TeleRehabilitation Overview and Preliminary Results

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TeleRehabilitation Overview and Preliminary
Results
Nigel Shapcott, M.Sc., A.T.P. Department of
Rehab Science and Technology, University of
Pittsburgh and Center for Assistive
Technology UPMC Health System
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Institutional Acknowledgements

• US Dept.of Agriculture SBIR I and II.
• Center for Excellence in Rural Medically
  Underserved Areas, PA.
• Veterans Affairs Rehab Research Development
  Service
• Dept of Rehab Science Technology at the
  University of Pittsburgh
• UPMC Center for Assistive Tech.
• UPMC Spinal Injury Center
• HERL VA Medical Center Pittsburgh

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People Acknowledgements

• Michael Boninger MD
• Laura Cohen PT
• Rory Cooper PhD
• Rosi Cooper PT
• Shirley Fitzgerald PhD
• Mark Schmeler OT
• Tricia Thorman OT

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TeleRehab- How we see it
Rural Site
Expert Hub
Visual and Audio Evaluation
Transfer of Eval Data Pressure/Dimensional
Delivery of various Rehabilitation interventions
remotely wheelchairs, wound care, follow up,
training etc.

• Assistive Technology Practitioner
• Assistive Technology Supplier
• Registered Nurse
• Certified Orthotist or Prosthetist
• OTR, PT
• Physiatrist

• Non Specialist OTR or PT
• COTA or PTA
• RTS Technician
• LPN
• Orthotist or Prosthetist
• Visiting Nurse

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TeleRehab- The Need

• Resources and Distances
• Not enough skilled people
• Large numbers of underserved
• Too many miles
• Earlier discharge
• Mortality rates
• Disability rates
• AT

Approx 200 miles Pennsylvania- West/Central
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TeleRehab- Why Are We Using Telephone Based
Systems Now?

• ATT, top picture 1994 (1500) poor performance
• ViaTV, 1998
• 1998, same widespread infrastructure (POTS)-
  better performance with lower costs e.g. ViaTV,
  Starview
• New units cost 300

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Potential Benefits of TeleRehab

• Better access to health care for those living
  outside metropolitan areas
• Fewer trips to clinics and hospitals for both
  patients and clinicians
• More specialists can take part in an evaluation
• Follow-up with clients after discharge

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TeleRehabilitation -Part II- Technologies and
Nomenclature
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BANDWIDTH- (Rate of Information)Available/Develop
ing Technologies

• Hard wired-T/4 Fiber optic Lines- high
• Hard wired-ISDN Digital Phone Lines- medium
• Hard wired-POTS- Plain Old Telephone Service- low
• Hard wired-Cable- medium/high
• Hard wired- Power Utilities- not known
• Hard wired- DSL Technologies- medium/high
• Wireless- Cell Phone 3G- medium/high
• Wireless- 2 Way Satellite (0.5m)- medium/high

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Connection Technologies-Summary

• Rapid changes in these
• Huge potential market
• Rural areas likely to be last in line
• Bandwidth will increase
• Video quality will improve
• Data capability will be further developed

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TeleRehabilitation -Part III- Results
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Clinical Issues

• Injury- Handover of responsibility
• Transfer
• ROM
• Training
• Qualifications at both ends
• Specialized training requirements
• Recognition of current limits
• No feel (ROM)
• Tremors (not picked up)
• More quantitative tools needed (Pressure etc)
• Multiple view issues

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Efficacy of Wheelchair System Prescription Using
POTS TeleRehab

• Aims and Method
• to establish a scientific basis for the reliable
  use and limits of video conferencing for remote
  prescription of Assistive Technology using POTS
  lines to transmit and receive the audio and video
  signals.
• to determine the potential of increasing the
  availability of AT prescription services to
  communities, underserved due to geographical
  and/or transportation and/or financial barriers.
• TeleRehab (TR) systems are used to evaluate
  individuals for their wheelchair seating needs
  and compared to the findings of In Person (IP)
  evaluations.

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Efficacy of Wheelchair System Prescription Using
POTS TeleRehab

• RESEARCH QUESTIONS
• Can experienced Clinicians using TR technologies,
  with defined operational protocols
• 1. Reliably determine if the TR process is
  appropriate and safe for a specific individual?
• 2. Reliably provide accurate decisions regarding
  the need for a wheelchair, at a detailed level?
• 3. Reliably obtain accurate assessments of
  medical history and physical examination?

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Efficacy of Wheelchair System Prescription Using
POTS TeleRehab

• Assessment/Evaluation
• Interview- with the "Model Patient" consists of
  access to information from a standard information
  sheet and an interactive session determining
  mobility goals, appropriateness of these goals,
  diagnosis, any changes in condition.
• Mat evaluation- a physical motor and measurement
  evaluation either carried out by the Clinician in
  the face-to-face situation or under the guidance
  of the Clinician by the Assistant via TR. The
  purpose of the mat evaluation is to establish
  passive and active ROM, of the upper and lower
  extremities, any pathological movement patterns,
  sitting and transfer skills, spinal orientation,
  and functional abilities related to mobility and
  other goals.
• Measurement- the Clinician or Assistant record
  linear and angular measurements as required by
  the data collection form and setting.

