Telerehabilitation: Lessons learned from two examples. William Durfee Department of Mechanical Engineering University of Minnesota Minneapolis, USA. MINNEAPOLIS, MINNESOTA. MINNESOTA, Land of 10,000 Lakes. Roadside “Art” in Minnesota. MINNEAPOLIS , City of Lakes. u. F. x,v.
Telerehabilitation: Lessons learned from two examples William Durfee Department of Mechanical Engineering University of MinnesotaMinneapolis, USA
MINNESOTA, Land of 10,000 Lakes
Roadside “Art” in Minnesota
u F x,v Muscle mechanics HUMAN/MACHINE DESIGN LAB Department of Mechanical Engineering University of Minnesota(www.me.umn.edu/labs/hmd/) Haptic interfaces for virtual product prototyping, smart knobs for cars • Rehabilitation engineering • Tele-rehabilitation • Stroke rehab • Driving simulators • Human assist machines • Compact power sources • Powered exoskeletons • Natural control Smart orthotics + electrical stimulation for gait restoration • Medical device design • Evaluation of surgical tools
OUTLINE • Overview of telerehabilitation • Example 1: Tele-assessment • Example 2: Home stroke trainer • Conclusions and lessons learned
Clinic Home TELE
Telehealth "Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration." HRSA Office for the Advancement of Telehealth
Telemedicine "Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status." American Telemedicine Association
Telerehabilitation "Telerehabilitation is 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
Local clinic Central clinic Patient+ Local clinician Expert clinician Home Central clinic Patient+ Caregiver Expert clinician Tele Locations
Telerehabilitation Applications • Consultation • Home and activity monitoring • Assessment • Motor relearning (robot, biofeedback) • Diagnosis and evaluation • Education and training
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
Example project #1 Technical Feasibility of Teleassessment
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)
Clinic Room #1 Clinic Room #2 Home Central clinic Approximations Simulated patient+ Simulated caregiver Patient+ Caregiver Expert clinician
Simulated impairments • MMT: added weights • Berg: stand on Dynadisk • TUG: walk a balance beam
camera camera TV Polycom ViewStation net video out net Polycom ViewStation TV video out Video capture (USB-Live) network PC PC USB serial dig dyna Interface net net LOCAL (PT) REMOTE (P and CG) Technology Layout
Range of motion Knee flexion
Shoulder abduction Shoulder external rotation Televideo
ROM Tele Measuring Methods • Caregiver places & reads goniometer • Caregiver places goniometer, therapist reads by zooming camera • Photo snapped, therapist holds goniometer up to screen • Photo snapped, therapist uses virtual goniometer
Manual Muscle Test With and w/o digital dynamometer Biceps, Quadriceps
Experiment Design • 10 subjects + 10 caregivers • 5 assessment instruments • Trained PTs • Co-located and remote testing
Key result No significant difference between any of the measurement methods
Discussion • Communication bandwitdh • High quality audio link essential, requirements for video not known • ROM • Caregivers could place goniometer • Snapshot + virtual goniometer • Need clear camera view • 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. Proof of clinical efficacy requires a home study with real patients.
Example project #2 Telerehabilitation for Training Recovery of Hand Function Following Stroke
Background • Post-stroke paralysis: dead cells + reduced excitability in surviving cellsChu et al., Stroke v.33, 2002 • “Learned nonuse”, compensatory use of non-impaired muscles, hinders recoveryTaub, 1980 • Constraint induced movement therapy (CIMT) targets learned nonuseTaub et al., Arch Phys Med Rehab, 1993; Liepert, Taub, Stroke, 2000 • Question: Is it forced use or forced learning? • Animal studies show repetitive movement is not enoughPlautz et al., Neurobiol Learn Mem, 2000
Strategy Provide patients with a movement task that requires learning. A task that requires concentration. A think-before-move task.
Pilot study: finger tracking in the clinic Carey et al., Brain, 2002.
Lesionon left Pre Post
Home-based tracking • Eliminate need for patients to travel to clinic • Patients can track on own schedule • Lower cost Primary science question: can tracking training be transferred to the home? Secondary science question: compare tracking training (learning) with movement training (no learning) Primary technology question: is home based tracking training feasible?