Telerehabilitation Applications

The rehabilitation service delivery field is trying to transition toward a more outcomes-oriented process that seeks to maximize function and social re-integration, subject to constraints on resources (see Figure below). This is similar to the engineering optimization problem, as suggested by the above figure and discussed earlier in Module 1. We've noted that there is great potential for telecommunications and information technologies to provide consumers with access to clinical services and providers with access to patients. Telerehabilitation can be viewed as relaxing some of the constraints imposed by the infrastructure, thereby expanding the solution space. This suggests new possibilities for re-engineering the system to maximize value, enhance access, and optimize the infrastructure for effective rehabilitative problem-solving.

This section addresses the needs, current applications, and future possibilities. It is largely based on several telerehab review articles (Winters, 2002; Rosen, Winters and Lauderdale, 2002), with a few updates.

Examples of Large-Scale Need (and Potential Opportunity)

The following very large target populations have needs that suggest opportunities for telerehabilitation solutions (Winters, 2002):

• Adult Neurorehabilitation from Trauma. This is largest client base within a typical comprehensive rehabilitation hospital, typically representing the majority of all inpatients, and includes stroke (also called cerebrovascular accident, CVA), traumatic brain injury (TBI), spinal cord injury (SCI)]. NIH considers stroke the leading cause of significant disability in the US, with over 4 million stroke survivors living with significant functional impairment. The continuum of care summarized in the above figure is common, and practice guidelines based mostly on expert consensus do exist (e.g., for stroke rehabilitation). At comprehensive facilities inpatients can receive physical and occupational therapy, and typically speech-language therapy and psychological, social and/or vocational counseling. Yet during the 1990’s the reimbursable period of time as in inpatient in a comprehensive rehabilitation facility has dropped dramatically, and has often even been replaced with stays at skilled nursing facilities (at considerably less cost, but also poorer outcomes). The burden for healthcare services has shifted toward outpatient and home visits, where distance can be a barrier. Key possibilities include:
  • tele-counseling / neurocognitive evaluation
  • general tele-management, often also involving support for a home caregiver
  • wound care (pressure ulcer) management
  • tele-assessment of the type performed by OT/PT/nursing professionals
  • tele-supported therapy (PT, OT, speech)
• Children with Neuromotor Impairment. The most notable population in this category are children with cerebral palsy, but there are many others (e.g., spina bifida, muscular dystrophy). Often families travel long distances to get to comprehensive hospitals for children (e.g., Children's Hospital, part of the MCW medical complex in Wauwatosa, is the only such hospital in the state of Wisconsin). Many children’s hospitals, including the Shriners network of 26 hospitals, are actively investigating roles for telerehabilitation. Obvious choices are H.320-technology conferences between local clinics/hospitals/schools and these specialty hospitals with unique expertise. However, another emerging area is family-centered home intervention in which therapists and family members function as a team, which implies opportunities for home telehealth that includes rehabilitation assessments. Key possibilities include:
  • tele-assessment of gait function and balance, related to clinical decision-making (e.g., whether to adjust or change orthotic braces, to come in for a detailed assessment and surgical planning)
  • general tele-support for family, related to case management
  • support for tele-play therapy
• Cardiopulmonary Rehabilitation. If cardiopulmonary rehabilitation is included within the “telerehabilitation” umbrella, this may be the largest current application of telerehabilitation. The need is staggering, both for rehabilitation following an episode (e.g., open heart myocardial revascularization, myocardial infarction) where there are over one million new survivors per year in US, and for persons with chronic conditions (e.g., 4.9 million persons in US with congestive heart failure, 16 million with chronic obstructive pulmonary disease). Post-traumatic and post-surgical intervention typically includes only a few days as inpatients. Many tertiary care facilities now serve clients in need of cardiopulmonary rehabilitation. Most receive intervention as outpatients and/or through community/home programs, which include aggressive use of exercise rehabilitation, medication, behavior modification (e.g., diet), and management of secondary complications; evidence supporting the benefits of exercise programs for these populations continues to mount. These areas represent some of the primary targets for many telehomecare programs, which may include both a telesupport/teleeducation program and selected sensor-based telemonitoring (e.g., vital signs). On the high end, a transtelephonic telemonitoring product suite does exist that targets interactive exercise telerehab for cardiopulmonary patients. Key possibilities include:
  • Tele-homecare management, often also involving support for a home caregiver
  • Tele-assessment of health status, e.g. timely measurement and screening of vitals
  • Tele-coaching, i.e. tele-supported exercise programs
• Supportive Telehomecare. One of the most intriguing developments during the latter half of the 1990’s has been the grass-roots emergence of telehomecare activities, primarily by visiting nursing practitioners in rural areas who recognized unmet needs. The systemic need is real: within the United States there are over 500,000 home health visits per year, mostly by nurses. Each visit by a nurse or rehabilitation therapist costs about $100 (less if made by aids), while a typical “televisit” costs about one-quarter of this amount (5). This implies that there could be more “televisits” for the same cost, or more likely, a mix of physical and tele-visits over the continuum of care. Several retrospective studies have suggested that roughly 70% of nursing visits could have been accomplished remotely, in that direct hands-on-care was not necessary. This has the potential to enhance access to services, with many key possibilities already mentioned. Others include many of the rehabilitative services that are performed by nurses and allied health professionals, as well as drug therapy by physicians such as physiatrists.
• Remote Rehabilitation Services. Examples include remote seating and positioning assessment, wheelchair and components prescriptions, and home and workplace accommodations (see also current Telerehab RERC).

