This document discusses the use of telemedicine in stroke care and rehabilitation. It begins by outlining current stroke therapies and limitations in access to care, particularly in remote areas. It then discusses how telestroke programs using videoconferencing have improved access to acute stroke expertise and increased administration of thrombolysis. Studies show telestroke allows accurate clinical assessments and treatment decisions. The document also examines how telemedicine can support neurorehabilitation through telerehabilitation programs, allowing remote monitoring and therapy that achieves outcomes similar to in-person care. Overall, the document argues that telemedicine improves stroke care and access to expertise.

1. 1
The present and future of telemedicine in stroke care and rehabilitation
Content Outline
 Introduction
 Stroke care, current therapies and access to neurological expertise
 Stroke care in remote areas
 Telemedicine and stroke care (Telestroke)
 Case Study of Video Teleconferencing Communication (VTC)
 Telemedicine and neurorehabilitation
 Cost Effectiveness of Telestroke
 Conclusions
The present and future of telemedicine in stroke care and rehabilitation
Remote telemedicine consulting via real-time audio-visual streaming is gaining
popularity in areas with populations deprived of enhanced clinical medical care
expertise. Benefits of telemedicine include diagnosis and management of an
array of neurologic disorders particularly stroke. Remote teleconferencing is also
beneficial in rehabilitation of patients recovering from stroke following
discharge from the acute care hospital.
Stroke Care
The past decades witnessed remarkable developments in the diagnosis and
management of stroke. Major breakthroughs have been achieved in our

2. 2
understanding and management of stroke risk factors, the introduction of
intravenous tissue plasminogen activator (tPA) for management of selective
patients with acute ischemic stroke, and modern acute stroke care units1. With
further improvements in technology, selected stroke patients have also benefited
from advanced interventions such as angioplasty, stenting, carotid
endarterectomy, and enabled increased access to acute stroke services through
video teleconferencing (VTC) programs. Levine and Gorman2 were the first to
introduce the term telestroke using telemedicine in the form of VTC to support
acute stroke intervention. Specialists employ dedicated, high-quality, interactive,
bidirectional audiovisual systems through this kind of VTC, also known as high-
quality videoconferencing (HQ-VTC) techniques to assess patients remotely and
review imaging.
Our improved understanding of mechanisms of brain injury, repair, plasticity,
and recovery has translated in improved stroke treatments and evolution of
stroke care systems has led to better hospital preparedness. From 1997 to 2007,
These developments may have contributed to a 44.8% decrease in the stroke
death and 14.7% decline in absolute stroke deaths in United States from 1997 to
20073.
In 1996, the Food and Drug Administration (FDA) approved the use of
intravenous rtPA for the treatment of acute ischemic stroke (AIS) patients within
3 hours of last known well time. This resulted in a reduction of long term stroke
morbidity in treated patients4. However, the need to administer intravenous rtPA
within a narrow time window still hampers its widespread use 5, 6. Moreover,
many hospitals, particularly in rural or remote areas, do not yet meet required
standards in terms of available stroke resources, protocols and expertise for
effective treatment of AIS with intravenous rtPA 7. In fact, the number of AIS
patients receiving intravenous rtPA is still reported to be fewer than 5% in even
after the US FDA approval8.
Factors influencing patient access to stroke care and rtPA administration relate
mainly to geography and available resources 9, 10. Furthermore, risk factors for
stroke are more prevalent in these rural and remote areas of the United States
rendering these regions particularly vulnerable 11, 12. Despite that several key
organizations, including The Joint Commision (TJC), the Brain Attack Coalition
(BAC) and the American Stroke Association (ASA), have thus provided guidelines
for the development of Primary Stroke Centers (PSCs), it is estimated that nearly
135 million Americans live more than 1 hour away from the nearest PSC13. The
remaining 40% live in counties with hospitals that have given rtPA to less than
2.4% of AIS patients14.
