Stroke is one of the main causes of disability in developed countries. Within the CLEAR project (ICT-PSP224985), AUSL11, Local Health Authority 11 of Empoli (Italy) focused its activity on rehabilitation of impairments and activity limitations of paretic upper limb (UL) after stroke. The UL is involved in a large variety of tasks which require the limb to produce different joint configurations and different timing and sequencing of arm movements. When UL is impaired an important characteristic of human functioning is lost. It has been reported that only 5-20% of patients regain full arm and hand function after stroke while 20% remain with no functional use. It is typically reported that most potential recovery of the upper limb take place in the first three months after stroke. However, studies of training, forced use, and other rehabilitation techniques commenced more than one year after stroke showed considerably recovery of UL function. This discrepancy can be at least partially explained. Although the cerebral lesion is the primary cause, there is sufficient quantity of data in published literature that leads to the conclusion that the disability due to the stroke is made worse by the addictive effect of inactivity. In addition, poor recovery may reflect an insufficient and time-limited therapeutic intervention for the upper limb.
In this context the objective of project in AUSL11 was to implement a new integrated approach of rehabilitation for stroke survivors with UL impairments and activity limitations extended outside the boundaries of the Health System and beyond the time limits of conventional treatment by using a new tele-rehabilitation ICT platform.
The rehabilitation protocol
The project is based upon the development of a telerehabilitation ICT platform, called Habilis which allows efficient and safe web connection between hospital clinicians (doctor station) and patients (patients station). The core idea of the project is to integrate hospital rehabilitation with home practice and with an intermediate moment called “kiosk”. The kiosk is intended to provide patients an environment, conveniently located near home to be easily accessible, where they can perform continued and intensive practice and receive the necessary supervision and assessment from health professionals by the use of the ICT Habilis platform.
The hospital is responsible to define the personalised treatment plan, updated with an incremental level of difficulty and progression, if necessary. The rehabilitation protocols used are designed according to the principles of the “motor relearning program”. Within the hospital setting, patients receive detailed explanation of how the long term task-oriented treatment works. The role of the hospital (patient education and updating treatment plan), the importance of home practice (regularity, intensity of training) and the role of the kiosk (for both practice and assessment by the Habilis platform) are emphasized. Subsequently, a physiotherapist (PT) instructs patients to practice an individually tailored list of therapeutic exercises aimed at meeting the specific rehabilitations needs derived by their UL impairments and activity limitations by using specific objects selected from a “rehabilitation kit”. In addition, patients are trained to use the patient station of the Habilis platform which they will find located in the kiosks. If necessary, a caregiver is associated to the entire process of training to assist the patient.
The rehabilitation kit (Figure 1) consists of objects with different shape and size (puzzle, printed paths to follow with different pens with different characteristics, etc.) and of a “reference pad” with different coloured lines, to give patients the reference to the position where the objects have to be moved during the exercise execution. These objects are very low cost and easy to find. Using the objects of the rehabilitation kit a library of exercises has been defined, in order to meet the rehabilitation needs of a wide variety of UL impairments and activity limitations.
Patients are discharged from hospital when they show to be consistently able to practice the selected set of rehabilitation exercises and use the patient station of the Habilis platform (usually after 3-5 training 2-hour sessions). At the moment of discharge they are given: a) for home rehabilitation: training objects, reference pad, home program sheet (list of the home exercises with specification of frequency and intensity of exercise training), and a logbook (to record practice sessions); b) for kiosk rehabilitation: a time schedule for a twice-a-week training. They are encouraged to practice according to the given training schedule both at home and at kiosks and to contact clinicians for further information whenever they feel it necessary.
Figure 2 shows the patient station equipment at the kiosk (panel PC, with mouse, keyboard headset and web cam, the reference pad and an adapter arm, for adjusting the web cam position). In the kiosk the exercises are assigned by the PT from the doctor station located in the hospital via the Habilis platform and sent trough the web. To make easier the patient to understand the assigned training program, all exercises are video-recorded by the PT (Figure 3). The objects of the rehabilitation kit are available at the kiosks, ready to be selected by patients to perform the prescribed rehabilitative exercises (Figure 4).
From of the hospital doctor station the PT may observe patient performance by videoconference (Figure 5), give advice for improving practice and, at regular intervals, reassess the patients. Alternatively, patients can record his/her practice to be later reviewed by the PT (asynchronous communication). Finally, patients may request immediate advice from PT via Habilis platform. If the treatment plan needs to be revised or if adverse clinical events are present, the PT asks the patients to return to the hospital to review the treatment program and/or a visit with a MD.
Presently eight kiosks have been set in seven municipalities of the AUSL11 inside the premises of no-profit associations, social clubs, or shopping centers where the patients can go for leisure or other daily life activities. Kiosks are supervised by volunteers during opening hours.
The Tele-Rehabilitation Service is based on the Habilis Platform. It is delivered through the following main equipment and software modules:
- Server: allows the management of the service; is installed at the hospital premises.
- Service Administrator Module: allows the execution of the administration tasks in relation to its clinical use; has the task to manage users, distribute and save password; assign license to each user to access the service.
- Patient Station: permits patients to receive the clinical protocols, therapies or exercises assigned by the clinical team; allows patients to see the videos containing the instructions; permits to record videos during the execution of the exercises and to transmit them automatically to the clinicians who can evaluate them offline afterwards.
- Doctor Station: allows clinicians to define a set of rehab exercises, record audio/video exercises, assign patients a set of exercises, suggesting the correct applications execution, control the quality of the execution remotely by playing the videos recorded by patients. Through the Doctor Station, clinicians can also directly communicate with the patients by the Videoconference Module to verify their recovery.
A pilot study on 15 stroke patients (age 64.9+10, 6M, 9F, time from stroke >6 months) with UL paresis was carried out for a preliminary evaluation of effectiveness and safety of designed rehabilitation program. Study design included 2 baseline evaluations at one week time-distance and a third evaluation after a one-month treatment (one-week hospital training and 3-week home and kiosk training).