TeleRehab for Stroke Patients Using Mobile Technology
TeleRehab for Stroke Patients Using Mobile Technology
Post-stroke communication deficits (PSCD) are a common symptom of patients having sustained a
 stroke. These deficits include difficulty to produce or understand language, motor speech
 disorders and cognitive-communication disorders. It is estimated that approximately 40% of
 stroke survivors will have communication disorders post stroke.

 In this randomized controlled study, the investigators' objective is to test the value of
 providing a mobile platform-based Speech Language Therapy (SLT) program to patients
 discharged from an acute care hospital with stroke and PSCD and awaiting outpatient rehab
 services versus standard of care treatment. The investigators will offer iPad-based
 SLT/standard of treatment to a convenience sample of 20 patients with post-stroke
 communication deficits. The primary outcome will be feasibility (recruitment rate, adherence
 rate, retention rate, and protocol deviations), and the secondary outcome will be improvement
 in PSCD.
A. APPLICANT INFORMATION

 Proposed Project Title TeleRehab for Patients with Post-Stroke Communication Deficits using
 Mobile Technology

 Primary Investigator

 Karen Mallet, M.H.Sc., M.Ed. SLP (C) Speech-Language Pathologist Champlain Regional Stroke
 Network and the Ottawa Hospital - Civic Campus 1053 Carling Avenue, Ottawa, ON K1Y 4E9

 Co-PI: Dariush Dowlatshahi MD PhD FRCPC Assistant Professor, University of Ottawa Scientist,
 Ottawa Hospital Research Institute Ottawa Hospital Civic Campus C2182b 1053 Carling Ave,
 Ottawa, ON K1Y 4E9

 Primary Research Site Ottawa Hospital Research Institute

 B. LAY SUMMARY Post-stroke communication deficits (PSCD) are a common symptom of patients
 having sustained a stroke. These deficits include difficulty to produce or understand
 language, motor speech disorders and cognitive-communication disorders. It is estimated that
 approximately 40% of stroke survivors will have communication disorders post stroke.

 Provincially, it is known that 39.8% of mildly disabled stroke survivors were discharged home
 without services and 13.8% were referred to outpatient rehabilitation services in 2012/13. In
 the Champlain Region, the overall percentage of patients being referred to outpatient
 rehabilitation services was only 4.1% in 2012/13 (provincial benchmark 12.8%). Meanwhile,
 27.9% of patients were admitted to inpatient rehabilitation . A one month audit at the Ottawa
 Hospital Civic Campus (October 2014) revealed that 3/39 (7.6%) of patients attended
 outpatient rehabilitation.

 The Champlain Region has identified a gap in services with regards to outpatient and/or
 community rehabilitation services. That is, the only dedicated outpatient stroke services
 available in the Champlain Region are at Elizabeth Bruyère. There is the possibility of
 accessing general outpatient speech and language services at the Montfort Hospital, the
 Queensway Carleton Hospital and Perth Hospital. However, there are no outpatient services for
 Renfrew County or the Eastern Counties.

 Community Care Access Centers (CCAC) are another source of outpatient rehabilitation.
 However, these services are limited and are not in keeping with Canadian Stroke Best Practice
 Recommendations, where it is recommended that clients should have a minimum of 45 minutes per
 day up to 3 hours per day, 3 to 5 days per week based on patient's needs and goals. Between
 2011 and 2013, the mean number of rehabilitation visits provided in the Champlain Region for
 CCAC was between 3.3 and 5.2 visits [this included the following disciplines Physiotherapy
 (PT), Occupational therapy (OT), Speech Language Pathology (SLP) & Social Work (SW)] .

 Other than publically funded/supported services, patients could access the services of SLPs
 through community services such as the Aphasia Center of Ottawa (fee for service), the
 University of Ottawa Inter-professional Clinic (Francophones only) and private SLPs (fee for
 service). Unfortunately, these are either cost prohibitive or language prohibitive.

 Patients being discharged home who require SLP services are sometimes placed on a waitlist to
 access these services. While others, are not able to access outpatient services because of a
 variety of reasons including: patient lives at too great a distance from the rehabilitation
 facility (>30 minutes); unable to access reliable transportation to and from outpatient
 services; or the patient does not have the stamina to participate in the demands/schedule of
 outpatient therapy and travel to and from outpatient service.

 In this randomized controlled study, the investigators' objective is to test the value of
 providing a mobile platform-based Speech Language Therapy (SLT) program to patients
 discharged from an acute care hospital with stroke and PSCD and awaiting outpatient rehab
 services versus standard of care treatment. The investigators will offer iPad-based
 SLT/standard of treatment to a convenience sample of 20 patients with post-stroke
 communication deficits. The primary outcome will be feasibility (recruitment rate, adherence
 rate, retention rate, and protocol deviations), and the secondary outcome will be improvement
 in PSCD.

 C. OBJECTIVES

 Research question:

 Is it feasible, practical and effective to deliver SLT using mobile technology (iPad) to
 patients with PSCD being discharged home/primary residence from the acute care setting?

