Stroke: Intervention Design and Implementation


Home telehealth is used to address the needs of post-stroke patients in a variety of ways.[1]  Those who are on oral anticoagulation therapy can use remote monitoring services to get feedback on medication dosage.  Rehabilitation can be facilitated by virtual-reality systems that allow patients to perform range-of-motion exercises at home while being guided by therapists in a different location.  Home telehealth can also be used for education and emotional support.  These interventions can incorporate web portals, videoconferencing sessions with providers, and online discussion forums or e-mail services.



Basic Model

Stroke interventions fell into 3 broad categories: rehabilitative, educational, and supportive of oral anticoagulation therapy management. While a basic model can be identified for each, none can be described as representative of the entire stroke canon.

Studies that focused on rehabilitation used videoconferencing units and/or personal computers at both ends of the patient-provider interface (Holden et al., 2007; Piron et al., 2006, 2009). Three-dimensional motion tracking technology was used to enable the care provider to remotely observe and guide the patient through rehabilitation exercises. These sessions took place in real time.

Interventions designed to facilitate education relied primarily on internet-enabled personal computers, although 1 also featured a messaging device that attached to a home telephone line (Lutz et al., 2009; Pierce et al., 2009; Steiner et al., 2008). The target populations in these studies included caregivers as well as stroke patients. In the study described in Steiner et al. (2008) and Pierce et al. (2009), caregivers of stroke patients were given access to a website that provided online education and support. Content included tailored information about stroke, links to other resources, a discussion forum, and a secure e-mail service that patients could use to contact the study nurse. In Lutz et al. (2009), education on stroke signs, symptoms, and risk factors was available through a messaging device tailored for stroke patients and family caregivers.

The remaining 3 studies (O’Shea et al., 2008; Ryan et al., 2009; Salvador et al., 2008) focused on the management of oral anticoagulation therapy for primary or secondary prevention of stroke. The technologies used in these interventions included internet-enabled personal computers at both ends of the patient-provider interface and mobile communication devices. Although the intervention design bears superficial resemblance to that used in the educational interventions described above, bi-directional communication was essential in these interventions. The management program CoagCare, in which an algorithm-based expert system provides patients with feedback, was used in 2 studies (O’Shea et al., 2008; Ryan et al., 2009). Participants were given instructions for accessing a secure website and entering clinical data on their symptoms, medications, diet, and self- tested International Normalized Ratio (INR). Normal values were set prior to beginning the intervention and the system was programmed to provide automatic feedback based on these lower and upper limits. A health care provider was able to override or adjust these recommendations if desired. Salvador et al. (2008) was similar, but lacked an automated component and used mobile technology. Patients self-tested their INR and sent this information to their physicians by cellular phone. Providers accessed this information remotely and responded directly to the patients with recommendations.


Human Resource Requirements

In the majority of studies, the primary health care provider involved in intervention delivery was either a therapist or a nurse (Holden et al., 2007; Lutz et al., 2009; Pierce et al., 2009; Piron et al., 2006, 2009; Steiner et al., 2008). Provider time commitment was given in 5 of the 8 studies. This tended to fall between 10 and 20 hours per month. A limitation of reporting in this area is the lack of precise breakdowns of this time commitment. Whether these estimates include time required for tasks such as administrative work is uncertain. Additional details can be seen in the table below (Table C.2.2.2: Human Resource Requirements).


Technical Requirements

Minimum hardware requirements in stroke interventions were internet-enabled personal computers and/or mobile devices. More specialized equipment included videoconferencing units with peripherals. One might speculate that the comparatively infrequent use of mobile devices in stroke interventions is partly attributable to patients’ physical limitations.

Software was in some cases quite complex. Several rehabilitation studies examined applications of recent advances in virtual reality software (Holden et al., 2007; Piron et al., 2006, 2009). Patients’ arm motions were translated into on-screen trajectories that could be viewed by remote providers. In the CoagCare management program, as mentioned previously, an algorithm automatically prioritized patients’ data uploads and used pre-existing dosing guidelines to respond with care advice and forward alarming test results to providers. Additional details can be found in O’Shea et al. (2008) and Ryan et al. (2009).


Departures from Basic Model

Lutz et al. (2009) was unusual in its use of a device programmed with a disease dialogue application: a set series of daily questions about physical status/impairment, incidence of and attitudes towards falls and near falls, symptoms of depression, and level of burden experienced by family caregivers. Patients used a device that attached to their home telephone to reply to these questions daily. Data was transmitted to a web-based program that was accessible to medical centre nurses. Patient information was then reviewed by the nurses and entered into the computerized patient record system.

In Salvador et al. (2008), patients were provided with a portable coagulometer that automatically transmitted test results to a provider-accessible server. Coagulation test results, as well as any alerts put out by the automated decision support system, could be accessed by the provider through a mobile device if desired. As noted above, this use of mobile devices was unusual in stroke interventions. Salvador et al. (2008) also stands out as somewhat unusual within this review as a whole; it was uncommon for mobile devices to be used on the provider side instead of – or as well as – on the patient side.


[1] Note that the definition of ‘home telehealth’ that was used in this review does not include telehealth systems designed to facilitate hospital-to-hospital or provider-to-provider contact.  So-called ‘hub-and-spoke’ stroke networks are therefore excluded, as are systems designed to be used during emergency transport.


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