Administering intravenous rtPA within 3 hours from onset of stroke symptoms
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 3-hour treatment window. Even though it is not mandatory that
every stroke patient be seen by a neurologist, guidance from experienced stroke
physicians has been associated with more appropriate rtPA use as decisions
influencing selection criteria and neuroimaging interpretation may be complex15,

3. 3
16. There is evidence to suggest that optimal administration of intravenous rtPA
for stroke patients can be much improved if hospitals comply with required PSC
standards and treatment protocols that include appropriate stroke expertise17.
However, wake-up strokes account for about 14% of ischemic strokes and are
typically ineligible for thrombolytic therapy due to the current time-window
restrictions18. However, ongoing research protocols are evaluating patients up to
12-hours (or even 24 hours in selective cases of basilar artery occlusive disease),
post stroke symptom onset. These efforts may benefit patients with wake-up
stroke.
Telestroke Care in Remote Areas
South Carolina tops the list of States for stroke incidence and mortality rates,
particularly among African-American patients and has been labeled as the
epicenter of the “Stroke Belt.” 19-23. Given this background, the Department of
Health and Environmental Control was asked by the South Carolina legislature to
develop an organized 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 intravenous rtPA and moreover, it extended its
support for further development the Remote Evaluation of Acute Ischemic
Stroke-Medical University of South Carolina (REACH MUSC). The REACH MUSC
has improved access to acute stroke care for the general population and specific
vulnerable segments of the population of South Carolina19-23.
A second stroke telemedicine network is the Remote Presence (RP) system
(InTouch Health, Santa Barbara, California, USA) whereof staff at emergency
department calls a toll-free number to activate the network, thus alerting the on-
call hub stroke expert who connects via the Internet to a RP robot that is
completely controlled remotely24. The on-call hub stroke expert utilizes a two-
way audio/video device that has the capability to conduct a neurological
assessment of the patient. The device can also be used to zoom in on the
information that is displayed on monitors and allows direct interaction with the
family and the medical staff 25, 26.
Similar research has been conducted by the tri-state (North Carolina, South
Carolina and Georgia) stroke network (TSSN) and the Centers for Disease Control
and Prevention (CDC) in Atlanta. The TSSN and CDC previously determined that
access to rtPA treatment was inadequate in the rural coastal plains. Estimates
indicated that the population in the tri-state region had access to rtPA treatment
within 30 min to 1 hour of stroke symptom onset. Therefore, access to a PSC was
30-minute drive for only a half of the population of NC, SC, and GA, while only
23% of rural residents had any access to a PSC27.
Telehealth, Telemedicine, and Telestroke
Telehealth is a general term applied to all forms of health information exchange
and interaction that utilize advanced technology and communication systems
such as the internet and cellular broadband. This includes long-distance learning
and healthcare provision. Telemedicine is not a treatment modality, but rather a
subdivision of telehealth methodology used to facilitate healthcare. Telemedicine
allows providers to perform medical procedures or examinations and review

4. 4
data remotely including facilitating interactions between patient and provider
and multiple providers. Telemedicine can be an especially helpful tool in time-
sensitive medical emergencies such as acute ischemic stroke whereby video-
conferencing equipment can be used to perform a real-time teleconsultation.
Without much proficiency required on-site, telestroke has emerged as an
effective delivery model for stroke specialist care to remote hospitals. However
there are still a few implementation barriers due to up-front costs of initial
acquisition and installation of telestroke equipment and training of practitioners
and ambiguous patterns of reimbursement29. Surveys conducted among stroke
specialists and emergency physicians suggest that telestroke can be an effective
way to bridge geographical barriers to stroke expertise and may be superior to
telephone consultation. Nevertheless, cost analysis of telestroke compared to
usual care indicates that long-term outcomes and resource utilization far
outweigh the estimated ambiguities resulting from short-term costs. For example,
the intravenous use of TPA reduces neurological disability, and telestroke
programs are associated with increased use of TPA utilization30. The combination
will likely continue to improve neurological outcome in stroke patients
geographically outside the reach of PSC’s. In addition, telestroke can offer a more
comprehensive stroke care beyond the acute thrombolysis phase, and has the
potential to improve research efficiency. Studies have shown that the National
Institutes of Health Stroke Scale (NIHSS) can be reliably performed via
telestroke.9, 34,35, 36.
