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TRAIL study brings new remote rehab potential to stroke survivors

The telerehabilitation programme will assess the impact of exercise-based therapy that has been traditionally done in-person



Through the use of telerehabilitation, stroke survivors are being supported in new ways to progress rehab that would traditionally have been done in-person. NR Times speaks to the Canadian-based pioneers of the TRAIL program, Dr Ada Tang and Dr Brodie Sakakibara, to learn more about their work

What is the purpose and intention of the TRAIL study?

We developed the TeleRehablitation with Aims to Improve Lower extremity recovery post-stroke (TRAIL) program to address the need for continued lower extremity rehabilitation after stroke that were not being met through standard hospital-based rehab services. 

The COVID-19 pandemic certainly contributed to further reductions in access to stroke rehabilitation, so we realised there were even greater gaps in care than ever before.

Our study is examining the effectiveness of the four-week TRAIL program through a randomised controlled trial. We will compare how participants with stroke do after TRAIL, compared to those who participate in an education program.

We will compare the groups in terms of various lower extremity functional measures of mobility (through the Timed Up and Go), strength, balance and motor impairment, as well as balance self-efficacy, health-related quality of life, and use of healthcare resources and healthcare

Dr Ada Tang


Why did you choose to investigate rehabilitation for lower extremity recovery after stroke – what is the existing provision in this area? 

Research shows that 80 per cent of people living with stroke report residual motor impairment that affect many daily activities such as dressing, bathing and walking.

There is lots of strong evidence showing that lower extremity exercise programs, delivered in-person and face-to-face, improves independence, walking and balance after stroke. Exercise also improves psychosocial outcomes such as balance, self-confidence and quality of life.

The rapid growth in internet use and mobile devices has opened up many possibilities for people with stroke to access specialised rehabilitation remotely from their homes and their communities (i.e. telerehabilitation). 

To date, most of the research around telerehabilitation focuses on check-in sessions, or education and counselling after stroke, whereas the use of technology to deliver remote exercise interventions for the lower extremity is much more limited. Instead, most exercise programs that focus on lower extremity recovery for walking and balance have been delivered in-person to manage safety issues and risk of falls.

How has your project developed since its launch in 2019?

When we first conceived TRAIL, we looked at the small body of research that has focused on telerehabilitaiton for lower extremity recovery after stroke and found that most studies provided very minimal therapist oversight, and none were conducted in the first year following stroke when the opportunity for neuroplastic change is greatest.

We designed the TRAIL program to provide opportunities for live videoconference interaction with a physiotherapist two times a week for four weeks for the exercise portion. We also designed the program to encourage independent exercise in at least one additional session per week, to add volume of exercise without using therapist resources, and to provide participants with strategies for exercise self-management. 

In early 2020, we were getting ready to soon launch the study when the COVID-19 pandemic swept across the globe. We quickly realised that telerehabilitation was needed more than ever, but we needed to change a few things about our study. 

Namely, we moved to virtual outcomes assessments in addition to virtual delivery of the exercise program. We consulted with many expert

Dr Brodie Sakakibara

therapists and researchers on how best to do this, who were incredibly generous with their advice and suggestions.

We conducted a pilot study of TRAIL in 2020-2021 that involved 32 participants. We also completed a qualitative study with our participants to help us understand how they perceived TRAIL, as well was with the physiotherapists for their perceptions of delivering TRAIL. We are in the process of analysing the data from the pilot study and the qualitative interviews right now.

In summer 2021, we were excited to learn that we received grants from the Canadian Institutes of Health Research and Canadian Medical Association to continue our work in TRAIL, which we are using now for the randomised controlled trial. 

Why did you choose to work on a telehealth project? What was the response to this pre-pandemic and how has this changed?

TRAIL was a way to fill and unmet need by providing access to lower extremity rehabilitation opportunities once in-person services had ended.

We started planning the first TRAIL study in late 2019 – little did we know that a global pandemic was about to hit and the need for telerehabilitation programs became even greater. 

How vital is the use of technology in joint working across the miles?

We wouldn’t be able to run TRAIL without technology! And are glad to be able to get lower extremity rehabilitation programs to more people.

Canada is a large country though with a large geographical area and many regions that are rural and remote. There will be some people who don’t have access to the technology needed to participate in TRAIL. 

In our studies, we are looking at the feasibility of TRAIL (for example, who can access TRAIL, how far (distance) can it go) as much as we are looking at its effectiveness.

What is next for TRAIL and what is its potential?

We are getting ready to launch the randomised controlled trial early this year. We have two of our five sites ready to go; the other three are not far behind. We aim to enrol 96 people into the study.

Once complete, it will be one of the largest RCT to date looking at telerehabilitation for lower extremity recovery after stroke.

  • Dr Ada Tang is an associate professor in the School of Rehabilitation Science at McMaster University. Dr Brodie Sakakibara is an assistant professor with the Department of Occupational Science and Occupational Therapy at the University of British Columbia

Dr Tang and Dr Sakakibara will discuss TRAIL and its impact at the Virtually Successful conference, a first-of-its-kind five-day event next week organised by Remote Rehab in association with NR Times, to assess the impact and potential of digitalisation in therapy.

For more details or to sign up, visit here