 Rationale PSCD affects 15-40% of patients during the recovery phase after stroke. It limits
 post-stroke rehabilitation, and is associated with increased disability and mortality. While
 screening can identify those patients at risk of PSCD, targeted treatment is not always
 available. Although quality of life in patients with PSCD is difficult to measure directly,
 the disruption in communication with its likely effects on employment status and social
 networks suggests that its impact can be profound. Patients with PSCD have greater morbidity
 than stroke patients without PSCD. While most, if not all, patients with post-stroke PSCD
 have some functional recovery, residual deficits are common.

 Objective 1: To test the feasibility and practicality of using mobile technology (iPad) for
 delivering SLT to patients with PSCD being discharged HOME/PRIMARY RESIDENCE from the acute
 care setting

 Objective 2: To explore the efficacy of using mobile technology in delivering SLT in patients
 with PSCD being discharged HOME/PRIMARY RESIDENCE from the acute care setting.

 D. APPROACH

 Study population: Patients being discharged HOME/PRIMARY RESIDENCE from the acute care
 setting at TOH and only requiring communication therapy. According to a 2013 Ottawa Hospital
 census, 50 patients per month are admitted to the Neurology inpatient service with a primary
 diagnosis of stroke. Also, an ongoing TOH research project using a similar design
 (iTherapist) was able to recruit approximately 3 to 5 patients per month over a 6 month
 period. For this study the investigators have selected a convenience sample of 20 patients
 over an 18 month period.

 Patient identification and selection: All patients admitted to the Civic Campus' Neurology
 inpatient service with a diagnosis of stroke AND communication deficit (as assessed by an
 SLP) that are being discharged home/primary residence awaiting outpatient SLP services will
 be screened by research personnel for study eligibility. Patients will first be approached by
 clinical SLP or clinicians within the circle of care and must give permission to speak to
 research personnel.

 Design and Methods:

 This is an 18 month randomized controlled trial, recruiting post-stroke patients presenting
 with communication deficits.

 Intervention: The intervention will consist of patients being randomly assigned to either
 standard of care or receiving an iPad upon being discharged home from the acute care setting.
 The iPad will be programmed with specific apps chosen from the following list:

 1. Tactus Therapy suite of Speech-Language therapy mobile applications, which include the
 following modules: Language, Category, Conversation and Questions.

 2. Speech sounds on cue for iPad by Multimedia Speech Pathology

 3. Lingraphica TalkPath Therapy

 4. Search 4 It

 5. This is to That

 6. Just Saying

 7. Get+Together

 8. RhymieStymie

 9. Morphos

 10. iVolution

 11. Blankety-Blank

 12. Chain of Thought

 13. Scrabble

 14. Fit brains

 15. Constant Therapy

 16. Boggle for iPad

 17. Pop words

 18. Anagram Twist

 19. Word explorer

 The apps chosen will be specific to their communication therapy needs. These apps will be
 monitored remotely by an SLP. A weekly check-in with the patient will be had with an SLP
 using one of the following: Skype, Facetime and/or Telephone.

 Patients will then be randomized to one of two groups on a 1:1 ratio:

 Group I (Treatment Group): The study SLP will cater the specific regimen to individual
 patients based on the pattern of communication deficits. In keeping with the Canadian Stroke
 Best Practice Recommendations and Quality Based Procedures Handbook, the study SLP will
 instruct the patient to use the apps for at least one-hour per day, until they are admitted
 to outpatient SLP services or for a maximum of 8 weeks, whichever comes first. Throughout the
 telemedicine treatment phase, patients' progress will be monitored remotely by a study SLP
 through Apps/Skype/Facetime/Telephone consultation on a weekly basis.

 Patients will also be instructed to record the amount of time they spend using the iPad in an
 electronic form on the device itself.

 Group 2 (Control Group):

 Patients will be sent home with standard of care.

 Data collection All patient data will de-identified. The investigators will retain age at
 enrollment, sex, co-morbid medical history (vascular and neurologic conditions: MI, CAD, HTN,
 DM), stroke type and severity (NIHSS and MRS stroke scores). The investigators will also
 retain baseline and follow-up language testing results, and total usage time of the iPad.
Inclusion Criteria:

 1. Patients with diagnosis of stroke being discharged from the Neurology unit and/or the
 Neurology Acute Care Unit in the Civic Campus of TOH.

 2. Patients presenting with overall mild to moderate communication deficits, And/or

 3. Patients with score ≥ 1 on the best language and/or dysarthria parameters of the
 National Institute of Health Stroke Score (NIHSS)

 4. Stroke Patients being discharged to their HOME/PRIMARY RESIDENCE awaiting outpatient
 speech and language therapy services.

 And/or

 5. Patients being discharged to their HOME/PRIMARY RESIDENCE who would benefit from SLP
 therapy services but are unable to receive these secondary to various accessibility
 challenges (i.e. remote geographical location, limited service availability,
 transportation, unable to pay for SLP services).

 6. Patients must have access to Wi-Fi connection at their HOME/PRIMARY RESIDENCE.

 Exclusion Criteria:

 -  1. Patients with pre-existing speech, language disorders or cognitive disorders (such
 as dementia).

 2. Patients with severe debilitating disease(s) that, in the opinion, of the
 investigator will not be able to perform the required tasks of the study (ex:
 end-stage malignancy, ALS).

 3. Patients with severe comprehension deficits 4. Patients not having access to Wi-Fi
 connection at HOME/PRIMARY RESIDENCE. 5. Patients who will be accessing the services
 of a private SLP while awaiting outpatient rehab.