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Efficacy of Wheelchair System Prescription Using
POTS TeleRehab

• 20 subjects acting as model patients
• 4 evaluations/subject
• Crossover study
• 2 Locations
• 2 In Person (IP)
• 2 TeleRehab (TR)
• Detailed Protocol Data Collection (Forms)
• 4 Clinicians (2 OT, 2 PT)
• 9 Assistants Trained
• TeleRehab evaluation
• Transfer
• ROM
• Dimensions

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2 Locations
UPMC Center for Assistive Technology Pittsburgh

• 2 Locations

VA Medical Center- Highland Drive Pittsburgh
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Experimental Schematic
DAY 2
Clinician 4 evaluation
Clinician 3 evaluation
CAT TR
CAT IP
VA IP
VA TR
Clinician 1 evaluation
Clinician 2 evaluation
DAY 1
3-7 DAY DELAY BETWEEN SESSIONS
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Efficacy of Wheelchair System Prescription Using
POTS TeleRehab

• Data Collection - A team consisting of a
  Physiatrist Statistician, 2 OTs 2 PTs and a
  Rehabilitation Engineer have developed
  comprehensive data collection forms to record
  information on the characteristics of the Model
  Patient their environment and the details of the
  prescription. The forms were derived over a
  series of iterations and reviews from a
  collection of existing in house forms and the
  work of the Assistive Technology Program in
  Tucson .

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Data Collection- Form 1
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Data Collection- Form 2
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Data Collection- Form 3
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Data Collection- Form 3
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Data Collection- Form 4
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Preliminary Estimations (9 of 20 subjects)

• Qu. 1. Further evaluation
• Multi- rater Kappa, 4 clinicians, 0.464 p0.07
• Multi- rater Kappa 3 clinicians, 0.615 p0.03
• TP vs IP Kappa 0.615, p013
• simple agreement 90
• (Weighted Kappa issue)

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Preliminary Estimations (9 of 20 subjects)

• Question. Wheelchair Type
• Manual Wheelchair- simple agreement 100 (n4)
• Powered Wheelchair- simple agreement 100 (n4)
• Scooter- simple agreement 100 (n1)

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Preliminary Estimations (9 of 20 subjects)

• Question. Wheelchair Features
• Manual Wheelchair (folding, rigid, TIS,
  recline)-simple agreement 75
• Powered Wheelchair Features (recline, TIS)-
  simple agreement 94
• Powered Wheelchair Drive (front, rear, mid)-
  simple agreement 69
• Scooter ( 3 or 4 wheeled)-
  simple agreement 50

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Preliminary Estimations (9 of 20 subjects)

• Question. Seating Dimensions
• Overall Seat width (lt16, 16, 18, gt18)-
  simple agreement 61
• Overall seat width In Person (lt16, 16, 18,
  gt18)- simple agreement 66
• Overall Seat length (lt16, 16, 18, gt18)-
  simple agreement 75
• Overall seat length In Person (lt16, 16, 18,
  gt18)- simple agreement 44

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Preliminary Estimations (9 of 20 subjects)

• Question. Seating/Cushion Features
• Cushion Supports (medial thigh, lateral thigh,
  medial hip)- simple agreement 86
• Cushion customization required (yes, no)-
  simple agreement 86
• Cushion pressure relief required (yes, no)-
  simple agreement 78

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Preliminary Estimations (9 of 20 subjects)

• Question. Seating/Backrest Features
• Back Lateral Supports (left, none)-
  simple agreement 83
• Back Lateral Supports (right, none)-
  simple agreement 83
• Back customization required (yes, no)-
  
• simple agreement 80

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Preliminary Estimations (9 of 20 subjects)

• Question. Headrest and Armrest
• Headrest required (yes, no)-
  simple agreement 94
• Armrest required (yes, no)-
  simple agreement 94

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Preliminary Estimations (9 of 20 subjects)

• Conclusions
• Simple to set up and use
• Good quality audio is essential
• Experienced clinicians required
• Linear measurement results diabolical- supports
  rationel for simple measurement rigs (Logan et al
  1998)

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TeleRehabilitation -Part IV- Future Technical
Issues
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TeleRehab- Future Needs

• Data Acquisition with video
• Pressure
• Dimensional

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TeleRehab- Future Needs

• Data Acquisition with video
• Wound Care

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TeleRehab- Future Needs

• Data Acquisition with video
• Temperature

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• Data Acquisition with video
• Shear
• Humidity

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TeleRehab- Future Needs

• Data Acquisition with video
• Data Glove

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TeleRehabilitation -Future Service Delivery ISDN
or Other High Bandwidth Systems
High bandwidth link to center in Texas followed
up with POTS link into home. TeleRehab services
are limited by funding to special cases and
demonstrations at this time.