Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2018;-:-------

ORIGINAL RESEARCH

Acceptance of Tele-Rehabilitation by Stroke Patients:

Perceived Barriers and Facilitators
Shilpa Tyagi, MPH,a,* Daniel S.Y. Lim, MBBS,b,* Wilbert H.H. Ho, MBBS,b,*
Yun Qing Koh, MBBS,b,* Vincent Cai, B.Sc (Hons),a Gerald C.H. Koh, PhD,a,b
Helena Legido-Quigley, PhDa,c
From the aSaw Swee Hock School of Public Health, National University of Singapore, Singapore; bYong Loo Lin School of Medicine, National
University of Singapore, National University Health System; and cLondon School of Hygiene and Tropical Medicine, United Kingdom.
*Tyagi, Lim, Ho, and Koh contributed equally to this work.

Abstract
Objective: To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists
in an Asian setting.
Design: Qualitative study involving semi-structured in-depth interviews and focus group discussions.
Setting: General community.
Participants: Participants (NZ37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling.
Interventions: Singapore Tele-technology Aided Rehabilitation in Stroke trial.
Main Outcome Measures: Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists.
Results: Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and
accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled
hypertension. Barriers identified by patients were equipment setuperelated difficulties and limited scope of exercises; barriers identified by tele-
therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient
characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation.
Conclusions: Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven
interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support
to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment
methods suitable for virtual platforms.
Archives of Physical Medicine and Rehabilitation 2018;-:-------
ª 2018 by the American Congress of Rehabilitation Medicine

In spite of unequivocal evidence supporting the role of timely
rehabilitation in stroke patients’ functional recovery,1 Chen et al2
reported poor compliance to post-discharge, supervised physical
rehabilitation by stroke patients in Singapore. Barriers enumerated
were mainly functional, social, and financial. The need to address
these barriers with innovative solutions is urgent. Tele-technology,
Presented as a poster at the American Congress of Rehabilitation Medicine (ACRM) Con-
ference, Atlanta, Georgia (October 25-28, 2017).
Supported by the Singapore Millennium Foundation (Grant Number: R e 608 -000 e 048 -
592) and Saw Swee Hock School of Public Health Tele-Health InnOvation Research (THOR)
Program Grant (Grant Number: R e 608 e 000 e 120 - 733).
Disclosures: none.
including tele-medicine and tele-rehabilitation (TR), is one such
avenue worth exploring.
While tele-medicine3 entails the remote exchange of data be-
tween patients and health care professionals as part of diagnosis
and management, TR refers to the subset concerning delivery of
rehabilitation services over electronic networks. Success of such
initiatives lies on the tenets of acceptability, adoption and sus-
tained stakeholder compliance. Realizing the importance of pa-
tient feedback in improvement efforts, researchers have previously
looked at patient satisfaction with tele-technologyemediated in-
terventions.4 One study adopted a mixed method perspective to
study TR substituting face-to-face visits for physiotherapy and

