Telerehabilitation for balance rehabilitation in the subacute stage of stroke: A pilot controlled trial

1 Introduction

Stroke is one of the most disabling cerebrovascular diseases in the adult population and represents a serious problem in the social health system in developed countries (Hankey, 2017; Katan & Luft, 2018; Feigin et al., 2017). Stroke survivors often require long-term medical care and rehabilitation (Lopez-Bastida et al., 2012; Lekander, 2017; Carvalho-Pinto & Faria, 2016). Spasticity, hypertonia, paralysis, hypotonia and paresthesia, are the most frequent sensory and motor disorders and balance and gait are the most important disability in stroke survivors (Suri et al. 2018; Kessner et al., 2016).

In the subacute stage, trunk impairments are frequent (Van Criekinge, 2017; Tasseel-Ponche et al., 2015). Trunk function is closely related to balance and gait (Jijimol et al., 2013). Previous studies reveal the association between trunk performance and the ability to maintain balance while sitting, standing, and even during the gait cycle (Kong & Ratha Krishnan, 2021; Quintino et al, 2018). On the other hand, the greater affectation of the trunk control is a factor of poor functional prognosis among stroke survivors. (Ishiwatari, 2021).

Lumbopelvic stability or core stability exercises should be included in the physiotherapy and rehabilitation sessions especially in the subacute stage (Cabanas-Valdés et al., 2016; Karthikbabu et al., 2018; Souza et al., 2019). Core stability exercises can be adapted to the needs and capacities of the patient; they do not need significant material resources and therefore are a good therapeutic exercise program to perform at home (Powers et al., 2019; Furie & Jayaraman, 2018). From this standpoint, telerehabilitation could be introduced as a guide to specific therapeutic exercises for stroke survivors (Saywell, 2021).

Telerehabilitation is understood as a rehabilitation method through the use of telecommunication devices. The health professional uses electronic devices to give therapeutic strategies and to follow up on patients who are in their homes (Chen et al., 2015; Sarfo et al., 2017). Currently, in the western world, it is considered a simple system that lacks special devices and is quite accessible. Devices for daily use (eg: smartphone or tablet) can support telerehabilitation tools in App format (Moral-Munoz et al., 2021).

Telerehabilitation has the advantage of reducing regional inequality in health care, reducing costs, and reducing the saturation of rehabilitation services, among other potential benefits (Schwamm et al., 2009). On the other hand, it can be a strategy to provide continuity to rehabilitation after discharge from the hospital of the stroke patients facilitating intensity in therapies when material and human resources are not sufficient (Cramer et al., 2021).

The demand for the use of telerehabilitation has increased during the lockdown situation due to the COVID-19 pandemic (Moradi et al., 2021). As a preventive measure in Spain rehabilitation services have been closed and care for patients affected by COVID-19 was prioritized. Many rehabilitation centres and home rehabilitation services closed their doors due to the scarcity of material, human and economic resources and the lack of mandatory characteristics according to approved regulations such as guaranteeing minimum distance or having ventilation systems (Sainz de Murieta & Supervía, 2020; López et al., 2020).

Building on current knowledge and professional practice in performing specific exercises adapted to the needs of stroke patients and the use of assistive devices for telerehabilitation, the aim of this work is to study the effectiveness and feasibility of core stability exercises guided by a telerehabilitation App.

2 Methods

2.1 Participants and procedure

A prospective controlled trial was developed. Forty-nine subjects were recruited from 4 hospitals in Catalonia, Spain (Consorci Sanitari de Terrassa, Fundació Hospital de la Santa Creu de Vic, Hospital Universitari Parc Taulí de Sabadell and Hospital Germanes Hospitalaries del Sagrat Cor de Martorell), from March 2019 to April 2021. All subjects were recruited after finalizing a previous 5-week randomized controlled trial comparing conventional physiotherapy versus core stability exercises (Cabanas-Valdés et al., 2021), at the moment of hospital discharge and return to home. Subjects were invited to participate in this extension study if they or the caregiver were regular users of a smartphone. Subjects with a worsening of their stroke symptoms or any of the comorbidities (eg: another neurological disease or orthopaedic problem of the lower limbs), suffering another stroke or fracture of any of the lower limbs or presenting important structural alterations were excluded. Written consent was obtained from all participants, along with participation in the previous study (Cabanas-Valdés et al., 2021).

At the time of hospitalization in the post-stroke rehabilitation services that participated in this study, patients had been randomly allocated to conventional physiotherapy (control group) or a core stability exercise program (experimental group) conducted by a physiotherapist for 5 weeks. After discharge, all participants continued with their usual care, but participants in the core-stability exercise group (AppG) (n = 20) were offered individualized access to a telerehabilitation application called “Farmalarm” in addition to the usual care (Salgueiro et al., 2021). After the initial assessment, participants in both groups were followed up at 3 months after hospital discharge (Fig. 1).

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Fig. 1

Study flowchart.

2.2 Telerehabilitation

Individuals in AppG had individual access to the “Farmalarm” App (instructions and private username and passwords) as a telerehabilitation tool to guide home-based core stability exercises (Salgueiro et al., 2021). Users have been able to voluntarily access the exercises guide on demand (description, photo and video) and to confirm and to evaluate their performance (Fig. 2). The core stability exercise program proposed in the “Farmalarm” App was known to the participants because they had used it previously during their hospital stay. All the exercises were produced by an experienced neurologic physiotherapist, who was also available for video calls using the App.

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Fig. 2

App user interface.

The principal researcher (CS) had access to the administration panel of the App for individual monitoring of each user and contacted them by phone call to encourage the use of the application and to clarify any possible doubts.

