This document summarizes a tele-rehabilitation case for a 42-year-old male stroke patient who experienced significant improvement through virtual therapy sessions over seven weeks, starting on April 9, 2020. The patient initially faced challenges such as right-side hemiplegia and slurred speech, but with a structured exercise regimen and consistent communication, his Barthel index improved from 30 to 80 by the end of the treatment. The report emphasizes the effectiveness of tele-rehabilitation in providing accessible, cost-effective, and convenient care while noting some challenges related to assessment and intervention limitations.

1. Tele-Rehabilitation of a Stroke Case
Dr. Gaurika Kapote (PT)
ReLiva Physiotherapy & Rehab
https://reliva.in

2. Case Summary
• Patient is 42 / M, based in Pune. Suffered a stroke (diagnosed with left MCA infarct causing
right side hemiplegia) on 16th March, discharged on 27th March 2020 and was advised home
physiotherapy
• Patient reached out to us on 8th April 2020
• Since there was a lockdown in place and with additional risk of infection, telerehab was
advised
• We conducted our first consultation and assessment session on 9th April 2020. This was
done online through WhatsApp video call.
• Subsequently, we worked with the patient over next 7 weeks. All the sessions were on video
conferencing.
• In this period patient experienced significant improvement.
• This case presentation is our effort towards sharing our experience

3. History
• Chief complaint : Difficulty moving right arm and difficulty to walk since 15 days
• Deviation of mouth left side
• 16th of march - realized that there's numbness and weakness in his right arm and his
mouth was deviated to left side of the face.
• Conscious & oriented
• On reaching home he called up his sister who is a doctor by profession.
• She immediately reverted by advising him to get admitted to a near by hospital & get a
MRI done.
• Cause of this episode was spike in the blood pressure which had shot up by 200/120
mmhg.
• Co- morbidities- hypertension and was on anti hypertensives (TAB MHS telmi AM) since 2
years
• Skipped the dosages in the last 10 days

4. Assessment & Consultation
• Observations & examination
• Build: Mesomorphic
• Posture / Attitude: unsupported sitting position
• Right upper limb adducted , internally rotated, elbow flexed
• Reduced weight bearing on the right side
• Gait: circumductory gait , hip hike & reduce arm swings of the right side
• External Support: maximal manual support
• Speech and Language: slurred speech
• Facial Discrepancy: Grade – 2
• Absence of wrinkles on the right side of forehead. Deviation of mouth to left
side
• No s/s of abnormal sensations, Muscle Wasting and Involuntary Movements.
• Muscle tone -probability of spasticity present
• Voluntary Control grades- Brunstorm stage of recovery 2 for Upper Limb and
lower limb
• Barthal index score- 30 (9th April)
• Balance: unsupported sitting position Static- intact
Screenshot of assessment session

5. Assessment & Consultation
• Functional Difficulties
1) Unable to hold an object from right hand
2) Difficulty to bend his right knee
3) Difficulty to sit to stand
• Goals
1. Education, counselling, Positioning
2. Easy transfers
3. voluntary control of right upper and lower extremity
4. Facial symmetry
5. independent in his day to day activities
These goals were communicated to the patient and we created weekly plans for the patient

6. Management
9th April – week 1
• Education, counselling
• Positioning and bed transfers- Upright sitting on the
bed every 4 hours
• Passive ROM exercise Right side
• Active ROM exercise Left side
• Diaphragmatic breathing exercise
We took 2 sessions with patient in week 1 to supervise the exercises and guide the patient appropriately

7. Exercise Prescription
Similar process was followed over subsequent weeks as the exercise prescriptions progressed

8. Subsequent weeks
After week 4, Barthal index was measured. It had improved to 60 from 30 at the time of start of treatment
Week 2
13th April
• Pelvic
bridging
• Facial
exercises
facing mirror
• Over head
shoulder
exercise
• Sit to stand
(major
support)
Week 3
21st April
• Quadripod
exercise
• Putty, smiley
ball
• Prone knee
bending
• Shoulder
shrugs
• Made to
stand – 5mins
(major
support)
Week 4
29th April
• weight
bearing in
sitting
• Side hip
abductions
and SLRs
• Ambulated
few steps
(minor
support)
Week 5
4th May
• Paper
blowing,
vowel
exercises
• PNF
stretching
exercise
• Able to walk
upto toilet
with support

9. • 6th week – 11th may
• Patient could independently move in his bed
• He could turn his sides and do over head
activity
• Feed himself
• He was able to walk longer distance from one
room to another but with support
• Improvement in independence and ADLs
7th week
Video was taken on 25th May
Patient video shared with consent
In the final follow up on 25th May 2020 – Barthal Index was measured at 80 and Facial MMT at Grade 4

10. Our Learnings
• Telerehab WORKS!!
Benefits
• Access to rehab
• Compliance & Convenience
• Patient supervision, counselling,
interaction
• Cost reduction for patient
• Family based rehab via telerehab
• Independent,ADLs,QOL
Challenges
• Limitations in assessment and
interventions
• Language barrier
Combining in-clinic/ home rehab with telerehab could offer a great approach
for patients

11. Literature Review – telerehab for stroke rehab
• Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A
Randomized Clinical Trial. Cramer SC, Dodakian L, Le V, et al.
JAMA Neurol. 2019;76(9):1079–1087. doi:10.1001/jamaneurol.2019.1604
https://jamanetwork.com/journals/jamaneurology/fullarticle/2736341
• Effectiveness, usability, and cost-benefit of a virtual reality-based telerehabilitation program for
balance recovery after stroke: a randomized controlled trial. Lloréns R, Noé E, Colomer C, Alcañiz
M. Arch Phys Med Rehabil. 2015;96(3):418‐425.e2. doi:10.1016/j.apmr.2014.10.019
https://pubmed.ncbi.nlm.nih.gov/25448245/
• Effectiveness of telerehabilitation in the management of adults with stroke: A systematic review.
PLoS ONE 14(11): e0225150. Appleby E, Gill ST, Hayes LK, Walker TL, Walsh M, Kumar S (2019)
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225150
Significant literature available which supports telerehab for stroke

12. Thank you…
Dr Gaurika Kapote (B.Pth)
Dr Sneha Kukreja ( BPt, MPt,Neuro)
Email: contact@reliva.in
Consultant Physiotherapists at ReLiva Physiotherapy and Rehab