The five ‘W’ of cognitive telerehabilitation in the Covid-19 era

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, is a global health problem that has radically transformed public and private healthcare organizations around the world [1]. To limit COVID-19 transmission, precautions must be taken, such as adopting careful personal hygiene, and wearing masks and gloves, as well as applying the so-called ‘social isolation’. COVID-19 mainly affects the lower respiratory tract and causes several flu-like symptoms, but in severe cases, pneumonia and acute respiratory distress syndrome can occur, causing also the death of the patient [2].

Neurological symptoms/signs, including hyposmia, headaches, weakness, altered consciousness, as well as encephalitis, demyelination, neuropathy, and stroke, have been also reported, due to both severe hypoxia and hypoxemia and the direct/indirect effects of the virus on the neurons [3]. It has been observed that the long period of intensive care and anoxic damage can cause spatio-temporal disorientation, memory disturbance, and even deficits in multiple cognitive functions, especially in the elderly and severely affected patients. Moreover, viral invasion of the brain may particularly target and alter brainstem and thalamic functions, resulting in sensorimotor dysfunctions and psychiatric disorders [3].

This health emergency and the consequent adaptation of healthcare facilities negatively influenced the rehabilitative treatments of non-COVID pathologies, with a negative impact on the quality of life of patients (especially those with cognitive symptoms) and their families. In our opinion, neuropsychology represents a fundamental activity, which must be included in the rehabilitation programs of COVID and non-COVID neurological patients [4].

In this regard, telerehabilitation could help support both the cognitive and psychosocial needs of all patients, independently from their geographical area [5]. In recent years, it has been shown that the use of telerehabilitation leads to clinical improvements that are at least equal to the conventional face-to-face rehabilitation program [6]. This is particularly important in the period of covid pandemic, in which the management of neurological diseases, both for adults and children, represents a great challenge for the national health systems worldwide [5,7].

In this editorial, we analyze the role of cognitive telerehabilitation following the journalistic ‘5W’, taking into account the growing interest in this matter in the ‘Covid Era’.

1. WHAT?

Telerehabilitation represents an emerging and innovative approach that can constitute a valid support during the home rehabilitation process for the improvement of motor, cognitive, or psychological disorders. It can provide interventions such as physiotherapy, speech therapy, occupational therapy, patient telemonitoring, and teleconsultation, assisting home-forced patients without the physical presence of therapists or other healthcare professionals [8,9].

In particular, cognitive telerehabilitation involves the recovery and/or compensation of impaired cognitive and behavioral skills, to improve the patient’s quality of life, as well as his/her family support, and social environment [6,8,9]. Cognitive telerehabilitation requires intensive home-based exercise under the supervision of a clinician via web. It offers a fair opportunity of accessing the rehabilitation services to people who live in remote areas or are unable to reach local healthcare services due to physical impairments or restrictions (like during pandemics). [6,8,9] There are different cognitive telerehabilitation softwares, using either the mobile phone with specific health apps or pc-based exercises, with different tasks involving the main cognitive domains. These devices have the possibility to adapt the level of difficulty of the exercises to the patient’s performance, and the possibility to choose different sets of exercises based on the cognitive deficit. These characteristics are fundamental to create activities tailored to the patient’s needs. The platforms are specifically created for cognitive rehabilitation with requirements and characteristics defined by physicians and psychologists skilled in neurorehabilitation, as well as engineers. Typically, the platforms have customized tracking systems that allow video conferencing and secure data exchange in electronic format. Thus, healthcare professionals can perform clinical assessments and monitor patient’s neurocognitive exercises. Patients can consult clinicians and solve self-training and/or technical problems by sending voice messages/e-mails or during the video conference. Nonetheless, home cognitive telerehabilitation could require intensive and daily interventions, and the adaptation of the intervention allows a continuous feedback to the patient, who becomes motivated with greater awareness of his/her cognitive competence [6,10,11].

Various studies have shown that cognitive telerehabilitation is effective, easy to use, motivating and accessible to different types of patients, so it could be useful in alleviating the current pressure on the healthcare system due to the pandemic [10,11].

2. WHEN?

COVID-19 caused multiple changes in the lifestyle of people forced to adjust their daily habits and activities. These changes particularly affect the subject’s cognitive and behavioral sphere with a possible impact on the quality of life, especially in fragile people [8]. In general, cognitive rehabilitation is considered necessary for patients with brain damage in order to limit long-term cognitive impairment and reduce the associated social and psychological consequences. It can be adapted both for the COVID-19 positive population to prevent the cognitive sequelae observed in post-hospitalization and neurological subjects to limit and improve the cognitive deficits.

The effectiveness of cognitive rehabilitation treatment increases if the stimulation programs are intense and continuous, even during the stay at home [5,6].