A randomized single blinded prospective trial of telephone-only consulting
compared to real-time audio-video streaming demonstrated that acute stroke
treatment decisions were adjudicated to be made correctly more often in the
telemedicine group than the telephone-only group (98% vs. 82%)8. Video
telemedicine was also more sensitive and specific than telephone only and
improved the determination of thrombolysis eligibility8.
Case Study of VTC Utilization
Schwamm31 described a study program set up at a hospital remotely located
with access to stroke expertise consultation via two-way videoconferencing.
Twenty-four patients with a possible acute stroke were evaluated over 27
months. Videoconferencing was done within 15 minutes allowing the patient, the
patient’s family, and both physicians to see and hear each other in full color
using two panels, tilt, and zoom cameras (ViewStation 512; PolyCom, Inc., Austin,
TX) connected to 13’’–21’’ televisions at each end. A stroke neurologist (SN)
examined all patients, documented the NIHSS score, interpreted the head
computed tomography (CT) scan, reviewed tPA eligibility criteria, and provided
management recommendations. Data transmission was at 256–384 kbps (full
CIF) at 30 frames/s. Compressed brain images were interpreted 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. The
physicians operated the system without requiring any real-time technical
assistance. Treatment recommendations regarding tPA were made by the SN.

5. 5
As the archive failure cases occurred in patients past the three-hour window, and
there were written records of key time points, the lack of videotape archive did
not compromise the care delivery. During the study the hospital admitted 106
patients with acute ischemic stroke. Ten patients presented to the emergency
department within three hours of symptom onset. Eight patients required
TeleStroke consultation within three hours after onset of symptoms, and two
more than three hours after stroke onset. Treatment with IV tPA was deemed
indicated in six of these 10 patients. 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 to none of 100 patients
with ischemic stroke admitted during the previous two-years despite availability
of IV tPA and written ED protocols.
Of 24 patients, 15 patients (62%) presented to the emergency department
within the three-hour window; Ten were ultimately diagnosed with AIS. Not a
single patient was excluded from receiving tPA as a result of the time required to
initiate or complete the consultation.
The study showed overall satisfaction on the quality of the videoconferencing
sound, image, and connection speed (>96%). Emergency physicians felt more
confident managing patients with telemedicine support and and also felt that
patient care was enhanced with each telemedicine consult interaction. Patients
rated this technique as good as face-to-face consultations almost 86% of the
time.
Telemedicine and neurorehabilitation
Costs of rehabilitation and long-term care for stroke patients have increased
considerably in recent years. Thus, there is an urgent need to develop effective
long-term care and rehabilitation strategies for stroke patients, encouraging
active patient involvement .
Several reports suggest that VTC may be a useful tool in stroke rehabilitation.
Known as telerehabilitation (TR), it facilitates interactive evaluations and
intervention recommendations among multiple specialists based on video
clinical presentation of stroke patients. 37. Objectives of tele-rehabilitation
represent a continuance of the rehabilitation process initiated at the hospital,
and now transferred at the patients' home. 38.
A small Slovenian study compared balance training in a conventional clinical
environment with a TR approach. Six stroke patients were enrolled in the virtual
reality (VR)-assisted study and treatment was done five times a week for three
weeks clocking up to 20 minutes each session. Results showed that those in the
VR-assisted balance training group achieved similar improvements in postural
function as conventional balance training done in traditional clinical settings.
Furthermore, performing balance training at home reduced the number of
outpatient visits, thus reducing associated costs 38.

