are still a few implementation barriers due to up-front costs of initial acquisition and installation of telestroke equipment and training of practitioners and ambiguous patterns of reimbursement29. Surveys conducted among stroke specialists and emergency physicians suggest that telestroke can be an effective way to bridge geographical barriers to stroke expertise and may be superior to telephone consultation. Nevertheless, cost analysis of telestroke compared to usual care indicates that long-term outcomes and resource utilization far outweigh the estimated ambiguities resulting from short-term costs. For example, the intravenous use of TPA reduces neurological disability, and telestroke programs are associated with increased use of TPA utilization30. The combination will likely continue to improve neurological outcome in stroke patients geographically outside the reach of PSC’s. In addition, telestroke can offer a more comprehensive stroke care beyond the acute thrombolysis phase, and has the potential to improve research efficiency. Studies have shown that the National Institutes of Health Stroke Scale (NIHSS) can be reliably performed via telestroke.9, 34,35, 36. A randomized single blinded prospective trial of telephone-only consulting compared to real-time audio-video streaming demonstrated that acute stroke treatment decisions were adjudicated to be made correctly more often in the telemedicine group than the telephone-only group (98% vs. 82%)8. Video telemedicine was also more sensitive and specific than telephone only and improved the determination of thrombolysis eligibility8. Case Study of VTC Utilization Schwamm31 described a study program set up at a hospital remotely located with access to stroke expertise consultation via two-way videoconferencing. Twenty-four patients with a possible acute stroke were evaluated over 27 months. Videoconferencing was done within 15 minutes allowing the patient, the patient’s family, and both physicians to see and hear each other in full color using two panels, tilt, and zoom cameras (ViewStation 512; PolyCom, Inc., Austin, TX) connected to 13’’–21’’ televisions at each end. A stroke neurologist (SN) examined all patients, documented the NIHSS score, interpreted the head computed tomography (CT) scan, reviewed tPA eligibility criteria, and provided management recommendations. Data transmission was at 256–384 kbps (full CIF) at 30 frames/s. Compressed brain images were interpreted in a browser window (AMICAS, Inc., Waltham, MA) on a Pentium-based desktop system equipped with a cathode ray tube monitor at 1024 3 768–pixel resolution. The physicians operated the system without requiring any real-time technical assistance. Treatment recommendations regarding tPA were made by the SN.

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As the archive failure cases occurred in patients past the three-hour window, and there were written records of key time points, the lack of videotape archive did not compromise the care delivery. During the study the hospital admitted 106 patients with acute ischemic stroke. Ten patients presented to the emergency department within three hours of symptom onset. Eight patients required TeleStroke consultation within three hours after onset of symptoms, and two more than three hours after stroke onset. Treatment with IV tPA was deemed indicated in six of these 10 patients. During the TeleStroke intervention, none of the patients received IV tPA without remote support. Thus, 6 of 106 (5.6%) of all patients with ischemic stroke received tPA, compared to none of 100 patients with ischemic stroke admitted during the previous two-years despite availability of IV tPA and written ED protocols. Of 24 patients, 15 patients (62%) presented to the emergency department within the three-hour window; Ten were ultimately diagnosed with AIS. Not a single patient was excluded from receiving tPA as a result of the time required to initiate or complete the consultation.

The study showed overall satisfaction on the quality of the videoconferencing sound, image, and connection speed (>96%). Emergency physicians felt more confident managing patients with telemedicine support and and also felt that patient care was enhanced with each telemedicine consult interaction. Patients rated this technique as good as face-to-face consultations almost 86% of the time. Telemedicine and neurorehabilitation Costs of rehabilitation and long-term care for stroke patients have increased considerably in recent years. Thus, there is an urgent need to develop effective long-term care and rehabilitation strategies for stroke patients, encouraging active patient involvement . Several reports suggest that VTC may be a useful tool in stroke rehabilitation. Known as telerehabilitation (TR), it facilitates interactive evaluations and intervention recommendations among multiple specialists based on video clinical presentation of stroke patients. 37. Objectives of tele-rehabilitation represent a continuance of the rehabilitation process initiated at the hospital, and now transferred at the patients' home. 38. A small Slovenian study compared balance training in a conventional clinical environment with a TR approach. Six stroke patients were enrolled in the virtual reality (VR)-assisted study and treatment was done five times a week for three weeks clocking up to 20 minutes each session. Results showed that those in the VR-assisted balance training group achieved similar improvements in postural function as conventional balance training done in traditional clinical settings. Furthermore, performing balance training at home reduced the number of outpatient visits, thus reducing associated costs 38.

