Stroke is a leading cause of adult disability worldwide, with upper limb impairment significantly reducing independence. Traditional outpatient rehabilitation poses challenges for patients with mobility limitations, financial constraints, or those living in remote areas. This randomized controlled trial compares the effects of conventional outpatient rehabilitation with and without adjunctive telerehabilitation on hand function and motor recovery in subacute stroke patients. Forty-eight participants will be randomly assigned to two groups: Group A receives conventional outpatient rehabilitation plus home-based telerehabilitation via WhatsApp video calls (30 minutes daily, 5 days/week for 6 weeks), while Group B receives conventional outpatient rehabilitation alone (same dose and content). Outcome measures include the Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Box and Block Test (BBT), and Physical Activity Enjoyment Scale (PACES), assessed at baseline and after 6 weeks.
Stroke persists as the most prevalent cause of disability in adults worldwide, with upper limb disability significantly diminishing the level of independence in stroke survivors. Traditional post-stroke rehabilitation typically requires frequent visits to outpatient facilities, which can be inconvenient for patients with mobility impairments, those facing high transportation costs, or individuals living in remote areas. Telerehabilitation, delivered through digital communication platforms, offers a promising alternative that may expand access to rehabilitation services while maintaining treatment intensity and quality. This study employs a randomized controlled trial design to investigate whether adding home-based telerehabilitation to conventional outpatient care produces superior outcomes compared to conventional care alone. The study will be conducted at three hospitals in Pakistan: Nusrat Fateh Ali Khan Hospital, Aziz Fatima Trust Hospital, and Madina Teaching Hospital. A total of 48 subacute stroke patients will be enrolled using convenience sampling, with sample size calculated using OpenEpi version 3 based on previous published data (Chen, 2020) with 95% confidence interval and 80% power. Eligibility Criteria: Participants must have a Fugl-Meyer Assessment for Upper Extremity score between 22-56, a Box and Block Test score of at least 1 block in 60 seconds at screening, and no other major neurological or psychotic diseases, cognitive impairment, or pregnancy. Randomization and Blinding: Participants will be randomly allocated using a computer-generated sequence. Allocation will be concealed, and outcome assessments will be performed by physiotherapists who remain blinded to group assignment. Interventions: Both groups receive identical exercise content and dosage. Group A (Experimental) receives conventional outpatient rehabilitation plus home-based telerehabilitation via live WhatsApp video chats supervised by a physiotherapist. Each session lasts 30 minutes, five days per week for six weeks. During video sessions, the therapist observes participant setup, provides online verbal assistance, checks movement quality and safety, and modifies compensatory strategies. Participants receive essential equipment (small objects, balls, TheraBand) and an internet data bundle to support connectivity. Group B (Control) receives conventional outpatient rehabilitation only, with on-site supervised sessions in neuro-physiotherapy outpatient departments. Sessions are 30 minutes each, five days per week for six weeks, using the same exercise content, dosage, equipment, and repetitions as the telerehabilitation group. A physiotherapist provides direct hands-on supervision, checks accuracy, and adjusts difficulty levels in real-time. Outcome Measures: Assessments occur at baseline (pre-intervention) and after the 6-week intervention period using: (1) Fugl-Meyer Assessment for Upper Extremity to measure motor recovery; (2) Box and Block Test to measure manual dexterity; and (3) Physical Activity Enjoyment Scale to measure patient enjoyment of physical activity. Statistical Analysis: Data will be analyzed using SPSS software. Normality testing will precede hypothesis testing to determine appropriate parametric or non-parametric statistical methods. Between-group differences will be analyzed using independent t-tests or Mann-Whitney U tests as appropriate, with significance level set at p \< 0.05.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
48
Telerehabilitation is delivered via live WhatsApp video chats supervised by a physiotherapist. Each session lasts 30 minutes, five days per week for six weeks. The therapist observes participant setup, provides online verbal assistance, checks movement quality and safety, and modifies compensatory strategies. Participants receive essential equipment (small objects, balls, TheraBand) and an internet data bundle to support connectivity. The therapy protocol is standardized using the Upper Extremity Task Specific Training after Stroke by Lang and Birkenmeier and the Accelerated Skill Attainment Program (Cramer et al., 2019).
Conventional outpatient rehabilitation is delivered on-site at neuro-physiotherapy outpatient departments of participating hospitals. Sessions run 30 minutes each, five days per week for six weeks, using the same exercise content, dosage, and progression criteria as the telerehabilitation group. Exercise components include: warm-up and proximal activation (shoulder shrugs, scapular retraction, trunk forward lean weight bearing) for 5 minutes, followed by task-oriented and strengthening exercises (reaching tasks, grasp and release, transfer of objects) for 20 minutes. A physiotherapist provides direct hands-on supervision, checks movement accuracy, and adjusts difficulty levels in real-time based on participant progress.
The University of Faisalabad
Faisalābad, Punjab Province, Pakistan
Change in Upper Extremity Motor Function
Measured using the Fugl-Meyer Assessment for Upper Extremity (FMA-UE). The FMA-UE is a stroke-specific, performance-based impairment index. It assesses motor functioning of the upper extremity. Scores range from 0 to 66, with higher scores indicating better motor function.
Time frame: Baseline (pre-intervention) and 6 weeks (post-intervention)
Change in Manual Dexterity
Measured using the Box and Block Test (BBT). The BBT quantifies gross manual dexterity by counting the number of blocks a participant can move from one compartment of a box to another in 60 seconds. Higher scores indicate better manual dexterity.
Time frame: Baseline (pre-intervention) and 6 weeks (post-intervention)
Change in Physical Activity Enjoyment
Measured using the Physical Activity Enjoyment Scale (PACES). The scale consists of 16 items rated on a 7-point bipolar Likert scale (1 = "I enjoy it" to 7 = "I hate it" for some items, reverse-scored for others). Total scores range from 16 to 112, with higher scores indicating greater enjoyment of physical activity.
Time frame: Baseline (pre-intervention) and 6 weeks (post-intervention)
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