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.04.033
2 S. Tyagi et al

speech and language therapy in older people.5 Currently, in-depth

Table 1 Demographic characteristics of patient and caregiver
qualitative research exploring the experience of such interventions
population
is limited to western settings, focusing mainly on single stake-
holders. Some of the exercise-based TR studies targeted specific Characteristics No. Participants
populations like patients post total knee arthroplasty,6 older pa- Sex (n) 13
tients undergoing rehabilitation,7 or patients who declined to  Men 7
participate in a tele-health trial focusing on self-care.8 Providing  Women 6
scenarios of physical TR services, 1 study asked the participants to Age (y)
reflect on the pros and cons of adopting them.9 A recent mixed-  Mean 59
method study incorporated elements of social support in their  Range 43-79
multi-component tele-health program for heart failure patients.10 Ethnicity (n)
Currently, none of the studies capture perspectives of all the  Chinese 9
main stakeholders, focusing on Asian population. Addressing  Malay 4
these gaps, our study aims to explore the barriers and facilitators Ward class* (n)
of TR as perceived by stroke patients, caregivers, and rehabilita- B 1
tion therapists recruited from one of the largest trials of TR in a  B1 1
developed Asian country to date.11  B2 6
C 5
Level of disability (Modified Rankin Scaley) (n)
Methods 1 1
2 2
Study design 3 0
4 6
This qualitative study was part of a larger RCT, the Singapore 5 1
Tele-technology Aided Rehabilitation in Stroke trial (see  Unavailable 3
supplemental table S1 for information on the trial, available online Total tele-rehabilitation min over 312 (202-744)
only at http://www.archives-pmr.org/). For more detailed infor- 12-wk period, median (IQR)
mation, please refer to the published protocol.11 Type of caregiver
 Family member 10
Participants  Foreign domestic worker 3
Abbreviation: IQR, interquartile range.
Adopting purposive sampling, stroke patients aged
21 years, * In Singapore, the inpatient hospital beds are categorized as class
able to understand and follow instructions, having caregiver A, B (B1 and B2), and C, depending on the amount of subsidy given,
support and having completed the TR program were enrolled with class C ward having the maximum subsidy. All Singaporeans and
along with their caregivers, to be interviewed at their homes. permanent residents can apply for subsidies based on their monthly
Similarly, sessions with tele-therapists aged
21 years were income.
y
conducted at their workplaces. Study was approved by institu- mRS e Modified rankin scale.
tional review boards. The stroke patients were aged between 43 to
79 years, mostly Chinese with few Malays, almost equal repre-
sentation of men and women with different levels of functional
ability. The median of total minutes spent on TR over a 12-week Documentation was done using field notes and postinterview
memos. Written informed consent was obtained from all partici-
period was 312 minutes (with interquartile range of 202-744min).
pants and data collected was securely stored with removal of
Among the 13 caregivers, 10 were family members ranging from
a young daughter to a middle-aged daughter-in-law to a spouse. identifiers to maintain confidentiality. The interview guide was
The therapists were all women, between 23 to 37 years old, developed based on past relevant literature (box 1).
having on average 4.3 years of rehabilitation experience (tables 1
and 2). Data analysis
Interviews were transcribed and translated to English (when in
Data collection Chinese and Malay) and coded using NVivo 11 software.a After
Eighteen semi-structured in-depth interviews involving 13 patient- data familiarization, S.T. used line-by-line coding to analyze the
caregiver dyads, 5 therapists, and 2 focused group discussions first few transcripts, identifying the main emerging themes.
(each involving 3 therapists) were conducted from February to Combining this inductive approach with prior literature and
April 2016 (supplemental table S2, available online only at http:// written memos, she developed a preliminary coding frame, which
www.archives-pmr.org/). Each interview, lasting between 30 and was finalized by the team.12 Thematic analysis was performed
