What to Know About Telehealth for Stroke

Telehealth is increasingly being used to treat strokes at all stages of the recovery and rehabilitation process. A stroke, also called a cerebrovascular accident (CVA), occurs when the blood supply in the brain is disrupted. There are different types of strokes, including ischemic (blood flow is blocked) and hemorrhagic (brain bleed).

The use of telehealth for people who have had a stroke has been shown to reduce complications and lower mortality in acute settings. It also can improve functional outcomes in rehabilitation settings. During the COVID-19 pandemic, telehealth has also been shown to be the best way of delivering health care to prevent transmission of the virus.

When to Use Telehealth for Stroke

Telehealth for stroke may not look the way that most people envision it—as remote video chatting with a healthcare provider. The term telehealth includes many different scenarios. Telehealth for stroke is also called "telestroke," particularly in acute hospital settings.

It is a general term that refers to any form of health care that is delivered remotely through means of electronic technology. In some cases, telehealth for stroke actually refers to physician-to-physician contacts, and not just patient-to-physician contact.

You can utilize telehealth with many different types of healthcare providers and clinicians. For people who have had a stroke, your telehealth team may include:

• Primary care physician
• Neurologist
• Cardiologist
• Dietitian
• Nutritionist
• Psychologist
• Occupational therapist
• Physical therapist
• Speech therapist

Some situations in which you might use telehealth for stroke include:

• If you are in a hospital emergency department and have just had a stroke, your healthcare provider may use telehealth (sometimes called telestroke in this context) to consult with a stroke specialist physician at another hospital. This specialist will help guide your care, including instructing a more general physician in reperfusion treatment (restoring blood flow).
• If you've previously had a stroke, or are at risk of having a stroke, your healthcare provider may perform remote patient monitoring of vital signs, which is a type of telehealth. An example of this is taking your blood pressure at home using an electronic blood pressure cuff, and uploading your readings to a patient portal or application for your healthcare provider to monitor.
• If you have barriers to leaving home due to your stroke, such as needing an assistive device, being at a high fall risk, or needing a caregiver to transport you to appointments, telehealth may be safer and more convenient.
• You might use telehealth for general healthcare appointments with your primary care doctor or dietitian, follow-ups with your cardiologist or neurologist, counseling or psychotherapy appointments, and more.
• Post-stroke rehabilitation is a large part of stroke care and may be done through telehealth visits for occupational therapy, speech therapy, and physical therapy. This is typically offered only in the subacute or chronic phases of recovery, once it is safe for you to be at home, and if approved by your healthcare provider.
• Some people who have had a stroke require an orthotic device to help correct their body alignment and enable safer walking and other movements. You may have a telehealth appointment to discuss available orthotics, or follow up with an orthosis specialist about your orthotic device.

Benefits and Challenges

There are many benefits to using telehealth. In general, telehealth has been shown to be cost-effective, convenient, accessible, reduce hospitalizations, and in the context of the COVID-19 pandemic, reduce virus transmission. There are also benefits of telehealth that are specific to people who have had a stroke.

Telestroke

For people who have had a stroke, telehealth in the acute emergency department phase could be lifesaving. Some hospital emergency departments use a form of telehealth called telestroke, which is a network that connects healthcare providers at one hospital to stroke specialists at a different hospital.

This is important because research indicates that hospitals with a certified stroke center are not evenly distributed within the United States. Hospitals in rural areas and low-income service areas are less likely to be stroke certified.

By consulting with a stroke specialist during immediate treatment, transport to a more specialized institution is avoided, keeping patients closer to home and saving precious treatment time immediately post-stroke.

A groundbreaking study published in March 2021 found that stroke patients who received telestroke care in the emergency department had higher rates of reperfusion treatment and a lower mortality rate compared with stroke patients at hospitals that do not use telestroke. This difference was most significant for patients 85 and older, at smaller hospitals, and in rural settings.

Rehabilitation

Telehealth can also be beneficial in the rehabilitation phase of stroke recovery. Most research has found that physical, occupational, and speech therapy rehabilitation for stroke survivors, when offered via telehealth, is equally if not more effective than in-clinic rehabilitation services.

A 2019 randomized controlled trial compared six weeks of upper extremity rehabilitation in the telehealth versus clinic settings among 124 stroke patients. The results in each setting were comparable, indicating telehealth is an equally effective and safe setting for stroke rehabilitation.

A similar 2020 randomized controlled study compared 12 weeks of motor rehabilitation in telehealth versus clinic settings among 52 people who had a stroke with hemiplegia. In this study, the telehealth group actually had a significant improvement in motor function compared with the traditional clinic group.

In addition to physical and occupational therapy, research also indicates that speech therapy is appropriate, safe, and efficacious via telehealth for stroke rehabilitation. A small 2017 study provided initial evidence that post-stroke dysphagia, or swallowing, evaluations via telehealth are safe, effective, and comparable to in-person evaluations.

