Phase 1: Development
After a non-exhaustive literature search, no validated lower extremity measure of motor impairment specific for telerehabilitation was found. According to Kwakkel et al. (2017), an international consensus on stroke outcome measures recommends the FM for wide use in clinical and research initiatives to measure motor impairment after stroke [10], with work by Barbosa et al. [11] and Duncan et al. [15] showing high validity and reliability of the FM. The American Physical Therapy Association Neurology Section Task Force recommends use of the FM from acute to chronic phases of recovery after stroke [16]. The Canadian Stroke Best Practice Recommendations on Telerehabilitation were consulted to ensure consistency of the FM-tele with Best Practice Guidelines [12]. Specifically, telerehabilitation is recommended to be part of integrated stroke services for rehabilitation including (1) real-time two-way video-conferencing for patient assessment and (2) efforts to ensure the video-conferencing used is easy to use and simple to operate [12]. Cluster analysis by Woytowicz et al. (2017) and Rasch analysis by Woodbury et al. (2007) indicate that reflex testing did not contribute to scores on the FM upper extremity [17, 18].
Based on the literature review and after consultation sessions, the clinical team generated these key principles to guide the development of the FM-tele: (1) safety of the participant in their home, (2) need to visualize the entirety of the bilateral lower extremities to ensure scoring clarity, and (3) minimize changes in position to reduce participant fatigue and reduce the need to adjust the videocam. Also, items that required a therapist, such as palpation of tendons or application of therapist-applied resistance, were modified to ensure content relevance from the FM was encompassed within the FM-tele. The following rationale was employed on an item by item basis (Table 1, Additional file 1):
Item 1 Reflexes
Reflexes cannot be completed without a trained health professional; thus, this item was eliminated. Literature review identified that for the upper extremity FM, eliminating the reflex item did not considerably alter scores for impairment level [17, 18].
Item 2 synergistic flexor synergy
This item was modified from a supine to sitting position to be consistent with key principle #1 (safety), #2 (visualize entire leg), and #3 (minimal position changes). As palpation of the distal tendons could not occur, to ensure that knee flexion was active, clear visual observation confirmed active knee flexion in sitting. Participants were instructed to flex the hip, knee, and ankle joint fully while in sitting.
Item 3 synergistic extensor synergy
This item was modified from a supine to sitting position to be consistent with key principle #1(safety), #2 (visualize entire leg), and #3 (minimal position changes). The FM requires resistance be applied to ensure movement is active and to evaluate both movement and strength. To mimic the effect of therapist-applied resistance, a resistance band was used for the FM-tele. The resistance band was approximately 1.25-m long without any knots or loops added to it. The ball of the foot was positioned in the middle of the length of the resistance band, and the participant held the ends of the resistance band with the non-paretic hand (Fig. 1A, B). From the position of full hip/knee flexion and ankle dorsiflexion in sitting, the participant was instructed to perform hip extension/adduction, knee extension, and ankle plantarflexion in a slow and controlled manner (i.e., over 3 s). If the participant demonstrated controlled and slow (≥3 s) movement, a resistance band was added under the ball of the foot, with the participant holding the end of the band in their hand. The participant then performs the same motion with this added resistance. To obtain a full score on a subitem (i.e., 2/2), the participant needed to demonstrate slow and controlled movement at that joint against the resistance band. If the participant could not assume the starting position, items #6 and #7 (combined knee extension/ankle plantarflexion) were assessed without hip extension/adduction (i.e., items #4 and #5 scored 0).
Item 4 movement combining synergy
As this item in the FM is already consistent with key principle #1 (safety), #2 (visualize entire leg), and #3 (minimal position changes) and is completed in sitting, there were no modifications made.
Item 5 movement out of synergy
In the FM, this item requires the participant to stand to assess knee flexion and ankle dorsiflexion while the hip is maintained at 0°. Based on literature review and clinical consultation, this item was deemed to be inconsistent with key principle #1 (safety) and #3 (minimal position changes). As a result, this item was eliminated as no modification in sitting could maintain the hip at 0° and still maintain content relevance with the FM.
Item 6 normal reflexes
This item was eliminated based on the same rationale as for Item 1.
Item 7 coordination/speed
This item was changed from supine to sitting position to be consistent with key principle #1 (safety), #2 (visualize entire leg), and #3 (minimal position changes). The same instructions as the FM were used.