90 minutes, was conducted in English, Chinese, or Malay. within the categories of coding frame, complemented by constant
comparisons at different levels, between content and code within
an interview, different subjects and different subject groups.13,14
List of abbreviations:
The team met regularly to discuss emerging themes, and deviant
DR day rehabilitation
cases, if any, were explored in-depth and incorporated in the final
RCT randomized controlled trial
results. The approach to deviant cases is explained in
TR tele-rehabilitation
supplemental table S3 (available online only at http://www.

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Tele-Rehabilitation Post-Stroke 3

caregiver, and T for tele-therapist, followed by the interview

Table 2 Demographic characteristics of tele-therapists
number, or FGD for quotes by focus group tele-therapists.
Characteristics No. Participants
Sex (n) 11 Facilitators: patient level
- Men 0 Affordability
- Women 11 Affordability of TR was identified as a facilitator of its uptake with 1
Age (y) participant describing it as a relative advantage for the not-so-well
- Mean 27 off: “Tele-rehab is actually a bonus for those not so well off, where
- Range 23-37 you don’t need to worry about (.) money (.) you can just continue
Area of specialization your exercises” (P03).
 Occupational therapist 8
 Physiotherapist 3 Accessibility
Years of rehabilitation experience Accessibility was enhanced by eliminating the need to travel to
 Mean 4.3 the day rehabilitation (DR) center and the flexible nature of the
 Range 2-13 program. One of the caregivers (C05) mentioned that many peo-
Experience with TR ple, including her care recipient, would not like to move around.
 Mean duration being engaged (y) 0.8 The views were shared by the patients, as illustrated below: “We
 Mean number of patients seen 2 don’t need to bother to find transportation (.) can do it face-to-
face at home” (P12).
Participants liked the fact that they could choose their exercise
archives-pmr.org/). Thematic saturation was reached after inter- timings and were not bound by the fixed schedule of the DR
viewing 13 dyads and 11 therapists. centers: “Daytime I cannot (.) I’m sleeping, because I work at
night (.) the time when I’m free (.) nobody will come and do it
(...) Because tele-rehab, I can choose the time that I want to
Results do” (P10).
The final coding frame comprised 4 parent, 14 child, and 42
grandchild nodes. Three themes identified were barriers, facilita- Facilitators: provider level
tors, and patient characteristics with 106, 141, and 167 coding Addresses a service gap
references respectively. We are reporting barriers and facilitators TR was also perceived as an interim rehabilitation while
affecting uptake of TR under 3 domains of patient, provider, and waiting for the DR sessions, which could range from 2 to 4
interaction. The patient domain comprised affordability and weeks. “Patients are discharged already; it acts as an interim
accessibility as facilitator sub-themes (15 sources) and setting up (.) eventually they will go to day-care or day rehab center (...)
of equipment and exercise scope as barrier sub-themes (13 sour- it acts as a consistency in maintaining their functional sta-
ces). The provider domain comprised addressing a service gap as a tus” (T01).
facilitator sub-theme (15 sources) and patient assessment, inter-
face problems and exercise scope as barrier sub-themes (9 sour- Facilitators: interaction between the patient and the therapist
ces). The interaction domain comprised unexpected health benefit Unexpected health benefits
and connectivity issues as facilitator (5 sources) and barrier (8 Therapists monitored patients’ general fitness including blood
sources) sub-themes. The patient characteristics (20 sources) pressure before each FaceTime session and one such encounter
theme comprises patient attributes as sub-themes. Figure 1 pro- allowed a therapist to detect her patient’s uncontrolled
vides diagrammatic overview of key themes. In the following hypertension, which was resolved later. The therapist was very
section, illustrative quotes are coded as P for patient, C for satisfied with this sudden, unexpected health benefit and

