There is growing interest in the use remote telemedicine consulting to enhance the clinical medical care in areas with populations that cannot support the demand for such expertise. Neurological disorders lend themselves to the visual benefits of telemedicine.

1. The present and future of telemedicine in stroke care and rehabilitation
Remote telemedicine consulting is gaining popularity in areas with populations
that have been deprived of enhanced clinical medical care expertise. Visual
benefits of telemedicine can be seen in areas of neurology and rehabilitation of
neurological disorders. The use of remote teleconferencing has also been found
to be beneficial in the rehabilitation of those patients recovering from stroke
after discharge form the acute care hospital.
Stroke Care
The past decade witnessed remarkable developments in the diagnosis,
management, and prevention of stroke. The major breakthroughs have been
achieved in the understanding of stroke risk factors and treatments of
hypertension and dyslipidemia with effective use of antithrombotic agents, and
introduction of tPA (tissue plasminogen activator) and modern comprehensive
stroke centers for successful management of patients with acute stroke1. With
improvements in technology, an increasing number of stroke patients have
benefited from advanced interventions such as angioplasty, stenting, and carotid
endarterectomy, and this has ensured increased reach of acute stroke services
through video teleconferencing (VTC) programs. To support acute stroke
intervention, Levine and Gorman2 were the first to name the term telestroke
using telemedicine in the form of VTC. To review brain images remotely,
specialists need to use dedicated, high-quality, interactive, bidirectional
audiovisual systems through this kind of VTC, which is also known as high-quality
videoconferencing (HQ-VTC) technique.
Significant strides made during the last decade have improved our understanding
of the mechanisms of brain injury, repair, plasticity, and recovery that will
translate to improved future post stroke treatments. From 1997 to 2007, the
stroke death rate fell by 44.8% in United States while the actual number of stroke
deaths declined by 14.7%, making stroke the fourth instead of the third leading
cause of death 3. Such advances in stroke prevention treatments should further
reduce stroke rates worldwide.
In 1996, the use of recombinant tissue plasminogen activator (rtPA), a fibrinolytic
drug, was approved by the Food and Drug Administration (FDA) for the
treatment of acute ischemic stroke (AIS) The long-term disability and physical
damage that can follow AIS can be reduced considerably with appropriate
administration of rtPA 4. Although rtPA was considered to be the first FDA-
approved treatment for AIS, the necessity to administer it within 3 h from the
onset of stroke symptoms limited its widespread usage 5, 6. For the most part,
many hospitals do not meet the required standards in terms of stroke expertise,
resources, and protocols for effective treatment of AIS with rtPA 7. In fact,
Capampangan et al.8 reported that the number of AIS patients who receive rtPA is
still fewer than 5% even after FDA approval was given for its use over a decade
ago.
Presently, the factors that influence patient access to stroke care and rtPA

2. administration are related to geography and resource shortage 9, 10. Risk factors
for stroke are more predominant in rural and remote areas than urban areas of
the United States as options for effective stroke treatment are far less accessible
11, 12. It is estimated that close to half of all Americans (135 million) live more than
1 hour away from the nearest “lifesaving stroke care”13, and the remaining 40%
live in counties with hospitals that have given rtPA to less than 2.4% of AIS
patients14. Several key organizations, including the Brain Attack Coalition (BAC)
and the American Stroke Association (ASA), have provided guidelines for the
development of primary stroke centers (PSGs). Many hospitals do meet the
standards required for access to expert, vital hospital-based resources, and
process norms to track appropriate use of rtPA.
Administering rtPA within 3 hours from stroke symptoms onset has other
limitations as well. Not all stroke patients can be seen by a neurologist within this
timeframe, as most patients arrive with less than 60 minutes remaining in the
treatment window. Even though it is not mandatory that every stroke patient
needs to be seen by a neurologist, guidance from experienced stroke physicians
can result in more appropriate rtPA use as decisions influencing selection criteria
for rtPA use and CT interpretation are often complicated15, 16. Evidence suggests
that the standard of care with optimal administration of rtPA for stroke patients
can be much improved if hospitals comply with the required PSC designation and
treatment protocols17. Wake-up strokes account for about 14% of ischemic
strokes and are typically ineligible for thrombolytic therapy due to the current
time-based restrictions18. There are research protocols currently entering
patients up to 12-hours post stroke symptom onset. These efforts benefit the
patient of the wake-up stroke and improve treatment while at the same provide a
better understanding of the risks.
Stroke Care in Remote Areas
In the United States, stroke contributes majorly to the cause of death and
disability19, 20. South Carolina tops the list of stroke incidence and mortality rates,
particularly in younger and African-American patients when compared to the rest
of the country21. Because of this, South Carolina has been referred to as the
epicenter of the “stroke belt.” 22, 23.
Given this background, Department of Health and Environmental Control was
asked by the South Carolina legislature to study stroke and make
recommendations for the development of a stroke system of care (South Carolina
Legislature1). This initiative was influential in developing and establishing a
system to treat stroke acutely with appropriate use of rtPA. With inadequate
resources at its disposal, South Carolina, like many other states, extended its
support for further development of REACH MUSC (Remote Evaluation of Acute
Ischemic Stroke-Medical University of South Carolina). The impact of REACH
MUSC in South Carolina can be evidenced in access to acute stroke care in the
state for the general population and specific segments of the population based on
age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke
mortality. Prior to this, a similar research conducted by the tri-state stroke
network (TSSN) and the centers for disease control (CDC) has also studied the