A 2020 study also found that post-stroke memory rehabilitation, delivered via telehealth, was feasible and effective.

Limitations

Despite the benefits of telehealth, there are also challenges in seeking health care in this manner. Lack of insurance access, electronic devices, or a reliable Internet connection are barriers to receiving telehealth care.

Many people who have had a stroke also live with cognitive deficits, including memory issues. This can create a barrier in learning and navigating new technology, which is required for telehealth.

A 2020 qualitative study found that stroke survivors with memory difficulties had low confidence in user ability before using a telehealth service and some difficulty building rapport with clinicians through telehealth.

Overall, though, the study found that participants benefited from telehealth in their memory rehabilitation, confidence in using technology, and integrating rehabilitation exercises into their home environment.

How to Prepare for a Telehealth Visit for Stroke

Preparing ahead of time will help you get the most out of your telehealth visit. Your preparations will vary depending on the type of visit, as well as what clinician you are seeing. Some general things you can do to prepare for your telehealth appointment include:

• Check with your insurance about coverage for telehealth.
• Discuss how telehealth works with your healthcare provider's office prior to the appointment. Each office will have unique protocols in place. You may need to download software or an app to use.
• Practice logging in to the patient portal or application, and pre-save your login details for easier access.
• You may need to sign consent forms or complete other paperwork or online forms before the visit.
• Prepare a list of questions and concerns prior to the appointment.
• Especially for physical or occupational therapy appointments, ask whether you will need to change positions or perform physical tasks or motions, and what equipment or seating will be most appropriate for the visit.
• Keep your current medications, blood pressure readings, and any assistive devices, orthotics, or splints nearby for easier discussion with your clinician.
• Find a quiet, well-lit area of your living space, with a stable Internet connection, to have your call from.
• If appropriate, schedule your telehealth visit at a time when your spouse, child, or caregiver is present. They may be able to help you participate in the telehealth session, such as providing information to healthcare providers or helping you through exercise programs with therapists.
• Some people struggle with their memory after a stroke. Use remediation strategies to help you remember your appointment, such as writing it on a big whiteboard calendar that you see daily, keeping a large electronic clock visible in your home, and setting an alarm.
• Wear a comfortable outfit you can move in and go to the bathroom prior to your appointment to help reduce interruptions.

What Happens During the Visit

Your healthcare professional will conduct the telehealth visit in their own way, depending on their specialty and the purpose of the call.

A telehealth visit will begin by signing into the portal or app, and you may first be greeted by a nurse or assistant, who ensures you are ready to meet with the healthcare professional. You may need to give verbal consent for treatment via telehealth or check an online form to consent.

Some things to discuss with your healthcare provider or therapist, depending on their specialty, include:

• How much recovery you can expect, and in what time period
• Any lifestyle changes that are recommended to prevent further strokes
• Reactions or side effects to any new medications
• Any physical or cognitive changes since your previous visit
• Recommendations for assistive devices or home modifications to keep you safe
• Whether you should be monitoring your blood pressure at home
• Referral requests to other clinicians
• Anything you have been struggling with since your stroke, whether that's emotional, physical, or occupational

A follow-up with your primary care physician may involve answering questions, discussing your current medications, and any recent lab test results. Based on remote patient monitoring of your blood pressure, your healthcare provider may also discuss lifestyle changes or suggested prescription medications.

A telehealth appointment with a rehabilitation professional, such as a speech, physical, or occupational therapist, may be more physically involved. If it's your first visit, your therapist will likely interview you and gather background information on your life before your stroke, how you are functioning after your stroke, and your therapy goals.

They may give you standardized screening tests or ask to see you move (such as transferring out of a wheelchair, walking around the living room, and movement in your hands and upper extremities).

For therapy visits, it is helpful to place your tablet or electronic device in a position where your therapist can see your whole body. You may also find it beneficial to have a caregiver present to help you throughout the session.

Summary

A stroke is a health emergency that can lead to lifelong functional changes and chronic health impacts. Telehealth can be a useful tool anywhere along the stroke recovery process. For someone who has had a stroke, telehealth is not only shown to be equally effective as in-person care, but it also is more accessible.

In addition to connecting you with stroke specialists located far away, telehealth can also mean, particularly for people with hemiplegia, less time navigating assistive devices and the complicated process of traveling to appointments, helping you save your energy for the activities that are meaningful to you.

Nevertheless, there are some limitations and challenges to using telehealth for stroke. A lack of insurance coverage and cognitive difficulties with navigating technology can lead to less equitable distribution of telehealth.

Additionally, despite technological advances, some situations will always require an in-person visit. This includes blood draws, some tests such as an EKG or EMG, and of course, any time someone is displaying the signs or symptoms of a stroke.