Box 1 Interview guide

General experience
How do you feel about your tele-rehabilitation experience?
Was the per-session duration (up to 1h) and total duration of rehabilitation (3 months) sufficient for your recovery? Why?
How do you feel about the therapist who led the session? (patient and caregiver only)
Barriers and facilitators
Is the equipment user-friendly? If yes/no, why? How can it be improved?
What do you think are the advantages of tele-rehabilitation?
What do you think are the disadvantages of tele-rehabilitation?
What do you feel is the effectiveness of tele-rehabilitation in comparison to home and day rehabilitation?
Decision on whether to continue with day rehabilitation (patient and caregiver only)
Did you continue with rehabilitation after discharge? If yes/no, why?
What is your ideal form of rehabilitation assuming no financial and time constraints?
Suggestions and further input
What is your opinion on the suitability of tele-rehabilitation replacing home and day rehabilitation in the long run?
Do you have any suggestions for improvement when implementing tele-rehabilitation on a national scale?

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4 S. Tyagi et al
Fig 1 Barriers and facilitators to uptake of tele-rehabilitation.
described her encounter as “serendipity”: “I had a woman who
was living with her family but there was (a) strained
relationship (...) her blood pressure was extremely high (...)
she had not been taking her medications (...) She started taking
it and her blood pressure (went) down to normal levels”
(FGD 1).
Barriers: patient level
Setting up the equipment
Many participants described difficulties related to setting up the
equipment and the lack of clear instructions. One of the patients
(P03) felt demotivated by the inconvenience associated with
frequent adjustment of heavy parts, making it impossible to set up
without his caregiver’s help. Another expressed his displeasure at
the routine of equipment setup: “A lot of it is setting up the
equipment that we don’t want to do. I hate doing it...” (P03).
Another issue raised mostly by patients was the lack of clear
instructions for setup. “Where to tie the strings, on which chair?
Because the iPad did not show very clearly (.) I have to use my
imagination” (P05).
Scope of exercises
Among those who talked about scope of exercises, some felt the
exercises were repetitive. A caregiver felt that the exercises were
not comprehensive enough to meet the needs of his care recipient:
“the movements are very basic, (...) I think maybe she can do
some more exercises (.) more of walking” (C11).
Barriers: provider level
Patient assessments
One of the main barriers perceived by the therapists was patient
assessments, highlighting the inherent limitations of the virtual
platform like inability to physically test muscle power or balance.
“I’ve never seen or (.) assessed the patient (.) via FaceTime.
Just see only, cannot touch. Which is very weird, and not very
natural (...) I actually had to think through (...) Even just giving
instructions to test MMT (manual muscle testing) was a
pain...” (T05).
Interface-related problems
The therapists described interface-related problems like screen size
and complicated graphs, which might demotivate future providers.
Except for a few, who felt the issue was with the screen size, most
viewed it more as a placement problem, which could be solved by
tilting or adjusting the iPad. Almost half of the therapists perceived
the graphs on the interface as complicated and hard to understand.
“When you look at the graphs, oh gosh you need to figure out. Might
as well press the video and see for yourself...” (FGD 2).
Scope of exercises
The therapists who talked about the TR exercises agreed on their
limited scope. Interestingly, one of them expressed her views
about linking the exercise scope with the program aims, empha-
sizing on the clarity of the desired outcomes.
Barriers: interaction between the patient and the therapist
Connectivity issues
Almost half of the therapists, a few patients, and 1 caregiver referred
to the connectivity problems encountered during the FaceTime
session. While therapists perceived these interruptions as minor, 1
of the patients felt discouraged by this issue: “Actually I can, but as I
said, always unable to connect. Then I feel discouraged” (P07).
Patient characteristics
Patient characteristics emerged as an important theme to consider
while implementing such a technology-driven program. It influ-
enced all the major themes including rehabilitation preference.
Age of the patient
Age of the patient was significant in use of the iPad system, as the
older patients found the system challenging and expressed the
need for assistance. “No, you still have to ask her (maid) do
(operate the iPad system) (...) Tell her to help” (P02).
Patient’s disability level
Interestingly, level of disability along with age affected patients’ drive
to continue TR. Two patients in their 50s expressed contrasting views
on their motivation to exercise. While 1 of them with mild disability
was strongly motivated, the other, moderately disabled expressed
difficulty in being motivated and felt reinforcement would help.
Cultural influence
In Singapore, with increasing workforce demands, it is a common
practice to hire foreign domestic workers as surrogate caregivers in a
domestic environment. Often, they come from neighboring countries
like the Philippines or Indonesia, undergo training programs, and are
matched with prospective employers, via government-accredited
employment agencies.15 This cultural context and presence of foreign
domestic workers affected the motivation of patients to continue TR
with patients being more accepting of their disability state. “A lot of it is
‘I’m sick, so somebody’s going to help me,’ way of thinking (...)
especially if they have a maid. I’m happy being in this sick role (...) The
rest, I’ll just leave to the maid to do (...) Then the tele-rehab system
becomes like, ‘why are you making me do this?’ No point” (T05).
Perception of therapist’s role
Different patients had different perceptions of a therapist’s role in
TR, with a few expressing preferences for physical sessions
involving personal touch, which they felt lacking in virtual ses-
sions. “They don’t know. Because at home, we are doing it and
they don’t know if you’re doing the wrong thing” (P01).
Sensory impairments
A case emphasized the role of patients’ sensory impairments in
their uptake of TR. This caregiver explained his wife’s decision to
discontinue TR because of hearing and eyesight issues, which
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Tele-Rehabilitation Post-Stroke
made it hard for her to engage in TR: “Only one problem, she
