1. Model for telerehabilitation
services for stroke survivors:
experiences of CLEAR project
Francesco Benvenuti
Dipartimento Riabilitazione-Fragilità
AUSL11, Empoli
Research brokerage workshop in Lodz
10-11 September 2013

2. Aims was CLEAR project
• To evaluate a tele-rehabilitation service
provided through the Habilis platform.
• The study was focused on the end users
(patients and clinicians):
– Satisfaction with the tele-rehabilitation
application
– Clinical effectiveness of the service
– Time investment for providing and receiving
the tele-rehabilitation service

3. Consortium
Coordinatore
Signo Motus
Designers
SITUS (IT)
UPM (ES)
RRD(NL)
Clinici
AUSL11 (IT)
FPING (SP)
RCR (NL)
MUW (PO)
Gruppo validazione
ISS (IT)
IE-UAB (ES)
TIC –Salut (ES)
RETOS (IT)
CSIOZ (PO)
MENZIS (NL)
Coordinator
Signo Motus
Clinical Centers AssessorsDesigners

4. Cinical studies
COPD ,
Chronic back pain,
Whiplash
Cognitive disorders
Acquired Brain
Injury
Osteoarthritis of
hip or knee before
and after total
joint replacement
Upper limb paresis
after stroke

5. Telerehab vs. Conventional
Treatment
Effectiveness Similar or superior
Safety Similar
Customer satisfaction Good/very good
Time investment for
clinicians and
patients
Reduced
CLEAR Results

6. Different rehabilitation treatment scenarios
Partial replacement
Time augmentation
Conventional
Addition
Conventional rehab sessions
Tele-rehab sessions

7. Stroke Epidemiology
• Incidence: 220/100000
• Survival:
• 1 year: 60-75%
• 3 years: 40-68%
• 10 years: >35%
• Prevalence: 600-800/100000
• Severely disabled: 35-40%

8. Recovery plateau
What we observe….
Rehabilitation
Rehabilitation
Rehabilitation
Rehabilitation
Time from stroke
Acute &
Subacute
Chronic

9. What we learn…..
Recovery plateau
Time from stroke
Acute &
Subacute
Chronic
Aims of CLEAR project in AUSL11:
•To extend rehabilitation in the subacute phase
of the disease
•To maintain/improve function in the chronic
phase

10. Methods
Hospital
Home Kiosk3 times/week 2 times/week
Treatment duration
3 months

11. Kiosks installed
HOSPITALs & KIOSKs LOCATION
Hospitals
Montelupo F.no

12. Clinical results
Safety
No significant ACEs associated to
the treatment program have been
observed in both groups

13. Clinical results
Effectiveness: analysis at individual level
Improved (>10%)
Unchanged (0-9%)
Worse (<0%)
Chi2 test
P=0.00011
Chi2 test
P=0.01924
Nine Hole Peg Test
0%
20%
40%
60%
80%
100%
Usual care group Treatment group
Motricity Index
0%
20%
40%
60%
80%
100%
Usual care group Treatment group

14. Clinical results
Logistic Regression Analyses
OR 95%CI
Female Gender 2.30 1.58 3.34
UL Paresis (Motricity Index) 0.94 0.92 0.96
Spasticity (Ashworth scale) 0.67 0.58 0.78
Adherence 2.39 1.77 3.21
Predictors of effectiveness
OR 95%CI
Home-kiosk distance 0.85 0.78 0.91
No help needed to go to kiosk 10.88 6.27 18.88
Predictors of Adherence

15. Clinical results
Patients’ Satisfaction
Satisfaction questionnaire: scores post-intervention
n=160
Component
Low
(score 1-2)
Average
(score 3-5)
High
(score 6-7)
Ease of use 3% 89% 8%
Usefulness 11% 51% 38%
Attitude 1% 96% 3%
Social Norm 2% 60% 38%
Self-efficacy 10% 90% 0%
Intention 3% 78% 19%
Satisfaction 2% 53% 45%
78% found the exercise program useful for them
70% patients found the Habilis platform well implemented
75% would recommend the Habilis service to others
Average patient grading of the Habilis service 7.4 (SD 1.8)

16. Clinical results
Time investment
Home-Kiosk-Home
Median (min-max)
Home-Hospital-Home
Median (min-max)
Single treatment session
travel distance (km)
5.8 (0.4-43.6) 22.2 (0.6-68.0)
3-months travel distance
for 22 treatment sessions
(km)
127.6 (9.2-959.2) 488.4 (13.2-1496.0)
3-months travel cost for
22 treatment sessions*
(€)
25.5 (1.8-191.8) 97.7 (2.6-299.2)
Median travel distance and cost per patient (n=165)
*0,20€/km

17. Clinical results
Time investment
Usual Care
During CLEAR
Project
Optimization
after CLEAR
Project
Physical Therapist
time/patient
(hour)
time/patient
(hour)
time/patient
(hour)
patient's assessment at baseline 1 1,42 1
patient's training to the use of Habilis platform 0 2 2
first week of treatment 0 1,75 1
successive 11 weeks of treatment 22 16,5 11
patient's final assessment 1 1 1
Total for Physiotherapist 24.0 22,67 16.0
Physiotherapist time investment for usual care,
CLEAR project, and optimization of treatment protocol

18. Future work
Limits Possible Corrective actions
•Problems of transportation and
social support to attend kiosks
•Increase geographical distribution of kiosks
•Assisted transportation
•Home tele-rehabilitation (using equipment already
available at home?)
•Very difficult to find space from no
profit organizations
•Economic support by Regional Health Authority
•Participation to costs by participants
•Limited number of patients •Extend the program to other conditions
•Integration with conventional treatment programs
•Poor connectivity in rural areas •Wide band
•Patients ICT interactions •Paedagocic incentive
•Exercise program very similar to that
performed at home
•Instrument the Habilis platform
•Serious games
•Limited computer skill of participants •More friendly interface
About kiosk experience

19. Main critical issues:
1. Acceptance;
2. Policy;
3. Infrastructures (broadband and
places);
4. Organizational problems;
5. Lack of a contextual
framework allowing continuity
of care.
Fracture and main intervention
area: management from hospital to
territory

20. Telerehab service future scenarios
Health House
District
• Information on continuity of care
• Empowerment
• Rehabilitation treatment (Kiosk like)
• Tele consultation/ videoconference
Home
• Rehabilitation treatment:
o stroke (bag+ Habilis)
o frailty (Otago libraries + Habilis)
o orthopaedics (libraries + Habilis)
o BPCO (libraries BPCO + Habilis)
o cognitive (libraries + Habilis)
•Teleconsultation / videoconference
•Telemonitoring
HOSPITAL
• Information on continuity of care
• Empowerment
• Initial treatment (sub acute phase)
• Tele consultation/ videoconference
GP/ACCESS POINTS
• Information on continuity of care
• Patient management
Habilis
Habilis
HABILIS
Service Centre
•Treatment management
Service acces points
Treatment provision
Patient routing

21. Horizon 2020
3. Advancing active and healthy ageing
– 3b Service and social robotics in support of active
and independent living
4. Integrated, sustainable, citizen-centred care
– 4d Advanced ICT systems and services for
Integrated Care
– 4f Citizen engagement in health, wellbeing and
prevention of diseases
– 4g mHealth for disease management
– 4h Patient empowerment

22. Thank You!
Francesco Benvenuti
Dipartimento Territorio-Fragilità
UOC Cura e Riabilitazione delle Fragilità
Azienda Unità Sanitaria Locale 11 di Empoli
f.benvenuti@usl11.toscana.it
www.usl11.toscana.it
www.habiliseurope.eu
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