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TRAIL study brings new remote rehab potential to stroke survivors

The telerehabilitation programme will assess the impact of exercise-based therapy that has been traditionally done in-person

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Through the use of telerehabilitation, stroke survivors are being supported in new ways to progress rehab that would traditionally have been done in-person. NR Times speaks to the Canadian-based pioneers of the TRAIL program, Dr Ada Tang and Dr Brodie Sakakibara, to learn more about their work

What is the purpose and intention of the TRAIL study?

We developed the TeleRehablitation with Aims to Improve Lower extremity recovery post-stroke (TRAIL) program to address the need for continued lower extremity rehabilitation after stroke that were not being met through standard hospital-based rehab services. 

The COVID-19 pandemic certainly contributed to further reductions in access to stroke rehabilitation, so we realised there were even greater gaps in care than ever before.

Our study is examining the effectiveness of the four-week TRAIL program through a randomised controlled trial. We will compare how participants with stroke do after TRAIL, compared to those who participate in an education program.

We will compare the groups in terms of various lower extremity functional measures of mobility (through the Timed Up and Go), strength, balance and motor impairment, as well as balance self-efficacy, health-related quality of life, and use of healthcare resources and healthcare

Dr Ada Tang

costs.

Why did you choose to investigate rehabilitation for lower extremity recovery after stroke – what is the existing provision in this area? 

Research shows that 80 per cent of people living with stroke report residual motor impairment that affect many daily activities such as dressing, bathing and walking.

There is lots of strong evidence showing that lower extremity exercise programs, delivered in-person and face-to-face, improves independence, walking and balance after stroke. Exercise also improves psychosocial outcomes such as balance, self-confidence and quality of life.

The rapid growth in internet use and mobile devices has opened up many possibilities for people with stroke to access specialised rehabilitation remotely from their homes and their communities (i.e. telerehabilitation). 

To date, most of the research around telerehabilitation focuses on check-in sessions, or education and counselling after stroke, whereas the use of technology to deliver remote exercise interventions for the lower extremity is much more limited. Instead, most exercise programs that focus on lower extremity recovery for walking and balance have been delivered in-person to manage safety issues and risk of falls.

How has your project developed since its launch in 2019?

When we first conceived TRAIL, we looked at the small body of research that has focused on telerehabilitaiton for lower extremity recovery after stroke and found that most studies provided very minimal therapist oversight, and none were conducted in the first year following stroke when the opportunity for neuroplastic change is greatest.

We designed the TRAIL program to provide opportunities for live videoconference interaction with a physiotherapist two times a week for four weeks for the exercise portion. We also designed the program to encourage independent exercise in at least one additional session per week, to add volume of exercise without using therapist resources, and to provide participants with strategies for exercise self-management. 

In early 2020, we were getting ready to soon launch the study when the COVID-19 pandemic swept across the globe. We quickly realised that telerehabilitation was needed more than ever, but we needed to change a few things about our study. 

Namely, we moved to virtual outcomes assessments in addition to virtual delivery of the exercise program. We consulted with many expert

Dr Brodie Sakakibara

therapists and researchers on how best to do this, who were incredibly generous with their advice and suggestions.

We conducted a pilot study of TRAIL in 2020-2021 that involved 32 participants. We also completed a qualitative study with our participants to help us understand how they perceived TRAIL, as well was with the physiotherapists for their perceptions of delivering TRAIL. We are in the process of analysing the data from the pilot study and the qualitative interviews right now.

In summer 2021, we were excited to learn that we received grants from the Canadian Institutes of Health Research and Canadian Medical Association to continue our work in TRAIL, which we are using now for the randomised controlled trial. 

Why did you choose to work on a telehealth project? What was the response to this pre-pandemic and how has this changed?

TRAIL was a way to fill and unmet need by providing access to lower extremity rehabilitation opportunities once in-person services had ended.

We started planning the first TRAIL study in late 2019 – little did we know that a global pandemic was about to hit and the need for telerehabilitation programs became even greater. 

How vital is the use of technology in joint working across the miles?

We wouldn’t be able to run TRAIL without technology! And are glad to be able to get lower extremity rehabilitation programs to more people.

Canada is a large country though with a large geographical area and many regions that are rural and remote. There will be some people who don’t have access to the technology needed to participate in TRAIL. 