Clinical Telerehabilitation Research Involving Rehabilitation Practitioners

To date, clinical telerehabilitation applications have been driven by creative teams of rehabilitation practitioners seeking to pragmatically address clinical rehabilitative needs. All of the process models discussed previously are relevant:

• Telemedicine: Rehab Teleconsults (e.g., expertise of physiatrist, PT, OT, SLP)
• Telehomecare/telemonitoring (e.g., nurses and exercise practitioners involved in cardiopulmonary rehab)
• Telehomecare/telemonitoring (e.g., nurses, therapists or physicians involved in wound care (pressure ulcer) management)
• Telemonitoring/teletherapy (e.g., therapists or nurses involved with stroke theapy programs)

Here are some specific examples:

• Distance consultation by clinical rehabilitation engineers or specialized therapists for seating and positioning and assistive technology (Burns et al. 1998; Shapcott 2002),
• Pressure sore management by physicians and nurses (Dang et al 1999; Vasmarovich et al 1999),
• Remote rehabilitation management or teleconsultation by physiatrists and specialized therapists for clinics, including prosthetics-orthotics and neurocognitive/neuropsychology assessment (Burgiss 2001; Borstad et al 2001; Scheidman-Miller 2001).
• Caregivers of persons post-stroke (Tran et al 2002, Buckley and Tran, 2001),
• social/vocational training for autistic persons (Trepanier et al 2001),
• neurocognitive telecounseling for brain injured persons (e.g., Glueckauf et al, 1999; Appel et al),
• virtual reality for stroke and orthopedic patients ([Burdea group]),
• therapeutic play for children in neurological impairments ([Lathan group]), and
• home telesupport for older adults with chronic health challenges such as cardiopulmonary or diabetes (e.g., Shaw et al 1998).  

Many of these studies were presented at the State-of-the-Science conference on Telerehabilitation (with proceedings available on the web). As summarized in a report on the conference (Rosen et al, 2002), there were several recurring take-home messages:

• Most existing projects use conventional teleconferencing tools, such as group conferencing rooms connected by ISDN or T1 (H.320 standard) or H.324 videophones (sometimes embedded within a more costly home telehealth system that includes vital signs). The largest use is for teleconsults.
• There are two key consumers: consumers of services (patients, caregivers) and providers of services (practitioners, caregivers). Patients are looking for convenience and access to services. Key criteria for practitioners is enhanced productivity and ease of use (and to learn). Providers include nurses, physicians (e.g., diagnosis, plan management, pharmaceuticals), and therapists.
• Numerous groups can point to success stories. Yet to date, the types of large-scale controlled randomized studies that provide conclusive evidence of improved client outcomes or cost-effectiveness do not exist.
• Many practical barriers remain, such as reimbursement , concerns about professional practice boundaries, and lack of a training infrastructure.
• There is considerable enthusiasm about the future of telerehabilitation, with the Telerehabilitation RERC at the University of Pittsburgh now in the position to help accelerate this bright future. Their core research and development projects, which tend to have a bias towards rehabilitation engineering, are
  • R1 - Remote Wheelchair Prescription
  • R2 - Remote Accessibility Assessment of the Built Environment for Individuals Who Use Wheeled Mobility Devices
  • D1 - Information Infrastructure and Architecture
  • D2- Development of a Model for Clinical Assessment and Use of Telerehabilitation Services
  • D3 - Assessment of Communication Function
  • D4 - Remote Behavioral Assessment and Job Coaching via Video and Motion Technology

Need for New Paradigms for Clinical Rehabilitation?

In the 1999 Workshop on Home Care Technologies for the 21 st Century, a consensus emerged around the vision of a more consumer-driven healthcare system driven more by a cooperative health patient-clinician partnership and less by the episodic model of care. At the foundation of this is self-care and caregiver support. Motivations range from the common perception that most home exercise equipment ends up in closets to the estimation that lack of compliance with medication (too much or too little) costs US society about $20-50 billion per year. Areas for home telehealth that relate to rehabilitation include:

• Management of therapeutic rehabilitative programs (e.g., home exercise telecoaching)
• Management of secondary risks and conditions
• Management of drug therapy through an integrated approach that could include not only reminders but also objective indicators related to performance evaluation (e.g., neurocognitive, neuromotor, activity).