Consequently, the FM-tele is scored out of 24 points (Additional file 1).
Phase 2: Feasibility
Five community-dwelling individuals with stroke were recruited from the GF Strong Rehabilitation Research Program database (age = 63 ± 5.7 years; female n = 1; Table 2). These individuals had a range of impairment levels and were at least 6 months post-stroke. One caregiver who assisted a participant with activities of daily living also supported the participant with the questionnaire. Five assessors with clinical experience with stroke assessment (PT students <2 years’ experience), trained by the same research PT (>10 years of experience), completed the questionnaires regarding the FM-tele.
Participant Questionnaire (Additional file 2)
No concerns were reported by any participants related to safety or following the standardized instructions given by the assessors. Technical concerns navigating the software were expressed by 100% of participants, with 60% of concerns being resolved during the session. The primary technical difficulties were related to the visual connection, such as screen freezing (reported by 40% of participants), and the inability to access clear audio on the platform (40%). Other logistical set up concerns were related to entering the personalized access codes to launch the online session (40%).
When asked to rank the ease of navigating the iPad system, participants gave an average score of 3.6 out of 5. Sixty percent of participants also reported that practice or familiarity with the iPad would have been beneficial, with one participant stating that they feel they would have benefited from more instructions on how to navigate the iPad. Furthermore, 80% of participants felt they would have had less difficulty navigating the device with repeated use. Sixty percent of participants reported that they either prefer or miss face-to-face interaction and 100% of participants either completely agreed or agreed that the overall physical therapy session was positive, despite the technical and logistical difficulties. Time efficiency of the session was the main reported benefit (40% of participants), with other perceived benefits including avoiding a commute (20%), familiarity with their environment (20%), and clarity of instructions (20%). When asked whether they would use telerehabilitation again in the future, all participants were either neutral, agreed, or completely agreed.
Assessor Questionnaire (Additional file 3)
Related to the FM-tele, all assessors agreed or completely agreed that the participants were safe during the telerehabilitation session; no adverse events such as falls or injuries occurred. Eighty percent of the assessors either agreed or completely agreed that the standardized instructions were effective in guiding the participant throughout the session. Deviations from the standardized instructions included adjusting the equipment setup to better visualize the participant. All of the assessors felt that they were able to give effective solutions when participants encountered problems with the assessment, which were mainly technological in nature (described below). Assessors also suggested that more detailed instructions for the environment setup and training for iPad use could have been beneficial for the participants.
All of the assessors found the software to be user friendly; however, all of them encountered malfunctions while using it. Most prominently, poor video quality due to video lag made the assessment difficult, especially when assessing coordination (Item 7). However, most assessors found that asking the participant to repeat the movement several times helped to perform an adequate assessment despite the poor video quality. Software glitches were also a common experience among the assessors, making establishing a timely and dependable connection with the participant challenging. This malfunction was often resolved by refreshing the eHAB platform or restarting the iPad. The audio failed to connect on two occasions, during which telephone was used to establish verbal communication with the participant instead. Common suggestions for improvement included ensuring a stable internet connection and developing software updates to minimize disruptions.
Phase 3: Proportional agreement
The same five individuals with stroke from phase 2, participated in the two sessions for phase 3. Additionally, the same five assessors from phase 2, administered and rated the FM-tele for phase 3.
Range of scores
Scores on the FM ranged from 18 to 27 out of a possible 34. Scores of 0–19, 20–28, and ≥29 out of 34 are considered to reflect severe, moderate, and mild impairment, respectively [19]. Based on these cutoffs, one participant was severely impaired, with the other four participants moderately impaired. Scores on the FM-tele (in person) ranged from 12 to 20 out of a possible 24. Scores on the FM-tele ranged from 13 to 23 out of a possible 24. The data collected from all assessments (i.e., FM, FM-tele (in person), FM-tele) conducted in-person and over telerehabilitation are presented in Table 1.
FM and FM-tele
Table 1 presents the number of participant scores on each item in agreement across the FM and FM-tele. For the flexor synergy (Item #2), extensor synergy (Item #3), and movement combining synergy (Item 4), 4 out of 5 or 5 out of 5 participant scores were in agreement (Table 1). For Item #7 Coordination/Speed, dysmetria and speed were in agreement for 3/5 and 2/5 participants, respectively, possibly due to the poor video quality described in phase 2.