6. 6
TR can be used in urban or rural settings. A Physical Medicine and Rehabilitation
(PM&R) specialist at a medical center can then monitor patients’ progress. Not
only can the PM&R specialist visually observe the patients execute movements,
but also quantitative data such as physical force and range of motion can be
recorded and transmitted via the network to the medical center.
A randomized single blind controlled study to treat motor deficits in post-stroke
patients was performed at a remote rehabilitation facility. The study consisted of
a VR-based system that provided motor tasks to patients via the Internet. A total
of 36 patients with mild arm motor impairment due to middle cerebral artery
territory ischemic strokes were enrolled. The study compared a TR approach to
the traditional motor rehabilitation method. All patients were evaluated with the
Fugl-Meyer Upper Extremity, the ABILHAND and the Ashworth scales one month
prior, at onset and termination of therapies, and one month post-therapy. Both
approaches showed considerable improvement in all outcome scores, but the
experimental approach exhibited better results in motor performance. These
preliminary observations may lead to an earlier hospital discharge 39.
Post-discharge rehabilitation requires a coordinated and well organized home-
based program. Outpatient programs can incorporate TR to evaluate the patients
home environment, assess mobility status and progress, initiate new treatments
and provide goal oriented assessments and feedback to patients and caregivers.
Over 75% of US veterans treated within the Department of Veterans Health
Administration with an acute stroke are cared for in hospitals without inpatient
rehabilitation bed-units (RBU), and fewer than 10% of them are transferred to a
RBU at another facility 52. A study conducted within the VHA assessed a TR
intervention in post-stroke patients following discharge home. The study
suggested that TR can provide home assessments and follow-up training with
prescribed equipment, and has the potential to effectively supplement existing
home health services, assist transition to home care and increase efficiency 40.
Another pilot TR study compared the degree of recovery and satisfaction in
patients having a VR-assisted therapy program at home to those having the
same therapy in a hospital setting (non VR-group) 41. The VR equipment installed
in patients’ home used a 3D motion tracking system to create a virtual
environment where the patient's movement was represented. Motor
performance assessment found that the Tele-VR group had a significant
improvement with (P < 0.05), while the non VR group also showed no significant
changes. The videoconferencing system also provided a good relationship
between patients and physical therapists at the medical center.
Another study comparing the effectiveness of traditional physical therapy and
TR of upper limb recovery following stroke, reported that both strategies
resulted in significant improvement in all outcome measures, but patients
assigned to the TR group using VTC showed greater motor recovery 39.
Additional studies have shown increased patient satisfaction and improved
outcome with TR programs 42, 43.

7. 7
Several remote physical sensor devices have been developed to enhance VTC.
An important technology for TR has been the introduction of an Internet-based
goniometer used for the remote quantification of joint range of motion (ROM).
This remote assessment of ROM was found to be a valid tool for measurement of
upper limb ROM, with a high level of intra- and inter-rater reliability44. Results
thus far suggest that therapists can confidently use the Internet-based
goniometer to measure the upper limb ROM in stroke patients. A virtual glove
has also 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. Digital forces are calculated from the deformations
impressed on some objects. This data is transmitted and integrated by a
computer at the medical center allowing providers to make further assessments
and recommendations45. A new ankle-foot-orthotic prosthesis with sensors for
monitoring via TR has been designed to count steps taken throughout the day.
This tool allows providers to remotely monitor a patient’s physical activity46. Of
note, a single case of functional improvement after remotely based functional
electrical stimulation for arm rehabilitation administered over the Internet using
personal computer-based cameras and free network meeting software has been
reported47.
In addition, remote assessment and therapy of speech and language among
brain-injured patients has been used for over a decade, but has gained more
attention following the incorporation of video 48. Several studies have evaluated
the effectiveness of remote speech and language therapy using VTC. Brenna and
colleagues compared traditional speech and language therapy with HQ-VTC
speech and language therapy. They reported a high diagnostic correlation
between in-person and HQ-VTC assessment, and no significant differences
between patient progress between the two methods49. This approach has the
potential for specialized speech and language therapy for patients living in
remote areas.
