Technical Feasibility of Tele-Assessments for

Rehabilitation

William Durfee1, Lynda Savard2, Samantha

Weinstein1

1University of Minnesota2Sister Kenny Rehabilitation Institute

Minneapolis, USA

5th International Workshop on Virtual Rehabilitation, August 2006

Telerehabilitation

"The clinical application of consultative, preventative, diagnostic, and therapeutic services via two-way interactive telecommunication technology."

American Association of Occupational Therapists Position Paper on Telerehabilitation

Why tele?

Clients in rural locations Clients in urban locations, but have

transportation challenges No car Poor public transportation

Eliminates transportation time

7 hrs

Telerehabilitation Applications

Consultation Assessment Diagnosis and evaluation Education and training Home and activity monitoring Motor relearning (robot,

biofeedback)

Tele-consultations: A Success Story ?

Requires a 2-way video/audio link

Only technical issue is bandwidth

Most popular, and most successful form of telerehabilitation

Cost, outcome benefits story remains uncertain

Telerehabilitation Flaws? Possibly adds cost

Technology cost Extra prep time for provider May not eliminate face visits

Technology growing pains Provider training Limited communications infrastructure Patient trust & familiarity Limited applications Unproven outcome benefits

Electrons Cannot Transmit Forces and Motions

Although rehab robots could migrate to the home

RESEARCH QUESTION

Can standard assessment instruments used by physical therapists be used with the patient located remotely?

Home ClinicTELE

ROM, MMT, FIM, BALANCE, COGNITION, ...

Prior studies Kohlman evaluation of living skills:

remote same as in-person (Dryer, J Allied Health, 2001)

NIH stroke scale: remote administration reliable (Shafqat, Stroke, 1999)

Speech disorder assessment: internet same as face-to-face (Theodoros, J Telemed Telecare, 2003)

Knee angle: captured photo same as in-person (Russell, J Telemed Telecare, 2002)

Approach

Standardized assessments essential Standard assessment instruments

exist, and have long history of use Match technology to assessment

rather than creating a new assessment to match the technology

Hypothesis

“Assessment instruments applied remotely are no different than assessment instruments applied locally”

Test hypothesis by implementing assessment locally and remotely on the same person, then look for differences in the results

Selection Criteria for Selection Instruments

Published measurement tool Reliable and valid Used widely by physical therapists Supported by standardized

instructions and scoring methods Likely to reveal strengths and

weaknesses of tele approach

Assessment Instruments

Range of Motion (ROM) Shoulder abduction, shoulder rotation,

knee flexion Manual Muscle Test (MMT) Berg Balance Test

Item 1: Sit-to-Stand Item 8: Forward Reach

Timed Up and Go Test (TUG)

Technology Layout

camera

PolycomViewStation

network

REMOTE (PT)

vid cap

TV

PC

camera

PolycomViewStation

CO-LOCATED (P & CG)

TV

PC

digdyna

Approximations

Patient+

CaregiverExpert clinician

Home Central clinicClinic Room #1 Clinic Room #2

Simulated patient+

Simulated caregiver

Simulated impairments

MMT: added weights Berg: stand on Dynadisk TUG: walk a balance beam

Range of motion

Knee flexion

Shoulder abduction

Shoulder external rotation

Televideo

ROM Tele Measuring Methods

1. Caregiver places & reads goniometer

2. Caregiver places goniometer, therapist reads by zooming camera

3. Photo snapped, therapist holds goniometer up to screen

4. Photo snapped, therapist uses virtual goniometer

C:\Documents and Settings\usr\Desktop\IWVR2006\VirtualGoniometer.exe

Manual Muscle Test

Biceps, Quadriceps With and w/o digital dynamometer

Berg Sit-to-Stand, Forward Reach

Timed Up and Go (TUG)

Experiment Design

10 subjects + 10 caregivers 5 assessment instruments Trained PTs Co-located and remote testing All testing in single session Order balanced

Key result

No significant difference between any of the measurement methods

Results details: ROM No difference among all methods (F =

1.69, Fcrit(.05) = 2.13, p = .12) Power to detect 1 degree = 77%, to

detect 5 deg = 100% No difference caregiver or PT reading the

goniometer (t = 1.15, tcrit(.05, 2-tail) = 1.99, p = .25)

Virtual goniometer same as holding physical goniometer on screen (t = .69, tcrit(.05, 2-tail) = 1.98, p = .49)

Results details (ROM)

No bias among 7 methods

-8.0

-6.0

-4.0

-2.0

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2.0

4.0

6.0

8.0

M1 M2 M3 M4 M5 M6 M7

Dev

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(d

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Results details: MMT

No difference co-located and remote visual (t = .21, tcrit(.05, 2-tail) = 2.09, p = .83)

No difference co-located and remote visual with digital dynamometer (t = .39, tcrit(.05, 2-tail) = 2.09, p = .69)

Discussion Communication bandwitdh

High quality audio link essential, requirements for video not known

ROM Caregivers could place goniometer Snapshot + virtual goniometer eliminates CG Need clear camera view Landmarks on obese patients

MMT Dynamometer not needed, but still could aid

Sit-Stand and TUG No difficulties for tele-implementation

Forward reach Need zoom camera Measurement technology would help

Limitations

Simulated patients Simulated caregivers Performance variation No inter-rater reliability

Conclusion

Some assessment methods are suitable for tele implementation with modest technology

High quality audio essential More technology = more training Proof of clinical efficacy requires a

home study with real patients

This work was supported by the Sister Kenny Foundation,

Minneapolis, USA.

camera

PolycomViewStation

network

REMOTE (PT)

vid cap

TV

PC

camera

PolycomViewStation

CO-LOCATED (P & CG)

TV

PC

digdyna