Table 1.
Symptoms | Nonpharmacologic Management | Pharmacologic Management | Telehealth Consideration |
---|---|---|---|
Mood (Anxiety/Depression) | CBT, neuropsychology,51 exercise & diet, breathing/relaxation techniques, Acupuncture | SSRI, SNRI, atypical antidepressants, TCA, serotonin modulators, MOAs | Patients with anxiety/depression shown to prefer telehealth visits vs F2F.52 Cochrane database review found telerehab for depressive symptoms poststroke to be noninferior to in-person.50 |
Agitation/Irritability | Same as abovementioned, anger management, behavioral modification | Beta-blockers have best evidence for reducing agitation,53, 54, 55 (propranolol best CNS penetration56) atypical antipsychotics,57 (seroquel and olanzapine) mood stabilizing AEDs,58 (valproic acid and carbamazepine) | Less likely to provoke patients with external stimuli. Increased safety for patient and provider. Video CBT shows significant and clinically meaningful reductions in anger.59 |
Posttraumatic Headaches | Physical therapy, ice/heat packs, CBT, biofeedback, massage therapy | Prophylaxis vs abortive, NSAIDs, APAP, ASA, triptans, beta-blockers, AEDs, TCAs | Please refer to the Don McGeary and Cindy McGeary’s article, “Telerehabilitation for Headache Management,” in this issue within this book. |
Insomnia/Sleep | Sleep hygiene, sleep study to rule out OSA, CBT | Melatonin, hypnotics, antidepressants, antipsychotics, antihistamines | Assess bedroom with patient's permission to consider environment modifications. Tele-CBT shown to decrease insomnia severity index and be effective at improving sleep.60 |
Fatigue | Address sleep as abovementioned, aquatic therapy, exercise & diet, self-management strategies | Methylphenidate and modafinil,61 melatonin51 | Telehealth visits can save up to 3 h per visit.16 Telerehab exercise programs show statistically significant improvements in fatigue.62 |
Cognitive Dysfunction | Neuropsychology evaluation,51 speech therapy, compensatory strategies | Neurostimulant for attention, concentration, processing speed, initiation, orientation, verbalization (amantadine63, 64, 65, 66 and methylphenidate57,58,63,67), donepezil for memory61 | Can reduce stress related to visit and save time from reduced transportation.16 Systematic review found telecognitive rehabilitation to be effective when compared with in-person rehabilitation.68 |
Vestibular (Balance) Deficits | Vestibular rehabilitation, balance training, habituation techniques, DME (Cane, FWW) | Should avoid chronic use.69 If needed acutely, antihistamines, anticholinergics, TCAs, SSRIs, and CCBs | Reduced fall risk. Can observe in home environment. Virtual reality rehab has been found to out-perform gait and balance training compared with conventional rehab.70 |
Visual Dysfunction | Neuro-ophthalmology referral, vision rehabilitation, visual scanning techniques, corrective eyewear | Ask if screen is causing any visual disturbance (headache, blurriness), consider phone visit if severe. Meta-analysis for screening for certain eye conditions found be effective using tele-ophthalmology services.71 | |
Auditory Dysfunction | Audiology referral, hearing devices, white-noise generators, tinnitus CBT, environmental modifications, tinnitus retraining therapy | Can have patient wear headphones to modify volume and improve communication during visit or using text-based communication. Patients show high satisfaction in web-based services for hearing health.72 | |
Motor Dysfunction/Deficits | Both telerehab and in-person physical therapy, occupational therapy; orthotics/bracing, electrical stimulation | Antispasmodics, fluoxetine, or other SSRIs potentially,73 botox | Systematic review of telerehab interventions for motor deficits after stroke were found to have equal or better effects when compared with in-person therapy.74 |
Abbreviations: ADLs, activities of daily living; AEDs, antiepileptic drugs; APAP, acetaminophen; ASA, aspirin; CBT, cognitive behavioral therapy; CCB, calcium channel blockers; DME, durable medical equipment; F2F, face-to-face visit; FWW, front wheel walker; MOA, monoamine oxidase inhibitor; NSAIDs, nonsteroidal antiinflammatory drugs; OSA, obstructive sleep apnea; SNRI, serotonin norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.