In our studies, we are looking at the feasibility of TRAIL (for example, who can access TRAIL, how far (distance) can it go) as much as we are looking at its effectiveness.

What is next for TRAIL and what is its potential?

We are getting ready to launch the randomised controlled trial early this year. We have two of our five sites ready to go; the other three are not far behind. We aim to enrol 96 people into the study.

Once complete, it will be one of the largest RCT to date looking at telerehabilitation for lower extremity recovery after stroke.

  • Dr Ada Tang is an associate professor in the School of Rehabilitation Science at McMaster University. Dr Brodie Sakakibara is an assistant professor with the Department of Occupational Science and Occupational Therapy at the University of British Columbia

Dr Tang and Dr Sakakibara will discuss TRAIL and its impact at the Virtually Successful conference, a first-of-its-kind five-day event next week organised by Remote Rehab in association with NR Times, to assess the impact and potential of digitalisation in therapy.

For more details or to sign up, visit here

Tech

GripAble praised by MP

Stephen Hammond MP hails its innovation and “extraordinary” success to date and potential

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The progress of GripAble has been hailed as “extraordinary” by its local MP, who praised its innovation and ongoing progress in transforming neurorehab and wider healthcare.

GripAble, the UK technology company digitising upper limb rehabilitation from hospital to home, welcomed Stephen Hammond, MP for Wimbledon, to its international sales and distribution centre.

Mr Hammond visited GripAble’s office in Wimbledon to learn how private equity investment has helped it to scale its industry-leading data platform and therapy services and expand GripAble into Europe and the US, as well as how an international company has successfully stemmed from the local business community. 

During his visit, the MP met the GripAble team and listened to a presentation by GripAble co-founder and CEO Dr Paul Rinne, who shared the background to GripAble and its growth story to date, as well as plans and ambitions for the future.

Prior to becoming an MP, Stephen Hammond worked for a leading fund management company and multiple investment banks, so was particularly interested in the funding GripAble has received to date, including the recent close of its $11m funding round. 

With more than 8,000 individuals having already used the platform, GripAble has established itself as a leading technology in the remote-rehab space in the UK, recording 100,000 activity sessions and 27 million movement repetitions across its users.

Stephen Hammond MP said: “GripAble proves that innovative companies of the future that are building products that will transform healthcare can be based anywhere, but I’m particularly proud that GripAble has started out in Wimbledon. 

“It’s been wonderful to see the development of the company over the last two years since first meeting Paul, and I’m sure the developments over the next three years will be equally extraordinary, particularly with the backing of private equity investment.”

Dr Rinne said: “Today’s visit was a fantastic opportunity for us to showcase GripAble’s story and vision to a Member of Parliament and explain how private equity investment can help UK-based entrepreneurs take ideas from seed stage through to global scaling, and compete on the international stage. 

“The investment we have received will accelerate GripAble’s journey to delivering end-to-end patient rehabilitation and connecting millions to their own personal home-based clinic. 

“With the backing of investors such as IP Group and Parkwalk, we will benefit from a wealth of insight and experience that will support us in growing our platform in the US and expanding our clinical and commercial evidence base. 

“It is great to be able to work with such supportive investors that make our lives so much easier.”

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Stroke

True impact of stroke underestimated, new research reveals

The Stroke Association study shows the lack of knowledge of the levels of disability it can cause, or that it is the UK’s fourth biggest killer

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More than half of people in the UK do not know stroke is the fourth biggest killer in Britain, with a fifth of people underestimating its impact, new research has revealed.

A new study from the Stroke Association reveals 51 per cent did not realise how deadly stroke can be, and 18 per cent did not know it is the UK’s fifth biggest cause of disability. 

In fact, two thirds of the 1.3million stroke survivors in the UK find themselves living with a disability, with over 50 per cent dependent on others for every day activities. 

The research also found that people do not understand the true long term damage a stroke can cause:

  • More than two-thirds (67 per cent) of people are unaware that fatigue is a common hidden effect of stroke
  • More than two thirds (67 per cent) don’t realise that stroke can cause depression and anxiety
  • Around a third of people (32 per cent) don’t know that communication difficulties are common after stroke
  • Almost three quarters of people (74 per cent) don’t know that stroke can affect hearing
  • Two thirds (66 per cent) are unaware that stroke survivors can experience vision problems.