Cost Effectiveness
Different economic modeling paradigms suggested cost efficacy of remote VTC
with evidence-based acute stroke therapies50.-51 Since tele-stroke costs are
upfront but benefits of improved stroke care are life-long, this new perception
often creates a barrier to use of telemedicine for acute stroke care.
Conclusions
Designated stroke centers have been established across many States and
communities in the United States 11. Delivery of advanced therapies, including
intravenous tPA is facilitated by specialized stroke and brain imaging expertise.
Telestroke videoconferencing consultation can improve access to time-sensitive
therapies for patients with acute ischemic stroke and possibly other neurological
emergencies. The use of TR to remotely address urgent patient care needs is
promising and has been identified as one of five major priority areas for future
development by the Department of Veterans Affairs 54.

8. 8
References
1. Schwamm L, Fayad P, Acker JE, 3rd, et al. Translating evidence into
practice: a decade of efforts by the American Heart Association/American Stroke
Association to reduce death and disability due to stroke: A presidential advisory
from the American Heart Association/American Stroke Association. Stroke;
2010; 41(5): 1051-65.
2. Levine SR, Gorman M. "Telestroke" : The application of telemedicine for
stroke. Stroke; 1999; 30(2): 464-9.
3. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al.
Heart disease and stroke statistics--2011 update: Areport from the American
Heart Association. Circulation. 2011; 123(4): e18-e209.
4. Alberts MJ. Treatment of acute ischemic stroke. Journal of Stroke and
Cerebrovascular Diseases . 2001; 10(2 Pt 2): 10-7.
5. Kleindorfer D, Kissela B, Schneider A, et al. Eligibility for recombinant
tissue plasminogen activator in acute ischemic stroke: a population-based study.
Stroke; 2004; 35(2): e27-9.
6. Meschia JF. Management of acute ischemic stroke. What is the role of tPA
and antithrombotic agents? Postgraduate Medicine. 2000; 107(6): 85-6, 9-93.
7. Gropen TI, Gagliano PJ, Blake CA, , et al. Quality improvement in acute
stroke: the New York State Stroke Center Designation Project. Neurology. 2006;
67(1): 88-93.
8. Capampangan DJ, Wellik KE, Bobrow BJ, et al. Telemedicine versus
telephone for remote emergency stroke consultations: a critically appraised
topic. The Neurologist. 2009; 15(3): 163-6.
9. Wang S, Lee SB, Pardue C, et al. Remote evaluation of acute ischemic
stroke: Reliability of National Institutes of Health Stroke Scale via telestroke.
Stroke; 2003; 34(10): e188-91.
10. Saposnik G. Teamwork, cooperation, innovation: Clues in the Canadian
success of stroke care. The Canadian Journal of Neurological Sciences 2009;
36(2): 133-4.
11. Eberhardt MS, Pamuk ER. The importance of place of residence:
examining health in rural and nonrural areas. American Journal of Public Health.
2004; 94(10): 1682-6.
12. Pearson TA, Lewis C. Rural epidemiology: insights from a rural population
laboratory. American Journal of Epidemiology. 1998; 148(10): 949-57.
13. Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA, Lyden
PD, et al. ACCESS: acute cerebrovascular care in emergency stroke systems. Arch
Neurol. 2010; 67(10): 1210-8.
14. Kleindorfer D, Xu Y, Moomaw CJ, et al US geographic distribution of rt-PA
utilization by hospital for acute ischemic stroke. Stroke; 2009; 40(11): 3580-4.
15. Webb DJ, Fayad PB, Wilbur C, , et al Effects of a specialized team on
stroke care. The first two years of the Yale Stroke Program. Stroke; 1995; 26(8):
1353-7.
16. Manobianca G, Zoccolella S, Petruzzellis A, et al. Low incidence of stroke in
southern Italy: a population-based study. Stroke; j2008; 39(11): 2923-8.
