Yelena Bogdanova, PhD

Rapidly evolving worldwide, the public health emergency of coronavirus disease (COVID-19) is quickly changing traditional health care approach and delivery methods. The restrictive measures implemented nationwide in an effort to control the spread of the pandemic present significant barriers and impose additional challenges for vulnerable patient populations, limiting their access to health care.1 Individuals with brain injury (BI) are among those most vulnerable to the ongoing outbreak and its effects on physical and mental health. Individuals with BI are more likely to be disproportionally affected by the COVID-19 pandemic, as people with cognitive impairments may be at higher risk of being infected due to difficulties in understanding and/or complying with preventive measures (social distancing, wearing personal protective equipment) and public health recommendations when provided in inaccessible form (through an opaque mask).2 Providing timely, continuous care is critical for patients with BI as it helps to avoid delays in clinical care and prevent negative effects of missed or interrupted neurorehabilitation efforts.

In this unprecedented time, health care providers are pressed to embrace the rapid change and to adapt and implement new methods of health care delivery. Technology can offer useful tools enabling practitioners to provide clinical care and decrease the risk of exposure of vulnerable patient populations during the ongoing COVID-19 public health emergency. Providing continuous clinical care and treatment monitoring to the patients practicing social distancing, observing quarantine restrictions, or patients residing in rural locations is now possible utilizing various communication tools and portable home-based treatment modalities.

Communication Technology supports telehealth services during the ongoing public health crisis. Technology enables and facilitates remote access to clinical services, which may also increase participation for medically and cognitively vulnerable patients or those who do not have easy access to rehabilitation centers and specialists. Communication technology and remote access can also help preserve the patient-clinician relationship while a face-to-face visit is not feasible.1 Telehealth enables provision of virtual services (synchronous, asynchronous, or remote monitoring) for evaluations and routine care, and supports delivery and continuous monitoring of long-term rehabilitation programs.

There are multiple technology home-based rehabilitation tools such as smartphones, tablets, computers, virtual assistants, and assistive devices, which can provide access to health information, health services, and even social connections for those in isolation.

The extraordinarily high demand for remote healthcare access, driven by the ongoing COVID-19 pandemic, prompted the unprecedented surge in telehealth services. Based on the current trajectory of the pandemic, the need for social distancing (for both patients and providers) is likely to continue and the demand for virtual care is likely to grow. The many benefits of telehealth, such as treatment accessibility, opportunity to provide interdisciplinary rehabilitation, continuous care and timely (early or chronic) treatment, as well as reduced cost and reduced travel burden (for the patient and their caregiver) provide additional incentive for the development of telehealth-specific rehabilitation protocols and home-based rehabilitation programs.

There are some situations in which telehealth visits may not be feasible or possible due to various factors, such as: limited access to technology/devices (smartphone, computer, or tablet) required for a telehealth visit or limited or no connectivity; patient’s discomfort disclosing personally sensitive information in virtual care sessions and other privacy concerns; personal level of comfort and capacity using technology (especially relevant for patients with BI); as well as family approval and cultural acceptance of virtual healthcare. Home-based neurorehabilitation programs with telephone-based treatment monitoring and support can provide a viable solution in these situations.

Telehealth or virtual visits, home-based treatment programs, and other web-based rehabilitation paradigms are being deployed in multiple medical centers across the US, either as a standalone rehabilitation treatment or as part of the interdisciplinary rehabilitation effort.

Innovative rehabilitation programs and methods of treatment delivery, such as home-based neuromodulation treatment for cognitive impairments and computer-based cognitive interventions have become an important part of virtual care for persons with BI.

The LED TBI Home Treatment Program is part of the interdisciplinary rehabilitation program at the Physical Medicine & Rehabilitation Service (PMRS) at Boston VA Healthcare System and Boston University School of Medicine.3 The LED TBI Home Treatment Program is the first program in the US that provides advanced neuromodulation treatment using light-emitting diodes (LED) for patients with chronic TBI. LED therapy is a non-invasive, non-pharmacological treatment that promotes healing of injured brain cells and improves cellular function.4,5 LED therapy improves attention and concentration, improves sleep, and reduces PTSD symptoms in patients with TBI.6,7 The LED Program provides 12-Week LED Home Treatment with telehealth support. The LED TBI Clinic services include clinical evaluation, individualized treatment plan, LED treatment, and follow up visits. To ensure the quality of home treatment and to further reduce the burden of travel, the LED Clinic provides telehealth support and followup visits.8 The LED TBI clinic was converted to completely virtual (contactless) care following the COVID-19 pandemic restrictions, and has continued to provide virtual treatment services for the last five months. Patients who completed the treatment program reported improved cognitive and neurobehavioral symptoms, and opted to continue the longterm home treatment program and virtual care appointments after the COVID restrictions are lifted. The LED TBI Clinic team is now providing virtual training for the VA PMRS providers in other states across the US.

Computer-based cognitive interventions have shown great potential for improving treatment access for individuals with BI by addressing the barriers and restrictions imposed by disability-related limitations, geographical and social barriers, and time constraints.

Computer-based cognitive interventions can improve traditional rehabilitation of cognitive functions by enhancing the treatment consistency and delivery and providing continuous adaptive adjustment of task difficulty based on a patient’s performance.9,10 The ACRM BI-ISIG Cognitive Rehabilitation Task Force has set forth guidelines for the use of computer-based interventions, such as direct-attention training for specific working memory impairments (Practice Guideline) in postacute rehabilitation of individuals with acquired BI.10 The Task Force presented new evidence on multimodal computerized training of attention, memory, and executive functions, demonstrating the effectiveness of this type of computerized intervention (Practice Guideline) for individuals with acquired BI. The guidelines emphasize that this type of computerized interventions is most effective when managed by a rehabilitation specialist and when the treatment adheres to the principles of neuroplasticity (including adaptive task difficulty adjustment and immediate objective feedback on task performance).

