CanStroke Recovery Trials researchers were recently awarded $100K in funding from the Canadian Institutes of Health Research to conduct a one-year pilot study of their virtual rehabilitation program for walking and balance, called TRAIL.
TRAIL – TeleRehab with Aims to Improve Lower extremity recovery after stroke – was developed by McMaster professor Ada Tang and UBC-Okanagan professor Brodie Sakakibara, both former trainees of CPSR research leader Dr. Janice Eng of the University of British Columbia.
The idea for TRAIL began in 2019 when Dr. Eng and Dr. Mark Bayley of Toronto Rehab, both leaders of the CanStroke Recovery Trials platform, first suggested leveraging Dr. Tang’s expertise in exercise and Dr. Sakakibara’s expertise in telerehab to develop a program to extend virtual rehabilitation to people with lower-limb impairment after stroke.
“Most tele-rehabilitation was not focused on lower-limb recovery,” says Dr. Tang. Virtual programs were more likely to target cognition, speech and language, psychosocial counselling or upper limb recovery, partly because of hesitancy resulting from perceived safety concerns about the use of virtual therapy for walking and balance.
Funded through a CPSR-Brain Canada grant, Drs Tang and Sakakibara developed a four-week, eight-session program that involved physiotherapists working with patients in real time to set goals, develop a self-management action plan, and take part in a targeted exercise program to gain strength and improve balance and walking. The overall goal of TRAIL was to extend the opportunity for rehabilitation for lower-limb impairment as patients transitioned home after hospital-based programs were finishing.
Because TRAIL protocols had been established and ethics approval was in process, the team was ready to hit the ground running when the pandemic struck and there was immediate demand for virtual programs in 2020. A national feasibility trial (to involve 32 participants) rolled out at CanStroke sites in Vancouver, Halifax, Toronto, London and Winnipeg.
Initially, TRAIL was designed to begin with in-person assessments but, because everything pivoted online in 2020, “we had to rethink how to roll out the trial without having to come into a centre,” Dr. Tang says. Participants were required to have a family member or caregiver on hand for initial virtual assessments before the program got underway.
To take part in TRAIL, participants need to be able to walk 10 metres without assistance, tolerate 50 minutes of activity (sessions are 60-90 minutes long, but not compromised solely of exercise), and have the cognitive, visual, auditory and communication skills to participate via Zoom. Before beginning, the therapist advises participants on setting up a space in their home with a six-to-eight foot-area free of obstacles.
Each week of the TRAIL program is progressive and has a specific focus. The first week focuses on building a base with a series of functional strength-based exercises, such as heel-toe raises, standing with feet hip-distance apart and shifting weight from side to side, marching, mini-squats with hands on the back of a chair, and sit-to-stand exercises to build balance. Therapists were able to make adjustments to the exercises to match the abilities of each person. From week to week, exercises are scaled up to make them more challenging and new exercises are interjected.
Each participant in the feasibility study, who could be up to 18-months post-stroke, required a 10-inch tablet or laptop and the ability to complete assessments at home. Many of the participants were identified for the study as they were leaving in-patient rehabilitation.
Dr. Sunil Mangal, an emergency room physician in Vancouver who had a stroke last year at age 56, was among participants in the TRAIL feasibility study. “The timing was really good because there was a bit of limbo after in-patient rehabilitation and waiting for outpatient stroke therapy” due to Covid. The study also eased isolation caused by the pandemic.
“It was nice to feel like my rehab was going well and things were progressing,” he says. “It was very positive. My balance definitely improved.”
Anne Harris, a physiotherapist at GF Strong Rehabilitation Centre in Vancouver, worked with five different individuals as part of the TRAIL study. Participants found it helpful to get therapy at home because they didn’t have to travel, especially as some were nervous about exposure to Covid. “We were able to cast our net a little wider,” she says. One participant lived in a remote community and would not have otherwise had therapy.
The one-year randomized controlled TRAIL trial, set to get underway this summer, will involve a larger sample size and a health economic analysis, asking questions such as: Does TRAIL change the need to access other services? What is the cost of delivering the program? Could it become an extension of outpatient rehabilitation? How do outcomes compare?
Researchers also want to do qualitative research in the next phase, looking at the experience from the participant’s and therapist’s point of view. “Telerehab isn’t new,” says Dr. Sakakibara. “But it really took something like this pandemic to accelerate it and to push widespread acceptance.”
“I think we are going to see more studies in this area,” he adds. “We want to optimize outcomes for patients, optimize training and determine what is needed to deliver this in the best way possible.”
To learn more about TRAIL, visit