17. Stradling D, Yu W, Langdorf ML, et al. Stroke care delivery before vs after
JCAHO stroke center certification. Neurology. 2007; 68(6): 469-70.

9. 9
18. Mackey J, Kleindorfer D, Sucharew H, , et al. Population-based study of
wake-up strokes. Neurology. 2011; 76(19): 1662-7.
19. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics--
2006 update: a report from the American Heart Association Statistics Committee
and Stroke Statistics Subcommittee. Circulation. 2006; 113(6): e85-151.
20. Hoody D, Hanson S, Carter D, Zink T. Implementing a stroke system of
care in a rural hospital: a case report from Granite Falls. Minnesota Medicine.
2008; 91(10): 37-40.
21. Shrira I, Christenfeld N, Howard G. Exposure to the US Stroke Buckle as a
risk factor for cerebrovascular mortality. Neuroepidemiology. 2008; 30(4): 229-
33.
22. Lackland DT, Bachman DL, Carter TD, et al The geographic variation in
stroke incidence in two areas of the southeastern stroke belt: the Anderson and
Pee Dee Stroke Study. Stroke; 1998; 29(10): 2061-8.
23. Lackland DT, Egan BM, Jones PJ. Impact of nativity and race on "Stroke
Belt" mortality. Hypertension. 1999; 34(1): 57-62.
24. Stone K. When seconds count: tackling neurological emergencies. Lancet
Neurology. 2009; 8(8): 702-3.
25. Lai F. Stroke networks based on robotic telepresence. Journal of
Telemedicine and Telecare. 2009; 15(3): 135-6.
26. Demaerschalk BM, Miley ML, Kiernan TE, et al. Stroke telemedicine. Mayo
Clinic Proceedings. 2009; 84(1): 53-64.
27. Khan JA, Casper M, Asimos AW, , et al. Geographic and sociodemographic
disparities in drive times to Joint Commission-certified primary stroke centers in
North Carolina, South Carolina, and Georgia. Preventing chronic disease. 2011;
8(4): A79.
28. Stewart SF, Switzer JA. Perspectives on telemedicine to improve stroke
treatment. Drugs Today (Barc). 2011; 47(2): 157-67.
29. Moskowitz A, Chan YF, Bruns J, Levine SR. Emergency physician and
stroke specialist beliefs and expectations regarding telestroke. Stroke; 2010;
41(4): 805-9.
30. Demaerschalk BM, Hwang HM, Leung G. Cost analysis review of stroke
centers, telestroke, and rt-PA. The American Journal of Managed Care. 2010;
16(7): 537-44.
31. Schwamm LH, Rosenthal ES, Hirshberg A, et al. Virtual TeleStroke support
for the emergency department evaluation of acute stroke. Academic Emergency
Medicine : 2004; 11(11): 1193-7.
32. Katzan IL, Furlan AJ, Lloyd LE, et al. Use of tissue-type plasminogen
activator for acute ischemic stroke: The Cleveland area experience. JAMA. 2000;
283(9): 1151-8.
33. Katzan IL, Hammer MD, Furlan AJ, , et al. Quality improvement and
tissue-type plasminogen activator for acute ischemic stroke: A Cleveland update.
Stroke. 2003; 34(3): 799-800.
34. LaMonte MP, Bahouth MN, Hu P, et al. Telemedicine for acute stroke:
triumphs and pitfalls. Stroke. 2003; 34(3): 725-8.
35. Schwamm LH, Holloway RG, Amarenco P, , et al. A review of the evidence
for the use of telemedicine within stroke systems of care: A scientific statement
from the American Heart Association/American Stroke Association. Stroke.
2009; 40(7): 2616-34.

10. 10
36. Shafqat S, Kvedar JC, Guanci MM, et al. Role for telemedicine in acute
stroke. Feasibility and reliability of remote administration of the NIH stroke
scale. Stroke. 1999; 30(10): 2141-5.
