Tele-rehabilitation of upper-extremity hemiparesis after stroke: Proof-of-concept randomized controlled trial of in-home Constraint-Induced Movement therapy

Article type: Research Article

Authors: Uswatte, Gitendra^{a; b; *} | Taub, Edward^a | Lum, Peter^c | Brennan, David^d | Barman, Joydip^a | Bowman, Mary H.^a | Taylor, Andrea^a | McKay, Staci^a | Sloman, Samantha B.^a | Morris, David M.^b | Mark, Victor W.^{a; e; f}

Affiliations: [a] Department of Psychology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA | [b] Department of Physical Therapy, UAB, Birmingham, AL, USA | [c] Department of Biomedical Engineering, The Catholic University of America, Washington, DC, USA | [d] MedStar Telehealth Innovation Center, MedStar Institute for Innovations, Washington, DC, USA | [e] Department of Physical Medicine & Rehabilitation, UAB, Birmingham, AL, USA | [f] Department of Neurology, UAB, Birmingham, AL, USA

Correspondence: [*] Corresponding author: Gitendra Uswatte, PhD, Department of Psychology, UAB, 1720 2nd Avenue S, STE CH415, Birmingham, AL, 35294, USA. Tel.: +1 205 975 5089; Fax: +1 205 975 6140; E-mail: guswatte@uab.edu.

Abstract: Background:Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT. Objective:Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis. Methods:Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants’ homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab. Results:Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d′ = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d′ = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants’ perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = –0.1, 95% CI = –1.3–1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome. Conclusions:This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Keywords: Stroke, upper extremity, hemiparesis, physical rehabilitation, telehealth, randomized controlled trial

DOI: 10.3233/RNN-201100

Journal: Restorative Neurology and Neuroscience, vol. 39, no. 4, pp. 303-318, 2021