3. impact and dominance of stroke and discovered that access to rtPA treatment
was inadequate in the rural coastal plains which incidentally has the highest
stroke death rates in the region. Estimates provided by them indicate that
population in the tri-state region has access to rtPA treatment within 30 min to 1
hour of stroke symptom onset. Therefore, access to a PSC was 30-minuet drive
for only a half of the population of NC, SC, and GA while only 23% of rural
residents had any access to a PSC24. This illustrates the need for communication
between outside centers and PSC’s.
Telemedicine
Telemedicine is not a treatment modality, but it is a methodology used for
providing healthcare using communication technologies like phone or Internet.
Telemedicine is also required remotely some times to perform medical
procedures or examinations by way of discussion between two healthcare
professionals over the telephone. Telemedicine may be perceived as a helpful tool
especially when there is a medical emergency. In addition, this can be used for
distance education purposes in medicine field. Probably, there can be usage of
satellite technology and video-conferencing equipment to perform a real-time
consultation (teleconsultation) between medical specialists from different places
as well.
Based on patient outcome data, there is established improvement in prognosis
when a neurologist is involved using teleconsultation techniques for strokes. This
approach allows the neuro-specialist to establish a prompt diagnosis of the
underlying mechanism of ischemic stroke thereby leading to a more effective and
rapid institution of interventions and secondary prevention therapy.
Telestroke care includes the initial telephone consultation, point-to-point, hub-
and-spoke networks, to web-based site-independent telestroke systems25.
Without much proficiency required on-site, telestroke has emerged as an
effective delivery model for stroke specialist care to remote hospitals, but there
are a few implementation barriers initially because of up-front costs involved
with the initial installation of telestroke and training practitioners in its usage.
Survey conducted among stroke specialists and emergency physicians reveal that
telestroke can be an effective way to bridge geographical differences in stroke
management and is superior to telephone consultation as well, but they also
mention the possible challenges during implementation phase with time spent on
training, installation cost, and reimbursement ambiguity26. However, analysis of
cost effectiveness of telestroke compared to usual care indicates that the long-
term outcomes with acute stroke assessment decision-making and resource
utilization far outweigh the ambiguities resulting from short-term costs. The use
of rTPA reduces neurological disability, and telestroke conferencing increases use
of rTPA27. The combination will likely continue improve neurological outcome in
stroke patients geographically outside the reach of PSC’s. In addition, Telestroke
can provide more complete stroke care beyond the acute thrombolysis phase, as
well as its potential to improve clinical research and the need for cost-effective
research

