Each year more than 795,000 people in the United States are newly diagnosed with a cerebral vascular accident, commonly referred to as a stroke (Virani et al., 2020). Strokes, a frequent cause of disability, often involve a loss of mobility. Rehabilitation for a person after a stroke typically involves focused activities and interventions to improve mobility. These activities often include standing activities and gait training. In-person home healthcare (HHC) and rehabilitation services were disrupted during the COVID-19 pandemic. This disruption necessitated a shift in therapy services to telehealth or telerehabilitation care delivery models for people who had a new stroke or needed ongoing HHC due to associated sequelae.

Telerehabilitation has been defined as "clinical rehabilitation services with the focus of evaluation, diagnosis, and treatment" and may be provided using audio, visual, or virtual technology synchronously or asynchronously (Prvu Bettger & Resnik, 2020). Standing, weight-bearing, and gait training activities pose challenges to providing safe and effective care using a telerehabilitation delivery mode. Although home exercise programs have often included standing or walking activities without healthcare professional assistance, there has usually been an in-person evaluation, along with associate measures and modifications to ensure patient safety. Safety is an important consideration as many falls in the home occur when a person is ambulating or attempting to get out of bed (Castro, 2019). Is there evidence for effectively providing standing and weight-bearing activities following stroke using telerehabilitation and are there strategies to enhance safety in the home setting?

A recent scoping review examined the research on the efficacy of standing and weight-bearing activities following a stroke (Ramage et al., 2021). The researchers also hoped to provide practical strategies to enhance safety of real-time activities delivered using telehealth technology. Seven studies conducted pre-COVID-19, for a total of 179 participants, met the criteria for analysis. Five of the studies were conducted in the home. The authors found that using telehealth to provide supervised activities in standing and weight-bearing activities may be helpful for some people who have had a stroke. However, the authors were unable to determine the amount of activity that was done in standing or in weight-bearing positions, and gait training was conducted in only one study. None of the studies reported that the initial assessment of the patient was conducted using telehealth technology. The authors found very limited evidence to make conclusions about utilizing telehealth safely or effectively for standing and weight-bearing activities after a stroke (Ramage et al.).

A meta-meta-analysis of the literature was also conducted in response to the COVID-19 pandemic "to determine if telerehabilitation could be an effective alternative to conventional rehabilitation in physical therapist practice" (Suso-Marti et al., 2021). The results found evidence that "telerehabilitation offers positive clinical results regarding physical function and even comparable with conventional face-to-face rehabilitation approaches, especially in patients with neurological conditions including stroke" (Suso-Marti et al.). The authors cite two benefits of telerehabilitation including the need for high doses of treatment to obtain functional improvements which may not easily be done in person and the ability to work with a person in the home setting which increases the likelihood of successful functional task training. The research analyzed included two different approaches to telerehabilitation including telerehabilitation only and telerehabilitation combined with typical in-person rehabilitation. So it is important to keep in mind that telerehabilitation combined with typical in-person rehabilitation may be the safer and more effective approach for some people in the home care setting.

Strategies to improve safety during standing and weight-bearing activities were described in the scoping review by Ramage et al. (2021). Suggestions included conducting the initial assessment and exercise prescription in person; having a nonhealth professional person on site during exercise; physiological monitoring pre, post, or during the activities; and training in person to use telehealth. Making sure that there is an appropriate and safe environment for the activities as well as caregiver support were also suggested. Typical strategies employed by therapists visiting the home, and discussed by Castro (2019), such as knowing the patient's condition, medications, home environment, and associated fall risks are also important. Many of these suggestions rely on a combination of telehealth and traditional in-person rehabilitation also referred to as a hybrid delivery model. Benefits of this type of combined approach have been described pre-COVID-19 in an article by Cary et al. (2016) on the benefits and challenges of delivering telerehabilitation services to veterans in rural areas.

Use of a hybrid delivery model including both telerehabilitation in combination with in-person rehabilitation in the home may become more accepted as we emerge from the COVID-19 pandemic. As Prvu Bettger and Resnik (2020) note, "The new normal for rehabilitation services after COVID-19 is likely to include some amount of telerehabilitation in different forms in different health systems." The authors suggest an approach "to the study of telerehabilitation [that] can promote innovation in optimal healthcare delivery and fuel new scientific discovery" (Prvu Bettger and Resnik, 2020). Persons with stroke may be the beneficiaries of this research coming out of the COVID-19 pandemic. Hopefully, therapists will see more research on effective strategies for safely providing standing, weight-bearing, and gait training activities in the home using telerehabilitation. Home healthcare therapists are well positioned to be at the forefront of providing the evidence for best practices in HHC telerehabilitation practice.

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