Telerehabilitation Decision Support System: Pilot Testing Protocol

This is a multi-centre pilot study to test the usability and feasibility of the TeleRehab DSS platform among a sample population across all five clinical sites.

Upon meeting the initial inclusion criteria, eligible participants will be scheduled for an appointment to attend the clinic and complete a cognitive assessment (MoCA) and gait assessment (FGA). If a participant is deemed fully eligible, they will proceed with the onboarding process and clinical assessment, including the collection of personal details and a set of health questionnaires. They will then be randomised into either the high-tech or low-tech TeleRehab DSS intervention group.

All study participants will attend two sessions weekly over 3-weeks at each clinical site, where they will complete a personalised multisensory balance rehabilitation programme using augmented reality while wearing motion tracking sensors. Clinicians will be present to attend to any technical or clinical queries during completion of the program. At the end of the 3-weeks, the artifical intelligence decision support system will suggest exercise progressions, tracking wether the clinical agrees or disagrees with these suggestions.

Participants will receive telephone calls each week to monitor their progress. Participants will also receive remote program reviews at weeks 3, 6 and 9, from a member of the research team to assess and change exercises as required. Participants will be advised to contact the research team by email or by telephone during working hours if they have concerns or questions about their rehabilitation program or the TeleRehab DSS system. The research team will judge whether an additional home visit is required. If a patient does not complete their exercises for three consecutive days, a flag/warning will appear on the patients dashboard as a priority patient to follow up with, within 24 hours.

TeleRehaB DSS supported, prescribed, progressed and delivered intervention. In the TeleRehaB DSS IG, the platform will suggest two possible management strategies, on an individualised basis, based on patient profiles and expected benefit: 1)The high-tech, full TeleRehaB DSS with all components of the intervention consisting of TeleRehaB DSS AI-progressed multisensory balance exercises with the use of the AR avatar, real time feedback, AR gamified intervention, sensor monitored exercise performance and additional cognitive training, 2) the low-tech, basic version of TeleRehaB DSS, with depth camera, sensors and tablet - multisensory balance exercises, real time feedback, sensor monitored exercise performance and cognitive games, with no exergames, no smartwatch, and no mobile phone. The clinician can override the TeleRehab DSS group allocation decision if it is deemed unsafe.

ALL PARTICIPANT Inclusion Criteria:

• Age 40-80 years
• community dwelling able to walk 500-m independently or with a stick
• Depression subscale on Hospital Anxiety and Depression Scale <10/21 (14-item questionnaire)
• No significant visual impairment (as self-reported by participants)
• Willing to comply with study procedures, proposed training and testing regime
• With capacity to consent
• No acute musculoskeletal or other injuries that would prevent participation in a structured exercise program
• Is not currently, and has not in the past 8-weeks received any falls/balance/vestibular and/or cognitive rehabilitation.
• Does not any implanted medical devices or a cardiac pacemaker.
• Does not have any other co-existing neurological conditions (ie. Multiple sclerosis, Parkinson's disease, neuropathy etc.)
• Does not have any language or communication deficits impairing their ability to communicate and/or express their thoughts.
• Has at least one functional hand for grip function and computer use.
• Fulfilling all of the criteria from one of the below sub-groups

STROKE COHORT who will fulfil the additional criteria:

• Individuals with diagnosis of focal ischaemic or haemorrhagic stroke, as confirmed by a clinical letter.
• Onset >/= 3 months prior to study.
• Montreal Cognitive Assessment (MoCA) score n >/=23
• At risk of falls (i.e. Functional Gait Assessment FGA score </=22/30; FGA is a validated quick balance task assessment) AND/OR having experienced a fall(s) in the last 12 months

MCI COHORT who will fulfil the additional criteria:

• Individuals with new or existing formal diagnosis of MCI, according to the International Classification of Disease 10 (ICD10) , as confirmed by a clinical letter.
• At risk of falls (FGA </= 22/30) AND/OR having experienced a fall(s) in the last 12 months.

VESTIBULAR COHORT who will fulfill the additional criteria

• Montreal Cognitive Assessment (MoCA) score n >/=23
• Individuals with a diagnosis of a vestibular disorder (peripheral and/or mixed peripheral and central):
• Peripheral vestibular disorder in which the balance problem lies in the vestibular/balance system within the inner ear.
• Mixed vestibular disorder in which the balance problem lies in the vestibular/balance system within the inner ear (peripheral) and involving the nerves or neuronal network in the brain/brainstem responsible for balance (central).
• Chronic dizziness and/or unsteadiness (>/= 3 months duration) that started at the time or after the vestibular disorder diagnosis.
• Dizziness handicap inventory (DHI >34) AND/OR At risk of falls (FGA </=22/30)

LONG COVID-19 COHORT who will fulfill the additional criteria:

• Montreal Cognitive Assessment (MoCA) score n >/=23
• Individuals with laboratory confirmed diagnosis of Covid (>/=6 months prior to study onset), as confirmed by a clinical letter.
• Who have been diagnosed with long Covid, as confirmed by a clinical letter.
• Who have chronic dizziness and/or unsteadiness which started after the Covid illness (self-report by the patient; duration </=3 months).
• Dizziness handicap inventory (DHI >34) AND/OR At risk of falls (FGA </=22/30)

Exclusion criteria

• Outside of the stated age bracket
• Unable to walk independently (even with use of a walking stick)
• MOCA score <23
• Score of 10 or higher on depression subscale of HADS
• Unwilling to comply with study procedures, proposed training and testing regime
• No capacity to consent
• Significant visual impairment or homonymous hemianopia (stroke cohort only) (self-reported)
• Orthostatic hypotension or uncontrolled hypertension
• Other neurological problem (e.g. Parkingson's disease, Multiple Sclerosis etc.)
• Language and communication deficits impairing ability to express thoughts (e.g. Aphasia)
• Has participated in a clinical drug trial in the past 6 months.
• Acute musculoskeletal injury that prevents participation in a structured exercise programme (e.g. lower limb fracture).
• Has an implanted medical device or cardiac pacemaker.
• Diagnosis of unstable Meniere's or with more than 4 migraines/month at the time of participating in the study
• Not fulfilling the inclusion criteria for one of the sub-groups (such as criteria for Stroke group, or MCI group, or chronic vestibular disorder group, or long-Covid group), as outlined above.
• Unable to provide a clinical letter confirming diagnosis.
• For those with stroke, no visual spatial neglect.