4. Telemedicine is especially advantageous through telestroke videoconferencing
that supports emergency-based evaluation and management of acute ischemic
stroke (AIS)28. This also facilitates tPA delivery in neurologically underserved
facilities. The use of thrombolysis for AIS) may be limited due to inadequate
emergency provider support systems. Studies suggest that tPA is less frequently
used in neurologically underserved communities, due to which there are higher
rates of complications, but tPA treatments can be increased if aggressive
measures are taken to improve access to stroke expertise thereby reducing
complications29, 30. Telemedicine is used to improvise the availability of real-time
stroke expertise9, 31. Studies have shown that the National Institutes of Health
Stroke Scale (NIHSS) can be reliably performed over the REACH system 9, 32, 33.
Capampangan8 compared the effectiveness of telephone-only consulting
compared to video telemedicine consulting. In this randomized single blinded,
prospective trial comparing telephone-only consultations to telemedicine
consultations for acute stroke, correct acute stroke treatment decisions were
made more often in the telemedicine group versus the telephone-only group
(98% vs. 82%) Video telemedicine was more sensitive than telephone only
(100% vs. 58%), more specific (98% vs. 92%), had a more favorable positive
likelihood ratio (LR: 41 vs. 7) and negative likelihood ratio (LR: 0 vs. 0.5), and
had higher predictive values (positive predictive value 94% vs. 76%, and
negative predictive value 100% vs. 84%) for the determination of thrombolysis
eligibility8.
Case Study of VTC Utilization
Schwamm28 described a study program set up in an island-based critical hospital
with access to consult with stroke expertise via two-way videoconferencing in
the evaluation of 24 patients with possible acute stroke. This small study will be
reviewed as a case study in the use of VTC in acute stroke evaluation and
treatment in remote geographical areas.
Videoconferencing was undertaken within 15 minutes for all cases and allowed
the patient, the patient’s family, and both physicians to see and hear each other
in full color using two pan, tilt, and zoom cameras (ViewStation 512; PolyCom,
Inc., Austin, TX) connected to 13’’–21’’ televisions on each end. A stroke
neurologist (SN) examined all the patients and documentation of NIHSS
reviewing tPA eligibility, viewing computed tomography (CT) of the head, and
providing management recommendations was taken place. Data transmission
was at 256–384 kbps (full CIF) at 30 frames/s. The physicians operated the
system without requiring any real-time technical assistance. The SN interpreted
the compressed brain images in a browser window (AMICAS, Inc., Waltham, MA)
on a Pentium-based desktop system equipped with a cathode ray tube monitor
at 1024 3 768–pixel resolution. Treatment recommendation regarding tPA was
made by the SN.

5. In this study, a total of 24 patients were referred for evaluation during the 27-
month study period (Figure 1). As the archive failure cases occurred in patients
past the three-hour window and there were written records of key time points,
the absence of videotape archive had no hindrance as to the delivery of care. The
critical access hospital admitted 106 patients with ischemic stroke during this
intervention. Out of 106, 10 patients with AIS presented to the emergency
department within three hours after the onset of symptoms; 8 of these required
TeleStroke consults within three hours after the onset of symptoms and 2
required after more than three hours. Treatment with IV tPA was needed in 6 of
these 10 hyperacute patients with AIS. During the TeleStroke intervention, none
of the patients received IV tPA without remote support. Thus, 6 of 106 (5.6%) of
all patients with ischemic stroke received tPA, compared with 0 of 100 patients
with ischemic stroke admitted during the two-year period before the
intervention despite emergency department availability of IV tPA and a written
protocol.
Out of 24 patients, 15 patients (62%) presented to the emergency department
within the three-hour window of potential tPA use; 10 of these were diagnosed
as AIS. TeleStroke consultation started within the three-hour window for 8 of the
10 AIS cases. Not a single patient was excluded from getting tPA treatment
secondary to the length of time required to initiate or complete consultation.
There was satisfaction on the quality of the videoconferencing sound, image, and
connection speed (>96%) and the emergency physicians felt confident managing
patients with telemedicine support (100%). Patient care was enhanced with
each telemedicine consult interaction, which the emergency physicians agreed
upon (100%). Both SNs and emergency physicians felt that telephone
consultation alone would not have sufficed the purpose (referring physicians—
96.2%; neurologists—100%). Patients often felt this technique was as good as
face-to-face consultation (85.7%).
Telemedicine and neurorehabilitation
The costs of rehabilitation and long-term care for stroke patients have increased
significantly in recent years. There is an urgent need for the development of an
effective long-term care and rehabilitation strategy for stroke patients that will
encourage patient involvement in the process.
Video teleconferencing has been found to be a feasible tool in stroke
rehabilitation as well. This has been referred to as telerehabilitation and allows
specialist to provide evaluations and intervention recommendations based on
the video clinical presentation of the patient. Most patients undergoing
rehabilitation following a stroke require many services that change over time34.
A neurologist and physicians specializing a stroke recovery are most qualified to
make these decisions. The objective of the telerehabilitation is a continuation of
the rehabilitation process, initiated in the hospital, in patients' home. The
telerehabilitation approach in VR assisted balance training improved balance in
stroke patients and had similar effect on patients' postural functional

