1. Technical Feasibility of Tele- Assessments for Rehabilitation William Durfee 1, Lynda Savard 2, Samantha Weinstein 1 1 University of Minnesota 2 Sister Kenny Rehabilitation Institute Minneapolis, USA 5 th International Workshop on Virtual Rehabilitation, August 2006

2. 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

3. Why tele? Clients in rural locations Clients in urban locations, but have transportation challenges No car Poor public transportation Eliminates transportation time

4. 7 hrs

5. Telerehabilitation Applications Consultation Assessment Diagnosis and evaluation Education and training Home and activity monitoring Motor relearning (robot, biofeedback)

6. 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

7. 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

8. Electrons Cannot Transmit Forces and Motions

9. Although rehab robots could migrate to the home

10. RESEARCH QUESTION Can standard assessment instruments used by physical therapists be used with the patient located remotely? HomeClinic TELE ROM, MMT, FIM, BALANCE, COGNITION,...

11. 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)

12. 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

13. 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

14. 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

15. 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)

16. Technology Layout camera Polycom ViewStation network REMOTE (PT) vid cap TV PC camera Polycom ViewStation CO-LOCATED (P & CG) TV PC dig dyna

17. Approximations Patient + Caregiver Expert clinician HomeCentral clinic Clinic Room #1Clinic Room #2 Simulated patient + Simulated caregiver

18. Simulated impairments MMT: added weights Berg: stand on Dynadisk TUG: walk a balance beam

19. Range of motion Knee flexion

20. Shoulder abduction Shoulder external rotation Televideo

21. 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

23. Manual Muscle Test Biceps, Quadriceps With and w/o digital dynamometer

24. Berg Sit-to-Stand, Forward Reach

25. Timed Up and Go (TUG)

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

27. Key result No significant difference between any of the measurement methods

28. 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)

29. Results details (ROM) No bias among 7 methods

30. 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)

31. 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

32. Limitations Simulated patients Simulated caregivers Performance variation No inter-rater reliability

33. 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

34. This work was supported by the Sister Kenny Foundation, Minneapolis, USA. camera Polycom ViewStation network REMOTE (PT) vid cap TV PC camera Polycom ViewStation CO-LOCATED (P & CG) TV PC dig dyna