There is a need to study what is optimum for various situations, while recognizing that often caregivers represent the largest “provider” of services. There are many challenges associated with implementing new technological tools for assessment and therapy. While it is generally accepted that the current approach toward delivering clinical rehabilitation services is suboptimal, allied health professions tend to take a cautious approach toward implementing change. For instance, at a time when areas ranging from radiology to visiting nursing agencies are rapidly adopting electronic patient records (EPRs), at comprehensive rehabilitation hospitals paper patient charts remain the norm. Also, therapists often see telerehabilitation as a threat. In 2002 the APTA Board announced that “Physical therapy services may be provided via telehealth when consistent with APTA policies, positions, guidelines, Standards of Practice, Code of Ethics, and the Guide to Physical Therapist Practice.” This is quite a change. While it is unknown whether any telerehabilitation-inspired paradigm shift in rehabilitative healthcare will bypass or include conventional therapists, what is clear is that there is a need to study teleproductivity of clinical stakeholders.

The Future?

Much like in the engineering optimization problem desired in Module 1, desired outcomes in the rehabilitation field typically include a balancing act between subcritiera that may be competing or orthogonal (e.g., measures of function, quality of life, quality of rehabilitation, customer satisfaction, cost effectiveness). Adding complexity is the trend within rehabilitative medicine from “service-based” to “outcome-oriented” rehabilitation, which impacts on telerehabilitation. A 2001 editorial in the journal Physiotherapy called this drive toward greater accountability and outcomes-driven practice a “tidal wave.” A key challenge for rehabilitative bioengineers is to develop outcomes measures that are reasonably quantitative and objective, and integrate with respected clinical scales. By objective evaluation, here we refer to using sensor-based measures as part of the evaluation process. Possible uses for evaluation include: i)diagnosis; ii) treatment planning; and iii) outcomes assessment.

There is a push toward uniform, standardized assessment tools. Uniformity in functional assessment allows comparability of results and over time between providers, thus increasing the likelihood for improving the processes of care (21) and helping establish cost-benefit guidelines. Of importance is that scales such as FIM are often used to classify patients into intervention categories (e.g., VA hospitals), which in turn can be used to establish viable desired outcomes, required costs, and discharge dispositions. While such scoring schemes are not sensor-based and thus may seem “subjective” rather than “objective” to rehabilitative bioengineers, the reality is that these scales have been subject to considerable interrater reliability and validity testing. The onus is in engineers to come up with better measures, and to date we have not met the challenge. Hence why our group has been involved in systematic studies to determine which of the scales commonly used for neurorehabilitation can be effectively measured remotely using telerehabilitation tools.

What technologies will be critical? We have seen that different challenges require different approaches. One key technical trend is convergence of IP-based videoconferencing and multimedia telecommunication sessions, likely to be based primarily on the SIP standard. Another is convergence of mobile wireless technologies, such as the slow-to-arrive but certainly coming 3G cellphone technology with similar PDA developments involving integrated wireless modes (wPAN-bluetooth, wLAN-WiFi, wMAN-cellphone). More and more people will have access to the type of bandwidth necessary for this to be effective. Thus there will be opportunities for more timely access to information and services. But perhaps the bigger challenge relates to the availability of appropriate human-technology interfaces that are usable, accessible and effective enough that people will choose to buy in and participate in tele-encounters on a regular basis. This in turn brings in behavioral modification considerations, and thus the model framework for scientific study of telehealth that was presented previously. From a technical perspective, it also brings in the need for intelligent agents and assistive interfaces that map user preferences/abilities with clinical needs within the continuum of consumer-centered care.

Consider the anticipated trends from the Workshop on Homecare Technologies of the 21st Century:

“Numerous participants cited the likely development of computerized smart devices and systems as major factors in home- and self-care over the next decade. Intelligent medical devices and personal support technologies were expected throughout the home and community for data acquisition, assessment, assistance with compliance, and integration of care with remote systems and databases. Participants envisioned the automation of mechanistic processes and expected the implementation of simple low-risk decisions by such intelligent devices and systems. Wearable, wireless systems were anticipated as well."

To summarize, changes are likely in the form of rehabilititation services, and telerehabilitation tools will have a role to play for certain aspects of this evolutionary process. The "what" and "how" remain open issues. But what is clear is that there are many opportunities for engineers who are willing to get embedded within the process.

References

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National Institute on Disability and Rehabilitation Research request for applications for Rehabilitation Engineering Research Center on Telerehabilitation, Federal Register, June 12, 1998 , 32526-32539.

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