can’t hear. And then the eyes, like blur like that. (...) Can, but if
you put here also no use” (C13).
Preferred choice
The majority chose no clear option; rather, it was a mix of re-
sponses favoring TR and DR. Interestingly, most of the patients
who preferred TR were relatively younger with mixed disability
levels. In contrast, the patients who chose DR were older and
generally had a severe disability.
Discussion
We have described the barriers and facilitators affecting uptake of
TR, with special emphasis on the patient characteristics. Our study
is the first, to the best of our knowledge, to describe the experience
of TR in an Asian setting. Generally, the end users saw TR in a more
positive light than the service providers, which is in agreement with
what was reported by Mair et al.16 Therapists described TR short-
comings in view of limited physical touch, which has been identified
as an integral part of a therapist’s interaction with the patient in
earlier literature.17 Due to the perceived limitations, the therapists
saw TR as playing a complementary role in stroke patients’ reha-
bilitation process, which is validated by previous studies.4,7,9
Generally, the barriers perceived by the therapists revolved
around adapting to a new way of providing service. Along the same
lines, Jensen et al17 demonstrated that the ease of adoption of tele-
technology depended on the experience of the therapists involved.
Future research should explore in-depth technology adoption by the
providers to ensure the success of such tele-health interventions.
Comparing our findings with a study exploring TR in older
patients, apart from drawing parallels with respect to the conve-
nience of TR and irreplaceable face-to-face sessions, our findings
differed from Shulver et al.7 While they mentioned fostering a
positive relationship with the therapist and mastery of technology
use, a lot of our older patients struggled to adapt to the
technology-driven TR. Our findings of perceived difficulty with
technology use and preference for physical sessions is validated
by previous literature exploring barriers in participants who opted
out of technology-based intervention.8 In this study, participants
associated use of such programs with severe ill-health and
increased negative dependency on caregivers. Our findings reflect
on this theme in a positive light, with TR users seen as
technology-aware and young.
A study in Sweden explored patient views on a video-based
physiotherapy program. Perception of the new program being user
friendly and the exercise routine being pain free were not replicated
in our study. Possible reasons could be differences in patient popu-
lation and interventions. However, many findings were similar, such
as convenience, eliminating travel, equipment quality, and connec-
tion altering the experience of both the patient and the caregiver.18
Cranen et al9 gave scenarios of technology-driven programs to
participants and documented perceived barriers and facilitators,
among which there was congruence in the findings of accessibility
and complementary role of TR. In a study conducted in Canada,
while there was agreement on the themes of comfort of home and
supplementary role of TR, our findings differed under the domain of
exercise scope, patients’ confidence in technology team, and
appreciation of communication in patientetherapist relationship.6
While literature on patient experience with technology is well
established, the focus on relevance of patient characteristics and
www.archives-pmr.org
5
context is recent with our study contributing to the latter in an
Asian context. While younger patients were technology tolerant,
older patients expressed need for assistance. A recent mixed-
method study explored the influence of contextual factors in
shaping the patient perspectives of tele-technology and reported
similar findings, with older participants requiring more sup-
port.10 However, their intervention and target population were
different from the current study’s scope. A toolkit developed as
part of the Telehealth in the Home project in Australia provides
extensive resources for implementing TR services using an iPad
for all stakeholders. While discussing TR suitability, they re-
ported age not to impede TR acceptability.19 Based on our re-
sults, we recommend giving further consideration to disability
level and cultural influence in contextualizing such resources for
local relevance. Interestingly, 1 case in our sample highlighted
the role of sensory deficits in uptake of TR. Eriksson18 reported
previously that elderly patients with visual and auditory deficits
did not appreciate TR service. To summarize, preference
emerged as a multi-factorial construct dependent on various
patient factors.
Study limitations
One of the limitations related to sample selection was not including
dyads that refused to participate in the RCT. Having representation
of decliners would have enriched our analysis by providing insights
into reasons for low uptake. However, we managed to get a good
representation of diverse views by purposive sampling of partici-
pants and no language-related exclusion criteria. This makes our
results more transferrable to other settings.
Following are the policy recommendations based on our work. To
overcome the barrier of equipment setup, we suggest incorporating
introductory step-by-step videos. Referring to our theme of patient
characteristics, we recommend providing technical support to the
older stroke patients, re-enforcement in the form of longer FaceTime
sessions or adoption of the hybrid model of DR and TR for severely
disabled and giving due consideration to sensory impairments as an
eligibility criterion. Considering that TR addresses a service gap, it
should be offered to patients as an interim or substitute rehabilitation
option depending on patient preference (supplemental table S4,
available online only at http://www.archives-pmr.org/).
Conclusions
Our study has highlighted the main barriers and facilitators for the
acceptance and adoption of TR by stroke patients and provided a
comprehensive account of patient, provider, and caregiver per-
spectives. Further, we have explored the importance of patient
factors and context in influencing the perceived barriers and
facilitators.
Supplier
a. NVivo, version 11; QSR International Pty Ltd.
Keywords
Caregivers; Patients; Qualitative research; Stroke; Rehabilitation;
Tele-rehabilitation
6 S. Tyagi et al
Corresponding author
Gerald C.H. Koh, PhD, Saw Swee Hock School of Public Health,
National University of Singapore, 12 Science Drive 2 #10-01
Singapore 117549. E-mail address: gerald_koh@nuhs.edu.sg.
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Tele-Rehabilitation Post-Stroke 6.e1

