A man who sustained a brain injury in a car accident is sitting in front of his laptop at home, while a researcher asks him to perform a variety of tasks. In this case, the doctor asks the patient to find the best route between a hotel and restaurant in Milan. He clicks through Google Street View, taking in the cafés and storefronts. But wait, the instructor says, we want to avoid construction on the route. Can you find another way?
This exercise, developed by Dr. Robin Green, a KITE Research Institute scientist and Canada Research Chair in Traumatic Brain Injury, Dr. Asaf Gilboa, an affiliate scientist at KITE and others, is helping people with brain trauma improve their problem solving and memory. What's more, this kind of mind-saving exercise can be done at home, without any in-person interaction with the instructor. It's just one example of virtual rehab, also known as telerehab, which has, naturally, taken off since the pandemic began.
Over the next months and potentially years, demand for telerehab is expected to explode. COVID-19 has forced clinicians around the world to rethink the ways they treat patients in every area, including rehab. Instead of having a patient drive to a hospital, which comes with risks for injured or elderly people, including potentially being exposed to the novel coronavirus, they can get the same kind of treatment without leaving their home.
“This is an opportunity to springboard telerehab forward,” says Dr. David Alter, a cardiologist and senior scientist at KITE. “We launched virtual rehab in a matter of weeks in response to the pandemic. Going forward, we can take advantage of the technology KITE has to monitor people in their homes and make sure the rehab they get is the best possible quality.”
While the pandemic caught a lot of medical professionals off guard, KITE already had some of the technology and tools in place to launch a COVID-19–related telerehab program. For the past three years, researchers have been testing out various telerehab methods, involving video chats, exercise-tracking software and wearable monitors. They've found that patients who engage in virtual rehab participate more consistently and for longer than those who do traditional in-person rehab. While many challenges still stand in the way of wide-scale adoption, from spotty internet to technical issues, KITE researchers are determined to make telerehab more accessible and more effective.
In 2017, Dr. Green helped establish the Telerehab Centre for Acquired Brain Injury at the University Health Network (UHN) because she saw that many people with an acquired brain injury – due to a stroke or an accident, for example – don't have access to scientifically proven rehabilitation methods. There may be a local community centre that offers helpful social programming, but not therapies and exercises that have been developed and tested specifically for patients with a brain injury; therapies that protect the brain and enhance thinking and mood, she says.
While Dr. Green uses new therapies like her Google Street View exercise, the main telerehab she and her colleagues provide is through live video conferencing to groups of patients in remote regions throughout Ontario. A therapist meets with groups who have similar brain injuries, and provides them with proven cognitive and mood therapies to help them adjust to and recover from brain injury. Teletherapy is powerful because it brings people with specific types of brain injuries together, even if they live hours apart. This is important, as research shows that engaging with people who are going through similar traumas is hugely helpful to patients, she explains. “Telerehab lets you reach and bring together very vulnerable people who are often already economically disadvantaged due to their disability; marginalized groups who have little access to care,” she says.
While telerehab for brain injury requires only a video conferencing app and an internet connection, Dr. Alter is looking into how wearables and other home monitors can enhance telerehab for cardiac patients. He's researching how to best incorporate everything from wearable fabrics, home heart rate monitors and blood pressure machines so he can offer guidance to other telerehab providers. “We have a lot of technology, but we need to be able to validate that technology scientifically to know that it is providing accurate information,” he says.
For the last three years, Dr. Alter has been leading a team of physicians, kinesiologists, dietitians and others who provide telerehab to patients with heart disease or those who may be at risk of getting it. Through weekly video conferences, they help patients adjust their diet, quit smoking, lower their stress levels and, most of all, exercise. Patients can track their exercise duration and intensity using software that allows the providers to follow their progress.
Dr. Alter's research has shown that, thanks to the video lessons, patients feel confident measuring their exercise progress each week, based on their heart rate and the duration and frequency of the exercise. They also know how much easier it is to set up appointments, which helps them keep their rehab going for longer, he notes. Most importantly, telerehab improves people's health. Patients with heart disease who've received telerehab often experience improvements in cardiac fitness, blood pressure, blood sugars, weight and quality of life, with less measurable breathlessness, within as little as three months, as compared to their health status prior to telerehab initiation.
With COVID-19 now making virtual rehab a must-do, doctors, therapists and others from across the world are turning to KITE for insights. Dr. Mark Bayley, Physiatrist in Chief at UHN, and Medical Director, Toronto Rehab, has spent the last few months researching the adoption of telerehab in the pandemic. He's looking at the barriers patients and providers have faced, including “video fatigue” and people's ability to download rehab-related apps. He wants to find ways to overcome these challenges and better understand in which situations in-person or telerehab is best.
For his own stroke patients, Dr. Bayley sees telemedicine as an important tool for getting a real-world view into a patient's life, which then helps him both care for his patients and find new ways of providing rehab. “If one wants to do a kitchen assessment (a type of assessment to see a stroke patient's everyday level of functioning), I don't have to bring them into my lab. I can watch them go through the routine of preparing lunch in their own environment.”
While telerehab has been around for a while, COVID-19 will only speed up its adoption – and the development of technology to enable this kind of care. In the future, artificial intelligence bots might tell a patient if they're working too hard or if their heart rate is high and they should ease off what they're doing, says Dr. Bayley. Basic video conferencing and even old-fashioned telephone appointments will also become more widespread. Dr. Green has already demonstrated that phone therapy has as many benefits as face-to-face therapy when it comes to treatment of depression and anxiety in neurological patients.
The ultimate goal is not to create a fancy new gadget – it's to provide care in an environment that people are comfortable in, and to remove the stress, time and cost of travel. As Dr. Bayley explains, “We know that when we provide care to people in their own homes, many people will do better.”