The COVID-19 pandemic significantly impacts healthcare providers who often work in a stressful environment of rapidly changing demands. Technology and IT support have become essential for providing and monitoring treatment and assuring the continuous quality of patient care. Many academic institutions and larger hospitals in the US and other countries have utilized various telehealth platforms and are already offering virtual visits with rehabilitation professionals and other health specialists. There are multiple telehealth-specific workshops and trainings offered through professional organizations and academic institutions nationwide. However, rehabilitation professionals in the private practice and smaller organizations may need additional support.

To accommodate the patients’ needs in the COVID-19 pandemic, rehabilitation providers have come up with innovative ways to deliver rehabilitation services for the individuals with BI and their caregivers. Systematic research of innovative interventions and methods of treatment delivery evaluating most optimal and lasting rehabilitation outcomes is needed to inform clinical recommendations and guidelines for persons with BI and other neurologically impaired populations.

Dr. Bogdanova is an Assistant Professor of Psychiatry at Boston University School of Medicine and a Principal Investigator at the VA Boston HCS. She holds a PhD in Behavioral Neurosciences and a PhD in Clinical Neuropsychology. Dr. Bogdanova is a Principal Investigator on the federally-funded clinical trials of cognitive rehabilitation and neuromodulation in TBI. Her program of research focuses on development and evaluation of multimodal neurorehabilitation interventions for TBI. She currently leads the Virtual Care and LED TBI Home Treatment Programs at the VA Physical Medicine & Rehabilitation Service. She serves on Cognitive Rehabilitation and AP Technology Task Force (ACRM).

Acknowledgements: This work was supported by the VHA Center for Compassionate Care Innovation (Clinical Lead: Yelena Bogdanova) and the VA Boston HCS Psychology Research and Physical Medicine and Rehabilitation Services.

1. Centers for Disease Control and Prevention. 2020. Coronavirus Disease 2019 (COVID-19). [online] Available at: <https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html> [Accessed 15 August 2020]. 2. Jesus TS, Kamalakannan S, Bhattacharjya S, Bogdanova Y, Arango-Lasprilla J, Bentley J, Gibson BE, Papadimitriou C, Refugee Empowerment Task Force, International Networking Group of the American Congress of Rehabilitation Medicine. (2020). People with disabilities and other forms of vulnerability to the COVID-19 pandemic: Study protocol for a scoping review and thematic analysis. Archives of Rehabilitation Research & Clinical Translation. [Epub, ahead of print] 3. VHA, Center for Compassionate Care Innovation (2020, June 15). LED treatment improves cognitive function for mTBI patients. https://www.va.gov/healthpartnerships/updates/cci/06152020.asp [Accessed 15 August 2020]. 4. Hamblin, MR. (2018). Photobiomodulation for traumatic brain injury and stroke. J Neuroscience Research, 96, 731-743. https://doi.org/10.1002/jnr.24190 5. Naeser, MA, Martin, PI, Ho, MD, Krengel, MH, Bogdanova, Y, Knight, JA, Yee, MK, Zafonte, R, Frazier, JA, Hamblin, MR, Koo, BB (2016). Transcranial, Red/near-infrared light-emitting diode (LED) therapy for chronic, traumatic brain injury. Photomedicine and Laser Surgery, 34(12), 610-626. https://doi.org/10.1089/ pho.2015.4037 6. Bogdanova, Y., Ho, V.T., Martin, P.I., Ho, M.D., Yee, M.K., Hamblin, M.R., Naeser, M.A (2017). Transcranial LED Treatment for Cognitive Dysfunction and Sleep in Chronic TBI: Randomized Controlled Pilot Trial. Abstract. Archives of Physical Medicine & Rehabilitation, 98(10), e122 -123. https://doi.org/10.1016/j. apmr.2017.08.398 7. Martin PI, Ho MD, Bogdanova Y, Krengel M, Knight J, Hamblin M, Koo B, Naeser MA (2018). LED therapy improves functional connectivity and cognition in professional football player with chronic TBI: case study. Abstract. Archives of Physical Medicine & Rehabilitation, 99 (10), e104 - e105. https://doi.org/10.1016/j. apmr.2019.02.011 8. Bogdanova, Y., Gilbert, K., Baird, L., Naeser, M.A. (2019). LED Home Treatment Program for Chronic TBI and PTSD: Clinical Program Evaluation. Abstract. Archives of Physical Medicine and Rehabilitation, Volume 100, Issue 12, e187-188. https://doi.org/10.1016/j.apmr.2019.10.077 9. Bogdanova, Y., Yee, M.K., Ho, V.T., & Cicerone, K.D. (2016). Computerized cognitive rehabilitation of attention and executive function in acquired brain injury: A systematic review. Journal of Head Trauma Rehabilitation. 31(6), 419-433. https://doi.org/10.1097/HTR.0000000000000203 10. Cicerone KD, Goldin Y, Ganci K, Rosenbaum A, Wethe JV, Langenbahn DM, Malec JF, Bergquist TF, Kingsley K, Nagele D, Trexler L, Fraas M, Bogdanova Y, Harley JP (2019). Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014. Archives of Physical Medicine and Rehabilitation, 100(8), 1515-1533. https://doi.org/10.1016/j.apmr.2019.02.011

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