Supplemental Table S1 Brief summary of the STARS RCT

Study Design: The Singapore Tele-Technology Aided Rehabilitation in Stroke (STARS) is a parallel, double arm, single blind randomized
control trial studying the effectiveness of an innovative, home based, physical therapy telerehabilitation program in improving the
functional outcomes of stroke patients post-discharge from acute care settings.
Participants: Participants were recruited from two settings in Singapore: inpatient rehabilitation unit of an acute hospital and an inpatient
rehabilitation hospital. Patients more than 40 years of age, with a stroke diagnosis within 4 weeks of date of recruitment and having a
caregiver were eligible for recruitment.
Intervention: Intervention was a set of exercises for different levels of functional ability delivered via an iPad based system. Each patient was
prescribed a set of exercises based on their initial assessment. The TR system comprises of 3 components: (1) hardware, which is the iPad
system, exercise bands, portable sensors and blood pressure monitoring machine, (2) software or the data management system and (3) the
exercises which involve use of resistance bands.
TR Interface: Researchers tried to make the patient interface simple and intuitive providing instructions in English, Chinese or Malay. They
could follow exercises displayed on the screen and get instant feedback on their performance via the sensors. Therapists’ interface displayed
information on patient’s performance of exercise tasks in an efficient manner with the help of graphs.
Exercise Regimen and Feedback: Patients were supposed to exercise 5-times a week with constant, inbuilt real-time feedback provided. This
was complimented by a facetime session with the tele-therapist once a week to interact with the patient, provide feedback and change the
prescription of exercises. Both patients and the tele-therapists were provided training to familiarize with the TR interface and other aspects
of the system.
Outcome Assessments: The patients are assessed at baseline by a physiotherapist and then subsequently at 3 and 6 months to monitor the
change in functional status and other outcomes.

Supplemental Table S2 Recruitment process details

Patient-Caregiver
Dyads (n)
Screened 32
Supplemental Table S3 Approach to deviant cases
Not eligible 3
- Not started TR yet 2 Example 1: Participants shared their views on difficulty adopting
- Refused to install the equipment 1 technology driven system being linked to age, with older ones
Approached to participate 29 reporting more practical problems than their younger
Refusal to participate 10 counterparts. However, the oldest participant didn’t report any
- Uncontactable 2 problem that he could not trouble shoot, which led the group to
- Non-communicative 1 focus on patient characteristics unique to this participant such
- No to voice recording 2 as positive attitude, severity of disability and availability of a
- Spouse unsupportive 1 support system.
- Due to poor recovery 1 Example 2: Another deviant case mentioned feeling no difference
- Recurrent stroke 1 between virtual and physical sessions, which was contrary to the
- No reason given 2 general observation of preference for physical sessions. After
Agreed to participate 19 exploring, the team concluded that participants with differing
Did not participate disability levels viewed the role of therapist differently, with
- uncontactable on the interview day 1 severely disabled ones preferring the physical sessions with
Participated in the interview 13* “personal touch”. Drawing on the above observations, the team
incorporated a theme of patient characteristics to highlight the
* Thematic saturation was reached by the 13th patient-caregiver
dependence of some themes on patient factors.
dyads were interviewed.

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6.e2
Supplemental Table S4 Policy recommendations
Broad domain Theme
Patient Setting up the equipment
- Physical setting up
- Lack of clear instructions
Scope of exercises
Context Patient characteristics
Age of the patient
Severity of stroke
Sensory impairment of the patient
Interaction b/w patient and Unexpected health benefits
therapist
Therapist Addresses a service gap
Assessment
Interface related barrier
S. Tyagi et al
Recommendation
- Provide an introductory step-by-step video demonstrating
equipment set up (including examples of placement for
resistance bands)
- Training the dyads beforehand on set-up and perhaps doing an
introductory session in the technical expert’s presence to
assist and troubleshoot
- Expand the scope of exercises beyond strengthening
- Customize the exercise program to patient’s needs and involve
him/her in the process of deciding on the exercise regimen
- Provide technical support to older stroke patients to increase
compliance
- Provide training to operate the TR system to the caregiver along
with the patient
- Provide external re-enforcement to the patients with severe
impairment in the form of either more facetime with the
therapist or complimenting the TR sessions with regular home
visits by the therapist.
- Hybrid model involving DR and TR which solves the assessment
problem at the therapist’s end and provides physical sessions to
the patient as a form of re-enforcement
- Set eligibility criteria for the patient accordingly, with inclusion
of assessment for sensory impairments along with functional
impairment.
- Expand the scope of TR from monitoring functional improvement
to inclusion of medical assessments and monitoring such as
blood pressure measurement.
- Offer TR to patients on discharge from hospital as an interim
rehabilitation option while waiting for a slot at DR center or a
substitute to DR center depending on patient preference.
- Training of therapist in new ways of assessing power on a tele-
platform (use of resistance band as a proxy for testing strength
or expand the scope of sensors from assessing movements to
assessing power)
- Hybrid model involving DR and TR which solves the assessment
problem at the therapist’s end
- Initial assessment done by the same therapist conducting future
TR sessions
- Hands-on training sessions for the therapists to learn about the
interface and operate it without any difficulty
- Make the graphs more user friendly or intuitive
- Expand the screen size or train the therapist and patient to
adjust the angle and distance for proper visibility
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