6. improvement as conventional balance training in clinical settings35. In addition,
when balance training is continued in the patient's home instead of the hospital,
it reduces the number of outpatients' visits and therefore the related costs.
In contrast to the telemedicine acute stroke care model, video telerehabilitation
can be used in urban or rural settings as the rehabilitation equipment is set up in
the patient’s home. A physician rehabilitation specialist in a medical center can
then monitor physical therapy and assessments. Not only can the physician
visually see the patients execute movements, digital data can be transmitted
through the videoconferencing for more specific assessment of progress.
Physical force and range of motion can be recorded on in-home equipment and
the data transmitted via the network to the medical 36center for interpretation
and assessment.
In one study, post-stroke patients completed 3 weeks of balance training, 2
weeks in the clinical settings and 1 week in the home environment utilizing
virtual reality based tasks
The challenge with discharge rehabilitation programs are that they require
coordinated and well organized home based rehabilitation after discharge. Out
patient programs can incorporate telerehabilitation to evaluate the patients
home environment, assess the patients mobility status and progress, initiate new
treatments and provide goal oriented assessments and feedback to the patients
and their caregivers37.
In a pilot telerehabilitation study with post-stroke patients, the degree of
recovery and satisfaction of patients undergoing a virtual reality (VR) therapy
program at home to satisfaction experienced by those undergoing the same
therapy in a hospital setting (VR-group) was compared38. The rehabilitation
equipment was installed in the patients home and utilized a 3D motion tracking
system to create a virtual environment in which the patient's movement was
represented. In tele-therapy, the equipment was connected to the hospital by
four ISDN lines at a total bandwidth of 512 kbit/s. Motor performance
assessment found that the Tele-VR group improved significantly (P < 0.05), while
the VR group showed no significant change. Patients assigned to the Tele-VR
group were able to engage in therapy at home and the videoconferencing system
provided a good relationship between the patient and the physical therapist in
the center.
In a separate study comparing effectiveness of traditional physical therapy and
remote rehabilitation of the upper limb recovery following stroke, Priron36 et al.
reported that both strategies resulted in significant improvement in all outcomes
measures, but the remote group using VTC to participate from their homes
showed greater motor recovery. There have been additional small studies that
have confirmed both patient satisfaction and improved outcome with a
telerehabilitation program39, 40.
Several remote physical sensors devices have ben developed to enhance VTC.
An important technology for telerehabilitation was the introduction of an
Internet-based goniometer that is used for the remote quantification of joint

