Often, when a study looks at whether any given treatment can be improved, patients can simply default to the existing treatment if the study doesn’t work out as expected. But for stroke survivors who live in rural areas, there is no Plan B, explained Edward Jauch, M.D., director of acute stroke trials at MUSC and principal investigator at the Southeast Collaborative Alliance for Stroke Trials.
In theory, these patients could have someone drive them into Charleston or another metropolitan area three days a week for six weeks so they could undergo intensive therapy to help them regain motor function and thereby restore some of their independence.
“The reality is that is not going to happen,” said Jauch, who said the realities of living in these areas were brought home to him when he researched access to stroke care in rural Georgetown County. A new study comparing the outcomes of tele-rehabilitation in the home to in-clinic therapy for people who suffered a stroke now offers a lifeline for rural residents.
MUSC was involved in the nationwide trial, which was conducted at 11 sites and led by neurologist Steven Cramer, M.D., of the University of California, Irvine. The study revealed that providing occupational therapy for arm movements via home-based tele-rehab was just as effective as traditional in-clinic rehab. The outcome is an exciting turn of events for members of the Southeast Collaborative Alliance for Stroke Trials. The alliance, housed at MUSC, includes faculty from emergency medicine, neurology, neurosurgery, radiology, the College of Health Professions and College of Graduate Studies, in conjunction with Greenville Health System, Augusta University and the University of South Carolina.
This particular study involved the MUSC Center of Biomedical Research Excellence (COBRE) in Stroke Recovery, with Michelle Woodbury, Ph.D., an associate professor in the Department of Health Science and Research and Division of Occupational Therapy, leading the MUSC team. “I wasn’t 100 percent either way” when the study started that the tele-rehab would or wouldn’t work, Woodbury said.
She worked as an occupational therapist for many years, and therapists are accustomed to working side by side and face to face with their patients as they encourage and push them to do more, she said. “I was skeptical anything could be as good,” Woodbury said. But with the results of this study there is now hope for the widely recognized problem of rural access to occupational therapy services. “We may be standing at the brink of a change in practice,” she said.
During the trial, patients were provided a large computer monitor and a specialized board that included a joystick, buttons, fasteners and squeeze grip, among other items. They played games that required them to use those devices. Not only could the therapist watch the patient via the two-way connection — like a “really fancy Skype” — but the board would relay information about the strength of the patient’s grip and how often they performed each function.
In therapy, practice is the name of the game, and therapists give their patients goals for how many repetitions they should do. The patient also receives homework to do on their own between OT sessions. In addition to the equipment, MUSC provided the Verizon connection so patients didn’t need to have their own Wi-Fi connections. Meanwhile, the patients receiving traditional therapy were performing the same exercises in a clinic setting and receiving similar instructions for self-directed sessions at home.
The results showed an increase for the in-clinic patients of 8.4 points on the Fugl-Meyer scale, which measures arm motor status, and an increase of 7.9 points for the tele-rehab patients, a difference that wasn’t statistically significant, according to experts at UC Irvine. Therapists envision recovery from stroke as a pathway lined with milestones, and an increase of eight points essentially means the patient has moved on to the next milestone, Woodbury said. For a patient who started the program unable to grasp anything and barely able to lift her arm from her lap to the table, this could mean she could now hold something. For a patient who started the program able to hold onto something, but not for long durations or anything very heavy, this could mean he was able to hold an object longer.
Considering the many mundane daily tasks that are difficult to nearly impossible to achieve with only one hand — from getting dressed and making meals to gardening or playing cards — conquering one milestone could have a significant effect on the patient’s life. That the tele-rehab patients improved as much as the in-clinic patients had a profound effect on patients and their loved ones. Woodbury described a tele-rehab patient in Kingstree, a small community in Williamsburg County some 75 miles from Charleston, whose entire family showed up to thank researchers when they returned at the end of the study to retrieve the equipment.
Another patient told researchers she felt like her therapist was right there in the living room with her and wondered what she would do without her when the researchers removed the equipment. Besides the effect it could have for rural residents, the study is also significant in that it points to a new direction of research for the National Institutes of Health’s NIH StrokeNet. The NIH typically has focused on immediate recovery, conducting studies at hospitals that focus on the first hours or days after a stroke, Woodbury said. This study marks the first time it has funded a study looking at rehab, the part of recovery that occurs weeks and months after a stroke.
One of the next steps would be to fund more rehab studies, Woodbury said. While this tele-rehab study focused on arm movements, future studies could look at whole body therapy and gross motor functions. Woodbury said Cramer, the lead researcher, could also make the study more broad, pulling in more subjects, or he could decide to zero in on a particular subset of patients. Another step would be to compare the costs of providing services through telehealth versus the traditional way so that insurance payers can cover the therapy.
Other telemedicine services are proving cost-effective, Jauch said, but tele-rehab will also have to prove itself. The positive news from the study comes as the Southeast Collaborative Alliance for Stroke Trials at MUSC has just been renewed as a NIH StrokeNet Regional Coordinating Center for another five years.
There is plenty to study, said Jauch, as some 800,000 people across the U.S. suffer strokes each year. South Carolina is part of the “stroke belt,” so named because the incidence of stroke is so much higher than the rest of the country. South Carolina has the sixth-highest rate of stroke deaths among the states, according to the Centers for Disease Control and Prevention. Strokes caused 16,484 hospitalizations in the state in 2016, and 39 percent of those hospitalized were less than 65 years old, according to the South Carolina Department of Health and Environmental Control.