TELE-

NEUROREHABILITATI
ON
CONTENTS
What is Tele-Neurorehabilitation (TR)
History of Telemedicine and Tele-Neurorehabilitation
Goals of Tele-Neurorehabilitation
Principles /Guidelines of TR by American association of Telemedicine
Evidence Based Practice in Tele-Neurorehabilitation
Take-home Message
TELE-
NEUROREHABILITATION
The American Telemedicine Association defines Tele-Neurorehabilitation as the delivery of
rehabilitation services to patients at a remote location through Information and Communication
Technologies (ICT) across distance or time
Tele-neurorehabilitation- An emerging and innovative approach - Provides many types of
interventions, including physiotherapy, speech, cognitive and behavioral therapy, occupational
therapy, telemonitoring, and teleconsultation

Brennan D, Tindall L, Theodoros D, Brown J, Campbell M, Christiana D, et al.. A blueprint for telerehabilitation guidelines. Int J Telerehabil. (2010)
6. Piron L, Tonin P, Trivello E, Battistin L, Dam M. Motor tele-rehabilitation in post-stroke patients. Med Inform Internet Med. (2004)
HISTORY
 HISTORY
The idea for modern Telemedicine that we use today appeared around 1960
In 1959, Clinicians at University of Nebraska were first people to use video communication for medical
purposes.
1960’s telemedicine or telehealth transmit vital signs with NASA for astronauts
1970’s progressed into real medical applications
1980’s military started using videoconferencing- to access specialists
1990’s Federal agencies started telemedicine programs

1997 Telerehabilitation created by

National Institute on Disability and Rehabilitation Research
(US Department Education).

Ryu S. History of Telemedicine: Evolution, Context, and Transformation. Healthc Inform Res. 2010 Mar;16(1):65–6.
HISTORY
Thomas Nesbitt described a 1925 cover of Science and Invention magazine showing a doctor
remotely diagnosing a patient via a yet to be invented radio and video device.
Some 95 years later, thanks to advances in telecommunications technology, it is now possible to
achieve this and so much more.

1925 Science and Invention Magazine cover

HISTORY
National Institute on Disability and Rehabilitation Research’ 4 priorities

1. Develop and evaluate telecommunication techniques for delivering training, education, and
counseling rehabilitation services at a distance
2. Develop and evaluate technologies for assessment and monitoring of progress and outcome of
rehab at a distance
3. Develop/evaluate technologies for therapeutic intervention at a distance
4. Conduct research on application of Telerehabilitation technologies to rehab
CONTINUUM OF TELEHEALTH
GOAL OF TELE-
NEUROREHABILITATION
Access to Neurorehabilitation
Cost of delivery – Telerehabilitation can reduce therapy cost by 50%
Convenience and Compliance
 Quality
TELE-NEUROREHABILITATION
PRINCIPLES
‘Telerehabilitation’ encompasses a range of rehabilitation and habilitation services
that include evaluation, assessment, monitoring, prevention, intervention,
supervision, education, consultation and coaching.
ICT used to deliver rehabilitation and habilitation services range from chat
messaging, video and audio conferencing, wearable technologies, sensor
technologies, patient portals or platforms, mobile health applications, virtual reality,
robotics, and therapeutic gaming technologies and so on…
PRINCIPLES/GUIDELINES FOR
DELIVERING TR SERVICES
..

 Administrative Principles
 Clinical Principles
 Technical Principles
 Ethical Principles

Richmond T, Peterson C, Cason J, Billings M, Terrell EA, Lee ACW, Towey M, Parmanto B, Saptono A, Cohn ER, Brennan D. American Telemedicine
Association's Principles for Delivering Telerehabilitation Services. Int J Telerehabil. 2017 Nov 20;9(2):63-68.
ADMINISTRATIVE PRINCIPLES
 Organizations and professionals shall be aware of and comply with laws, regulations, guidelines
by nationally recognized professional associations.

Organizations and/or professionals shall be aware of and comply with any federal or state laws or
licensure regulations

Organizations and professionals that engage in collaborative partnerships and/or vendor

agreements shall be aware of applicable legal and regulatory requirements for appropriate
written agreements.