7. range of motion (ROM). This remote assessment of ROM was found to be a valid
tool for the measurement of upper limb ROM with consistent findings as in
person ROM testing. The Internet-based goniometer was also shown to possess a
high level of intra- and inter-rater reliability41. The results suggest that
therapists can confidently use the Internet-based goniometer to measure the
upper limb ROM in people who have had a stroke. A virtual glove has been
designed for hand rehabilitation for stroke patients that is software based, and
tracks hand movements by using images collected from webcams and digital
analysis. Finger forces are calculated from the deformations impressed to some
objects. This data is transmitted and integrated by a computer in the medical
center and allows the therapists and physicians to make assessment and
recommendations42. A new ankle-foot-orthotic prosthesis with sensors for
telemonitoring and telerehabilitation has been designed and constructed to
count steps taken through out the day. His allows the medical center staff to
monitor the physical activity of the patient43. There was a publication of a single
patient that underwent remotely based functional electrical stimulation for
affected arm rehabilitation after stroke. The stimulation and assessment regimen
was administered over the Internet using personal computer-based cameras and
free network meeting software. The patient exhibited reduced impairment and
functional limitation after the remote intervention. The patient also expressed
enhanced satisfaction with his ability to improved ability to perform ADLs44. This
report suggests that this method of remote stimulation in the rehabilitation of an
extremity is feasible and effective.
Tele-assessment and therapy of speech and language in brain-injured patients
have been used for over a decade, but has gained more attention since
incorporating a video component45. Several studies have evaluated the
effectiveness of speech and language therapy using VTC. Brenna et al compared
traditional in-person speech and language therapy and compared the results to
HQ-VTC speech and language therapy. There was a high diagnostic correlation
between in-person and HQ-VTC assessment and no significant difference was
found comparing the effectiveness of the therapy progress between the two
methods46. This will allow for specialized speech and language therapy fir
patients in remote areas or inability to transport for in-person sessions.
Cost Effectiveness
The clinical efficacy of intravenous tPA in acute ischemic stroke is proven, and is
realized through reduction in disability and associated long-term care. Limited
use of tTPA prevents greater cost savings to the health care industry. Economic
modeling suggested cost efficacy of remote VTC in using evidence-based acute
stroke therapies47. In an analysis of cost-effectiveness of telestroke using a
decision-analytic model, over a lifetime perspective, telestroke appears cost-
effective compared current typical care48. Since telestroke costs are upfront but
benefits of improved stroke care are life long, this creates a barrier to increased
the use of remote VTC medical care. If the barriers of low reimbursement rates
and high equipment costs are modified, telestroke has the potential to diminish
the striking geographic disparities of acute stroke care in the United States.

8. Conclusions
Thrombolytic agent administration is a concern for emergency physician
organizations due to inadequate provider support and inaccessibility to stroke
physician. The recent National Institute of Neurological Disorders and Stroke
consensus conference, ‘‘Improving the Chain of Recovery for Acute Stroke in
Your Community,’’ endorsed the use of provider support systems, including
telemedicine, to increase the utilization of AIS therapies [16]. TeleStroke door-
to-needle time is still lengthy compared with recommended targets but is
consistent with the actual treatment times in many community and academic
facilities and likely can be lowered with focused efforts [16, 9].
Even though there is growing evidence of video teleconferencing effectiveness in
acute stroke care and post-stroke rehabilitation, the viability of this technology
is, in great effect, in the hands of either government based health agencies or,
more likely, third party payers49.
Telerehabilitation is driven by innovative technologies that enhance therapies
and support home based rehabilitation with improved outcomes and potential
cost savings
As a facilitator of exchanging critical information between physicians and
healthcare providers working with limited resource environment and
professionals who can provide expert advice, telemedicine continues to offer
promise to the underprivileged for over a decade now. With rapid advancements
in technology and Internet usage becoming ever more universal, value of
telemedicine programs have become more and more important, as have the
expectations from this technology [13].
There has been a progressive improvement in the field of acute stroke care, and
designated stroke centers have been set up across many states and communities
in the United States for improvement of acute stroke care delivery [11]. Often
times, delivery of advanced therapies, including intravenous tissue plasminogen
activator (tPA), is facilitated by specialized stroke and brain imaging expertise,
but widespread inequalities are common in gaining access to specialty care
across the United States. Telemedicine has been suggested as a method to
increase the access in a cost-effective manner, particularly for geographically
remote areas. TeleStroke videoconferencing consultation may support
evaluation of patients with acute stroke and the delivery of IV tPA. In order to
further determine the benefits of this expensive and cumbersome
videoconferencing technique and CT image interpretation compared to the
comfortable and flexible traditional voice communication, a prospective
randomized trial is needed. Additional uses for neurological care using VTC is
being developed as well50
Using a remote desktop and the public internet, breakthroughs have been
achieved in secure transmission of medical data through telemedicine

9. information system. Apart from improving the prognosis of patients, it can also
be used in education and training. As there is no necessity for specific license,
contract, or initial investment, it is possible that this system could eradicate the
scarcity of experts faced currently to a greater extent. Therefore, this system
could well empower the appropriate use of medical resources and reduce
medical expenses in the days to come.
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