TeleRehabilitation Overview and Preliminary Results

1. 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

2. Institutional Acknowledgements • US Dept.of Agriculture SBIR I and II. • Center for Excellence in Rural Medically Underserved Areas, PA. • Veteran’s 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

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

4. 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

5. 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

6. TeleRehab- Why Are We Using Telephone Based Systems Now? • AT&T, 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 +

7. 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

8. TeleRehabilitation -Part II- Technologies and Nomenclature

9. BANDWIDTH- (Rate of Information)Available/Developing 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

10. 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

11. TeleRehabilitation -Part III- Results

12. 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

13. 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.

14. 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?

15. 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.

16. 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

17. 2 Locations UPMC Center for Assistive Technology Pittsburgh • 2 Locations VA Medical Center- Highland Drive Pittsburgh

18. 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

19. 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 .

20. Data Collection- Form 1

21. Data Collection- Form 2

22. Data Collection- Form 3

23. Data Collection- Form 3

24. Data Collection- Form 4

25. Preliminary Estimations (9 of 20 subjects) • Qu. 1. Further evaluation • Multi- rater Kappa, 4 clinicians, 0.464 & p=0.07 • Multi- rater Kappa 3 clinicians, 0.615 & p=0.03 • TP vs IP Kappa 0.615, p=013 • simple agreement 90% • (Weighted Kappa issue)

26. Preliminary Estimations (9 of 20 subjects) • Question. Wheelchair Type • Manual Wheelchair- simple agreement 100% (n=4) • Powered Wheelchair- simple agreement 100% (n=4) • Scooter- simple agreement 100% (n=1)

27. 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%

28. Preliminary Estimations (9 of 20 subjects) • Question. Seating Dimensions • Overall Seat width: (<16”, 16”, 18”, >18”)- simple agreement 61% • Overall seat width In Person : (<16”, 16”, 18”, >18”)- simple agreement 66% • Overall Seat length: (<16”, 16”, 18”, >18”)- simple agreement 75% • Overall seat length In Person : (<16”, 16”, 18”, >18”)- simple agreement 44%

29. 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%

30. 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%

31. Preliminary Estimations (9 of 20 subjects) • Question. Headrest and Armrest • Headrest required: (yes, no)- simple agreement 94% • Armrest required: (yes, no)- simple agreement 94%

32. 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)

33. TeleRehabilitation -Part IV- Future Technical Issues

34. TeleRehab- Future Needs • Data Acquisition with video • Pressure • Dimensional

35. TeleRehab- Future Needs • Data Acquisition with video • Wound Care

36. TeleRehab- Future Needs • Data Acquisition with video • Temperature

37. Data Acquisition with video • Shear • Humidity

38. TeleRehab- Future Needs • Data Acquisition with video • Data Glove

39. 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.