A resource efficient, high-dose neurorehabilitation program for chronic stroke at home

Following a stroke, both accumulating scientific evidence and medical guidelines recommend that patients receive high-dose neurorehabilitation to aid in recovery. The reality, however, is that most patients receive a fraction of the dose required. This gap between required and actual dose is due to implementational barriers, with lack of therapist availability and costs of high-dose delivery arguably being the two main ones. Here, we investigated the extent to which these barriers could be alleviated by using gamified self-training technologies at home under remote therapist supervision. We delivered a comprehensive full-body, high-dose neurorehabilitation program to chronic stroke patients entirely at home. The goal was to achieve approximately 36 hours of Active Training Time (ATT) over 12-18 weeks. The program was designed to be resource efficient, relying mostly on the patient training on their own (asynchronously) with the MindMotion GO gamified therapy solution. Additional telerehabilitation (synchronous) sessions with a therapist were interspersed once weekly, during which therapists used teleconference technologies to deliver additional training and provide direct feedback. Throughout, therapists were able to use a web application to continuously monitor and manage the training program remotely. We assessed effectiveness through reporting ATT, a measure more closely reflecting delivered dosage as opposed to scheduled dose. Patient recovery was evaluated with standardized impairment and functional clinical measures, and patient self-reported outcome measures. Finally, a cost model was computed to evaluate the resource efficiency of the program. Data from 17 patients was included in this retrospective analysis of a real-world clinical service. Patients completed an average cumulative ATT dose of 39.7 ±21.4 hours and maintained high levels of training adherence over the course of 19.2 ±3.3 weeks. The majority of the total ATT was delivered asynchronously (82.2 ±10.8% of total ATT). Patients showed improvements in both upper-limb (Fugl-Meyer Upper Extremity, 6.4 ±5.1 points; p¡0.01) and gait and balance measures (Functional Gait Assessment, 3.1 ±2.6 points; p¡0.01; Berg Balance Scale, 6.1 ±4.4 points; p¡0.01). Overall, the program was viewed very favorably amongst patients, with 73.7% respondents being satisfied or very satisfied, while 63.2% of respondents reporting subjective improvements in physical abilities. Finally, therapist costs associated with the program amounted to 338 USD, thus representing a resource efficient alternative to delivering the same dose via one-on-one in-person training sessions (therapist costs amounting to 1903 USD). This work demonstrates that effective high-dose neurorehabilitation can be delivered via gamified therapy technologies in the home setting. Furthermore, we show that training time can be successfully decoupled from therapist-presence without compromising therapy delivery and outcomes or patient satisfaction. In the context of a growing concern over therapist availability worldwide, this program presents a human resource-efficient model that delivers high-dose neurorehabilitation as mandated by recent medical guidelines, complementing existing clinic-based approaches.