3 Results

Table 1 presents the data related to the characterization of the sample at the baseline. All the results of this preliminary study can be consulted in Table 2.

Therapeutic techniques such as muscle stretching, passive and functional mobilization of the affected body segments, balance exercises and gait training were included as usual care (Teasell et al., 2020). Core stability exercises were not included in usual care therapies. The treatments frequency ranged from 0 to 3 days per week, with an average of 2.5 sessions per week, depending on the needs of the subjects, medical prescription and availability of the rehabilitation centers whose operations were affected by the COVID-19 health crisis.

4 Discussion

The use of a telerehabilitation App “Farmalarm”, as a guide for core stability exercises, seems to bring effectiveness to the usual care in relation to the balance of stroke survivors. However, the results of this preliminary study are not conclusive. In addition the levels of adherence to the use of the App have been very low.

It was not possible to carry out a previous homogenization of the study groups because the participants were recruited after completing a 5-week in-hospital study. However, the groups presented similar characteristics at the beginning of this study. Usual care has not been defined exhaustively. The participants underwent rehabilitation in different rehabilitation services and their management was left to the discretion of each therapist who followed the clinical practice guidelines. It is known that the participants in both groups have undergone an average of 2.5 hours of therapy per week. At the time of hospital discharge, care for the stroke survivor depends on their disabilities, medical recommendations, social and health resources from the public and private, and the involvement of the affected person and their caregiver.

This feasibility study not only focuses on the use of telerehabilitation but also on its content, in this case, core stability exercises, whose efficiency is known in previous studies (Van Criekinge et al., 2019; Cabanas-valdés et al., 2017). The results suggest the introduction of the trunk approach in the recovery process of stroke survivors (Teasell et al., 2020; Arienti et al., 2019).

In a recent review by Cabrera-Martos et al. (2020), the authors conclude that core stability exercises performed in isolation or in combination with other physiotherapy techniques are effective in relation to trunk performance. Similar results were found in this preliminary study. The greatest changes have been observed in sitting balance, directly related to trunk function.

The use of the Telerehabilitation App “Farmalarm” also seems to add benefits to users with regard to balance while standing. The results of this preliminary study were not significant enough to assume a definitive conclusion and establish a correlation with the performance of the proposed exercises.

In the recent study by Wu et al. (2020), significant improvements in balance were found in patients who underwent telerehabilitation immediately after deinstitutionalization, even compared to patients who only underwent regular rehabilitation. The study had a greater number of participants and a shorter intervention time.

Telerehabilitation seems to have had a positive influence on gait. The results of the specific gait analysis have been scattered due to the poor number of participants with autonomous gait. Even so, there was an improvement in patients who have been offered to use the App to perform exercises at home. In the early stage of stroke rehabilitation, some patients may not have had the ability to walk. However, previous studies establish the relationship between the trunk and balance and gait (Van Criekinge et al., 2017; Kong et al., 2021). Specifically, the correlation between sitting balance and mobility has been recently studied by Lee et al. (2021).

The lack of greater results may be related to poor adherence to performing exercises autonomously at home and for the loss of participants. This practice can go through telerehabilitation that seems to be as effective as performing therapy in person in the health services (Chen et al., 2019; Knepley et al., 2021). Although there are no clear results, telerehabilitation can be effective in maintaining the physical condition of users and preventing deterioration (Saywell et al., 2021).

In Spain, as in the rest of the countries affected by COVID-19 pandemic, rehabilitation and physical medicine services have been indirectly affected by the decrease and / or absence of face-to-face activity and by the transfer of physical and human resources to the care of patients affected by COVID-19 (Expósito Tirado et al., 2020). Although it is recommended to incorporate telemedicine into clinical practice, this has only been observed with the health crisis of COVID-19 (Beare et al., 2021; Anil et al., 2021). With this analysis, the lack of information and the absence of publications, it is assumed that telerehabilitation, in the case of survivors of stroke, is not established in the health system in Spain, although it is recommended by clinical practice guidelines (Winstein et al., 2016).

Currently, it is possible to see the improvement of digital systems for remote rehabilitation, in this case easily accessible Apps, and their possible usefulness as a complement to regular care. They are not only emerging in the face of periods of isolation such as confinement by COVID-19 (Moradi et al., 2021; Sainz de Murieta & Supervía, 2020) but they can also be beneficial in cases of geographic isolation to reduce the costs of transfers or the saturation of rehabilitation services (Schwamm et al., 2009). The Apps offer the immediate continuity of rehabilitation at the time of hospital discharge (Chen et al., 2015; Zerna et al., 2018; Halbert & Bautista, 2019). The increasing cost of institutional healthcare to society has triggered an ever-growing interest in moving healthcare services beyond the boundaries of hospitals and clinics. Moving parts of healthcare processes into the private homes and everyday life of the patients means an increased responsibility for people to actively engage in managing their health conditions.

Self-responsibility behaviors of stroke survivors should be reinforced in their recovery process (Burns et al., 2020). One of the strategies could be to clarify the participants and their families the relationship between the recommended exercises and the possible achievements at a functional level and the contribution of greater intensity to the rehabilitation process (Cramer et al., 2021).

5 Conclusion

The use of the Telerehabilitation App “Farmalarm” as a core stability exercise guide seems to improve the balance and gait of patients with stroke in the subacute stage. Telerehabilitation could be included in current clinical practice but future studies and strategies must be explored to increase adherence to its use.

The education process before discharge from hospital seems to be essential to involve and increase the compromise, engagement and self-responsibility of the patient and / or their caregiver in the rehabilitation process.