Telerehabilitation in the Home Versus Therapy In-Clinic for Patients With Stroke

Substantial evidence indicates that occupational and physical therapy improves outcomes after stroke, and that larger doses are associated with superior outcomes. However, many patients receive suboptimal doses of therapy for reasons that include cost, access, and difficulty with travel. This problem is likely to increase with time given the aging of the population and the increased rate with which patients survive stroke. Telehealth, defined as the delivery of health-related services and information via telecommunication technologies, has enormous potential to address this unmet need.

The current study will test the effectiveness of a novel home-based telehealth system designed to improve motor recovery and patient education after stroke. A total of 124 subjects (the number may be larger depending on the rate of subject dropout) with arm motor deficits 4-36 weeks after a stroke due to ischemia or to intracerebral hemorrhage will be randomized to receive 6 weeks of intensive arm motor therapy (a) in a traditional in-clinic setting or (b) via in-home telerehabilitation (rehabilitation services delivered to the subject's home via an internet-connected computer). The intensity, duration, and frequency of this therapy will be identical across the two groups, with subjects in both treatment arms receiving 36 sessions (18 supervised and 18 unsupervised), 80 minutes each (including a 10 minute break), over 6 weeks. The primary endpoint is within-subject change in the arm motor Fugl-Meyer (FM) score from the Baseline Visit to 30 Day Follow-Up Visit. Arm motor status is the focus here because it is commonly affected by stroke, is of central importance to many human functions, and is strongly linked to disability and well being after stroke.

Telerehabilitation will be evaluated using an assessor-blind, randomized, non-inferiority study design. This study seeks to establish comparable efficacy between the two treatment arms based upon a non-inferiority margin of 2.05 points on the arm motor Fugl-Meyer scale. Key study features include enrollment of a diverse stroke population, standardized and blinded outcomes assessment, a standardized treatment protocol, covariate-adaptive randomization, and use of an active comparator that is matched for duration, frequency, and intensity of therapy. The FDA has determined that this investigation is a non-significant risk device study.

A minimum of 5 clinical sites will participate in this study. Each clinical site will conduct all testing and treatment at a single central site, although each clinical site is encouraged to recruit subjects from their referral hospitals. At the central study site, an Assessment Therapist will perform all study testing, blinded to treatment assignment (the subject by necessity is not blinded), while a Treatment Therapist will provide in-clinic therapy as well as direct home-based telerehabilitation. Potential enrollees may be identified through any of several routes, for example, during the acute stroke admission at the clinical site or a referral hospital, during inpatient rehabilitation at the clinical site or a referral hospital, or through other means of community-based recruitment. Study conduct will be highly standardized, including selecting therapy content, delivering therapy, and testing.

The current study aims to critically evaluate the utility of a telehealth approach to motor therapy and stroke education. Telehealth has enormous potential to address unmet needs in the growing population of stroke survivors.

Inclusion criteria

• Age ≥18 years at the time of randomization
• Stroke that is radiologically verified, due to ischemia or to intracerebral hemorrhage, and with time of stroke onset 4-36 weeks prior to randomization
• Arm motor FM score of 22-56 (out of 66) at both the Screening Visit and Baseline Visit
• Box & Block Test score with affected arm is at least 3 blocks in 60 seconds at the Screening Visit
• Informed consent signed by the subject
• Behavioral contract signed by the subject

Exclusion criteria

• A major, active, coexistent neurological or psychiatric disease, including alcoholism or dementia
• A diagnosis (apart from the index stroke) that substantially affects paretic arm function
• A major medical disorder that substantially reduces the likelihood that a subject will be able to comply with all study procedures
• Severe depression, defined as GDS Score >10
• Significant cognitive impairment, defined as Montreal Cognitive Assessment score < 22
• Deficits in communication that interfere with reasonable study participation
• A new symptomatic stroke has occurred since the index stroke that occurred 4-36 weeks prior to randomization
• Lacking visual acuity, with or without corrective lens, of 20/40 or better in at least one eye
• Life expectancy < 6 months
• Pregnant
• Receipt of Botox to arms, legs, or trunk in the preceding 6 months, or expectation that Botox will be administered to the arm, leg, or trunk prior to completion of the 30 Day Follow Up Visit
• Unable to successfully perform all 3 of the rehabilitation exercise test examples
• Unable or unwilling to perform study procedures/therapy, or expectation of non-compliance with study procedures/therapy
• Concurrent enrollment in another investigational study
• Non-English speaking, such that subject does not speak sufficient English to comply with study procedures
• Expectation that subject cannot participate in study visits
• Expectation that subject will not have a single domicile address during the 6 weeks of therapy, within 25 miles of the central study site and with Verizon wireless reception.**

• A site may enroll a person who does not meet exclusion criterion # 17 if this is specifically approved by the site's study PI.
• Because Montreal Cognitive Assessment scores may be difficult to interpret for patients with aphasia, at the discretion of the site's study PI, exclusion criterion #5 ("MoCA score cannot be <22") can be waived.