In light of these considerations, the stimulation of cognitive function during a health emergency, as COVID-19 is, can exploit the potential of remote telerehabilitation to improve cognitive performance, regardless of the diagnosis (congenital or acquired damage), the specific cognitive profile of the participants, and the patient’s age (developmental, adult or old age). This allows stimulating alternative activities that involve and motivate patients, promoting a better quality of life [6]. People can safely stay at home, while improving their cognitive performance and this is the best one person can do to avoid such terrible infection. Indeed, this new approach could be used not only during the pandemic, but also after the end of the ‘lockdown’ period.

3. WHY?

The different national health systems undergo continuous changes, which require the reorganization of primary care, the integration between the different levels of care, and the continuity of care. Cognitive telerehabilitation can respond to these needs for the provision of rehabilitation services in situations where the healthcare professional and the patient (or two professionals) are not in the same location [6,8,9]. Indeed, traditional cognitive rehabilitation has some limitations relating to the time, costs, and accessibility of patients to these services, especially considering the ‘restrictions’ activated for the pandemic [1,5]. The use of rehabilitation technology allows the provision of services remotely, using a ‘non-medical’ setting with new rehabilitation programs that increase the opportunities and the consistency of the therapy [8]. During delicate phases, including the COVID-19 emergency, cognitive telerehabilitation might allow the continuity of care and precise monitoring of patient performance through ICT [6]. The latter allows providing an accurate and reliable patients’ management, influencing attitudes and behaviors toward daily life, potentially improving their mental and medical conditions. This could reduce the overload of healthcare workers, already employed in the fight against the COVID-19 and unable to take prompt action in the event of emergencies unrelated to the pandemic [7].

4. WHO?

For the use of cognitive telerehabilitation, two categories of individuals must be considered: the users and the operators (mainly clinicians). A crucial role is played by the healthcare professional, due to his/her ability to involve patients in the treatment process. Indeed, an accurate neuropsychological assessment determines the cognitive treatment, in terms of personalization, settings of cognitive exercises and feedback, and the participation of the patients. For this reason, it is important to train the clinicians involved in ICT to meet the multiple needs that this phase and the new modalities of assistance require. In addition, a proper operator training can encourage the use of these innovative systems, reducing the concerns about the cost and time expenditure of using the telerehab platforms. In fact, in the past the platforms required licenses and restrictive payments, aspects currently solved through the diffusion of new low-cost technologies (such as skype, android apps, etc.) that allow the provision of professional services by reducing the costs necessary for cognitive telerehabilitation.

As for the users, potentially all patients affected by neurocognitive deficit may benefit from telerehabilitation. Previous research has highlighted the usability and efficacy of the system for both developmental and adult brain disorders and elderly subjects [8–11].

However, to our knowledge, no published data are available concerning the efficacy of cognitive telerehabilitation during this COVID-19 pandemic. Many countries in the world have been in lockdown since March 2020 until the mid-May 2020, and despite several challenges, there has been early success. The major conflict now is the health benefits weighed up against the deleterious psychological, social and economic consequences of prolonged lockdown. As for the psychiatric disorders [12], we expect this unprecedented calamity could potentially cause or exacerbate various cognitive and behavioral problems, which might be successfully managed using ICT.

5. WHERE?

Telerehabilitation should be used in all countries of the world, especially in those most affected by the COVID-19, since many rehabilitation hospitals and local services have not worked or have been converted into COVID centers. In particular, this innovative service should be provided and could be effective for patients living in rural places, islands, and mountain areas. In fact, cognitive telerehabilitation can reduce the need to travel to hospital centers, especially for aged patients and with chronic polypathologies [6,8,9]. The tool offers the opportunity to safely access rehabilitation services for people living in remote areas or areas where access is restricted to either the patients or the clinicians due to COVID-19 restrictions. For security and clinical practice reasons, the platform and the related ICT service should follow the guidelines by the WCPT/INPTRA Digital Practice Final Report, released on March 2020.

6. EXPERT OPINION

we believe that cognitive telerehabilitation could have a pivotal role in the covid-19 era: it may promote the patient’s functional recovery in a safe manner, as there is no direct contact between the clinician and the patient, and improve social functioning and psychological well-being by also avoiding isolation. In the near future, the diffusion of technologies as an effective therapeutic alternative approach during the pandemics will be possible if the factors that facilitate human-technology interaction will be identified and well defined. The intervention must be modeled according to the user needs, in order to encourage acceptance of the innovative and highly technological healthcare program. Moreover, it is important to actively train healthcare professionals, address concerns about the remote treatment modality, and engage them to facilitate a more effective planning intervention.

Different cognitive telerehabilitation approaches and studies coming from different countries are needed to confirm the importance of telemedicine in managing neurological patients during these ‘unpredictable’ pandemics.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One peer reviewer serves as a telehealth advisor for Bluejay Mobile Health, Inc. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.