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TR can be used in urban or rural settings. A Physical Medicine and Rehabilitation (PM&R) specialist at a medical center can then monitor patients’ progress . Not only can the PM&R specialist visually observe the patients execute movements, but also quantitative data such as physical force and range of motion can be recorded and transmitted via the network to the medical center. A randomized single blind controlled study to treat motor deficits in post-stroke patients was performed at a remote rehabilitation facility. The study consisted of a VR-based system that provided motor tasks to patients via the Internet. A total of 36 patients with mild arm motor impairment due to middle cerebral artery territory ischemic strokes were enrolled. The study compared a TR approach to the traditional motor rehabilitation method. All patients were evaluated with the Fugl-Meyer Upper Extremity, the ABILHAND and the Ashworth scales one month prior, at onset and termination of therapies, and one month post-therapy. Both approaches showed considerable improvement in all outcome scores, but the experimental approach exhibited better results in motor performance. These preliminary observations may lead to an earlier hospital discharge 39.

Post-discharge rehabilitation requires a coordinated and well organized home-based program. Outpatient programs can incorporate TR to evaluate the patients home environment, assess mobility status and progress, initiate new treatments and provide goal oriented assessments and feedback to patients and caregivers. Over 75% of US veterans treated within the Department of Veterans Health Administration with an acute stroke are cared for in hospitals without inpatient rehabilitation bed-units (RBU), and fewer than 10% of them are transferred to a RBU at another facility 52. A study conducted within the VHA assessed a TR intervention in post-stroke patients following discharge home. The study suggested that TR can provide home assessments and follow-up training with prescribed equipment, and has the potential to effectively supplement existing home health services, assist transition to home care and increase efficiency 40. Another pilot TR study compared the degree of recovery and satisfaction in patients having a VR-assisted therapy program at home to those having the same therapy in a hospital setting (non VR-group) 41. The VR equipment installed in patients’ home used a 3D motion tracking system to create a virtual environment where the patient's movement was represented. Motor performance assessment found that the Tele-VR group had a significant improvement with (P < 0.05), while the non VR group also showed no significant changes. The videoconferencing system also provided a good relationship between patients and physical therapists at the medical center. Another study comparing the effectiveness of traditional physical therapy and TR of upper limb recovery following stroke, reported that both strategies resulted in significant improvement in all outcome measures, but patients assigned to the TR group using VTC showed greater motor recovery 39. Additional studies have shown increased patient satisfaction and improved outcome with TR programs 42, 43.

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Several remote physical sensor devices have been developed to enhance VTC. An important technology for TR has been the introduction of an Internet-based goniometer used for the remote quantification of joint range of motion (ROM). This remote assessment of ROM was found to be a valid tool for measurement of upper limb ROM, with a high level of intra- and inter-rater reliability44. Results thus far suggest that therapists can confidently use the Internet-based goniometer to measure the upper limb ROM in stroke patients. A virtual glove has also been designed for hand rehabilitation for stroke patients that is software based, and tracks hand movements by using images collected from webcams and digital analysis. Digital forces are calculated from the deformations impressed on some objects. This data is transmitted and integrated by a computer at the medical center allowing providers to make further assessments and recommendations45. A new ankle-foot-orthotic prosthesis with sensors for monitoring via TR has been designed to count steps taken throughout the day. This tool allows providers to remotely monitor a patient’s physical activity46. Of note, a single case of functional improvement after remotely based functional electrical stimulation for arm rehabilitation administered over the Internet using personal computer-based cameras and free network meeting software has been reported47. In addition, remote assessment and therapy of speech and language among brain-injured patients has been used for over a decade, but has gained more attention following the incorporation of video 48. Several studies have evaluated the effectiveness of remote speech and language therapy using VTC. Brenna and colleagues compared traditional speech and language therapy with HQ-VTC speech and language therapy. They reported a high diagnostic correlation between in-person and HQ-VTC assessment, and no significant differences between patient progress between the two methods49. This approach has the potential for specialized speech and language therapy for patients living in remote areas. Cost Effectiveness Different economic modeling paradigms suggested cost efficacy of remote VTC with evidence-based acute stroke therapies50.-51 Since tele-stroke costs are upfront but benefits of improved stroke care are life-long, this new perception often creates a barrier to use of telemedicine for acute stroke care. Conclusions Designated stroke centers have been established across many States and communities in the United States 11. Delivery of advanced therapies, including intravenous tPA is facilitated by specialized stroke and brain imaging expertise. Telestroke videoconferencing consultation can improve access to time-sensitive therapies for patients with acute ischemic stroke and possibly other neurological emergencies. The use of TR to remotely address urgent patient care needs is promising and has been identified as one of five major priority areas for future development by the Department of Veterans Affairs 54.

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