Despite the devastating impact of stroke, stroke research remains underfunded and receives far less funding than other health conditions that have similar life-long effects.

For personal trainer Glen Eastick, his stroke happened when he was just 33 and a new father in July 2020, during the pandemic period when hospital visits for stroke decreased significantly.

Glen’s symptoms started while he was preparing his lunch. 

“I briefly lost the use of my arm for about ten seconds and dribbled a bit but then continued making lunch,” said Glen.

“Then when I went into my next online session I realised I couldn’t talk. Nothing was coming out except the odd word. My client was saying ‘Are you ok?’

“My girlfriend Bex was out on a walk with our six-week-old baby Evie and as soon as she came back she realised something was wrong as I was struggling to talk. She called the ambulance and I was rushed into hospital.”

Ironically, the stroke specialty doctor waiting to treat Glen at the Queen Alexandra Hospital in Portsmouth, was James Beckett who is also one of his personal fitness clients.

A scan confirmed that Glen had had a stroke and he was thrombolysed – given special drugs to dissolve the clot which was blocking the blood supply and killing cells in his brain.

Thanks to the prompt action by Bex who spotted the “FAST” stroke symptoms, the skills of hospital staff and his own determination, Glen has made a good recovery.

Now Glen is backing the Stroke Association’s call for more research into stroke.

Juliet Bouverie, chief executive of the Stroke Association, said: “Stroke strikes every five minutes in the UK and while it changes lives in an instant, the brain can adapt and rebuild after stroke. 

“That’s why research means everything to our nation’s 1.3 million stroke survivors and their families, because of the life-changing impact it could have on their future.

“Our pioneering research has been at the centre of major breakthroughs that have saved lives and sparked innovation in stroke care and treatment. 

“From laying the foundations for the Act FAST campaign, one of the most successful public health awareness campaigns in England, to funding early research into the emergency stroke treatment thrombectomy, many patients have been spared the most devastating effects of stroke as a result of our research.

“Despite stroke still being the fourth biggest killer in the UK, research has helped to more than halve the rate of deaths from stroke over the last three decades. It’s absolutely crucial that we continue this progress, but we can’t do this without vital funding.”

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Stroke

Online intervention ‘can improve stroke survivors’ quality of life’

Accessible, interactive and tailored support can deliver significant health benefits, a new study reveals

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Online support for adult stroke survivors that provides accessible, interactive and tailored interventions is associated with better health-related quality of life, new research has revealed. 

Stroke can lead to serious physical and cognitive disability, with lifestyle and health behaviours including smoking and drinking, physical activity, diet and depression all being important in survivors’ quality of life. 

Now, a new study has revealed that online programmes which support stroke survivors with such factors can deliver great benefits. 

It builds further on existing research into other forms of remote rehab to show how impactful online and virtual support can be. 

“Online platforms are a viable and impactful model to address the health information needs and behaviour change challenges of stroke survivors,” says Dr Ashleigh Guillaumier, from the University of Newcastle.

Led by Dr Guillaumier, and senior author Professor Billie Bonevski from Flinders University, the study undertook a randomised control trial to evaluate the online program Prevent 2nd Stroke” (P2S), which encourages users to set goals and monitor progress across various health risk areas.

399 adult stroke survivors with an average age of 66 were asked to complete a telephone survey, following which they were randomly assigned to receive either a list of generic health information websites or 12 weeks of access to the P2S online program. 

The group with P2S access also received additional text messages encouraging use of the program.

Nearly all participants then completed a six month follow-up survey, with the researchers finding those who received P2S access had a higher health-related quality of life (HRQOL) score than those who received the generic health information.

Compared to those in the control group, significantly higher proportions of people in the group who received access to P2S also reported having no problems with personal care and an ability to participate in their usual daily activities.

The authors say that while most of the participants were generally “well” stroke survivors, with little to no disability, limiting the scope of the study, it still points to the benefits of the online program.

“This paper is the culmination of eight years of research, starting with a small grant from the National Stroke Foundation that funded the development of the online program which was co-developed with consumers and key stakeholders,” added Professor Bonevski.

“The next step for Prevent Second Stroke is to scale up its implementation to ensure it reaches and benefits the highest number of people who have experienced a stroke, including those with greater stroke-related disability.”

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