Richmond T, Peterson C, Cason J, Billings M, Terrell EA, Lee ACW, Towey M, Parmanto B, Saptono A, Cohn ER, Brennan D. American Telemedicine
Association's Principles for Delivering Telerehabilitation Services. Int J Telerehabil. 2017 Nov 20;9(2):63-68.
CLINICAL AND TECHNICAL
PRINCIPLES
Professionals shall be aware of and comply with laws and regulations and shall integrate
guidelines, and standards set forth by nationally recognized professional associations (e.g.,
American Physical Therapy Association, APTA)
Professionals shall be aware of and comply with all professional state board regulations
and any guiding scope of practice policies.
Professionals who use ICT hardware, software, or devices to deliver information or services
should be trained in equipment and software operation and troubleshooting or readily
have available the technology vendor or IT support.
Organizations and professional sshall comply with all relevant laws, regulations, and codes
for technology and technical safety.

Richmond T, Peterson C, Cason J, Billings M, Terrell EA, Lee ACW, Towey M, Parmanto B, Saptono A, Cohn ER, Brennan D. American Telemedicine
Association's Principles for Delivering Telerehabilitation Services. Int J Telerehabil. 2017 Nov 20;9(2):63-68.
ETHICAL PRINCIPLES
Organizations and professionals shall incorporate organizational values and ethics into policy
and procedures related to telerehabilitation.

Organizations and professionals shall be aware of and comply with any applicable
laws, regulations, statutes, and/or telerehabilitation-related policies and
adhere to professional codes of ethics.

Organizations and/or professionals shall inform clients of their rights and responsibilities when
receiving rehabilitation and habilitation services through telerehabilitation, including their right to
refuse or discontinue services.

Richmond T, Peterson C, Cason J, Billings M, Terrell EA, Lee ACW, Towey M, Parmanto B, Saptono A, Cohn ER, Brennan D. American Telemedicine
Association's Principles for Delivering Telerehabilitation Services. Int J Telerehabil. 2017 Nov 20;9(2):63-68.
TELE-NEUROREHABILITATION
DISCIPLINES
Tele- neurorehabilitation disciplines endorsed by the American Occupational Therapy Association
and the American Physical Therapy Association and American Speech-Language-Hearing
Association
Tele-physical therapy
Tele-audiology
Tele-Occupational therapy
Tele-psychology
EVIDENCE BASED PRACTICE-
TELENEUROREHAB

Published on 31 January 2020

Moderate‐quality evidence for TR

Review stated that there was no difference in activities of daily living between people who received
a post‐hospital discharge telerehabilitation intervention and those who received usual care
(based on 2 studies with 661 participants
(SMD) ‐0.00, 95% confidence interval (CI) ‐0.15 to 0.15)).
EVIDENCE BASED PRACTICE-
TELENEUROREHAB

Population – Stroke Patients with arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66)
Intervention – Home-based Tele-rehabilitation
Comparison- Traditional in-clinic Rehabilitation
Outcome- FM Score
 Trial Design- Non Inferiority, assessor blinded RCT N= 124
Sites- 11 US sites in NIH StrokeNet Clinical trials network

RESULTS

Both groups showed significant treatment-related motor gains,

with a mean (SD) unadjusted FM score change from baseline to 30 days after therapy of
8.36 (7.04) points in the IC group (P < .001) and 7.86 (6.68) points in the TR group (P < .001).

The adjusted mean change in FM score was 0.06 points larger in the TR group (95% CI, −2.14 to 2.26; P = .96).
The noninferiority margin (30% of the mean FM score change in the IC group) was 2.47,
which fell outside of this 95% CI, indicating that TR was not inferior to IC therapy on the primary end point;
PICOT
Population – Stroke patients (Ischemic or hemorrhagic)
Intervention – Tele-rehabilitation
Usual care
Comparison-
Outcome-
Primary Outcome Measure-
Self reported disability~ disability component of Late-Life Function and Disability Instrument
Secondary Outcome Measures-
1) Timed five-metre walk test
2) Two-minute walking distance
3) Modified Barthel Index (BI)
4) Activities-Specific Balance (ABC) scale26
5) EuroQoL (EQ-5D)
 Trial Design- Dual center, parallel, two-arm, single blinded RCT
Sites- Two hospitals in Singapore (N=124)
Results-

Time spent on TR>> Centre-based R

Conclusion- Patients in the intervention group who had access to tele-rehabilitation and patients in the
control group who had access to usual care (i.e. center-based rehabilitation) presented similar
improvements in functional outcomes.
TAKE-HOME MESSAGE
Telerehabilitation may complement center-based rehabilitation, especially when
access to specialized rehabilitation services is limited or difficult.
This innovative and novel approach has the potential to widen the horizon of
rehabilitation access, alleviate transportation barriers, promote compliance and
offering the patients an opportunity to exercise at their home!