37. Lai JC, Woo J, Hui E, Chan WM. Telerehabilitation - a new model for
community-based stroke rehabilitation. Journal of telemedicine and telecare.
2004; 10(4): 199-205.
38. Cikajlo I, Rudolf M, Goljar N, et al. Telerehabilitation using virtual reality
task can improve balance in patients with stroke. Disability and Rehabilitation.
2012; 34(1): 13-8.
39. Piron L, Turolla A, Agostini M, , et al. Exercises for paretic upper limb after
stroke: a combined virtual-reality and telemedicine approach. Journal of
Rehabilitation Medicine. 2009; 41(12): 1016-102.
40. Chumbler NR, Rose DK, Griffiths P, et al. Study protocol: home-based
telehealth stroke care: a randomized trial for veterans. Trials. 2010; 11: 74.
41. Piron L, Turolla A, Tonin P, , et al. Satisfaction with care in post-stroke
patients undergoing a telerehabilitation programme at home. Journal of
Telemedicine and Telecare. 2008; 14(5): 257-60.
42. Lutz BJ, Chumbler NR, Roland K. Care coordination/home-telehealth for
veterans with stroke and their caregivers: addressing an unmet need. Topics in
Stroke Rehabilitation. 2007; 14(2): 32-42.
43. Winters JM, Winters JM. Videoconferencing and telehealth technologies
can provide a reliable approach to remote assessment and teaching without
compromising quality. The Journal of Cardiovascular Nursing. 2007; 22(1): 51-7.
44. Hoffmann T, Russell T, Cooke H. Remote measurement via the Internet of
upper limb range of motion in people who have had a stroke. Journal of
Telemedicine and Telecare. 2007; 13(8): 401-5.
45. Placidi G. A smart virtual glove for the hand telerehabilitation. Computers
in Biology and Medicine. 2007; 37(8): 1100-7.
46. Giansanti D, Tiberi Y, Maccioni G. New wearable system for the step
counting based on the codivilla-spring for daily activity monitoring in stroke
rehabilitation. Conference proceedings : Annual International Conference of the
IEEE Engineering in Medicine and Biology Society IEEE Engineering in Medicine
and Biology Society Conference. 2008; 2008: 4720-3.
47. Hermann VH, Herzog M, Jordan R,, et al.. Telerehabilitation and electrical
stimulation: an occupation-based, client-centered stroke intervention. The
American Journal of Occupational Therapy 2010; 64(1): 73-81.
48. Hart J. Expanding access to telespeech in clinical settings: inroads and
challenges. Telemedicine Journal and e-health.. 2010; 16(9): 922-4.
49. Brennan DM, Georgeadis AC, Baron CR, Barker LM. The effect of
videoconference-based telerehabilitation on story retelling performance by
brain-injured subjects and its implications for remote speech-language therapy.
Telemedicine Journal and e-health. 2004; 10(2): 147-54.
50. Fearon P, Quinn TJ. Making the call: is telestroke cost effective? Expert
Review of Pharmacoeconomics & Outcomes Research. 2012; 12(1): 15-8.
51. Nelson RE, Saltzman GM, Skalabrin EJ, et al. The cost-effectiveness of
telestroke in the treatment of acute ischemic stroke. Neurology. 2011; 77(17):
1590-8.
52. Hoenig H, Sloane R, Horner RD, Zolkewitz M, Reker D: Differences in
rehabilitation services and outcomes among stroke patients cared for in veterans

11. 11
hospitals. Health Serv Res 2001, 35(6):1293-1318
53. Kaur K, Forducey PG, Glueckauf RL. Prototype database for tele-
rehabilitation. Telemedicine Journal and e-Health. 2004;10(2):213–222. doi:
10.1089/tmj.2004.10.213
54. Darkins A. VA's Use and Development of Telemedicine. Testimony to the
House Committee on Veterans Affairs. Hearing. 2005.