1. Equivalence of Face-to-face and Videoconference Administration of the ESS and Functional Reach for Post-Stroke Patients Sue Palsbo, PhD National Rehabilitation Hospital / George Mason University Steven J. Dawson, PT INTEGRIS/Jim Thorpe Lynda Savard, PT Sister Kinney Rehabilitation Institute Marc Goldstein, EdD American Physical Therapy Association

2. Funding Robert Wood Johnson Foundation, Methodologies Grant, #49143 US Department of Education, National Institute on Disability and Rehabilitation Research (NIDRR), Rehabilitation Engineering and Research Center (RERC) on Telerehabilitation #H133E990007-00C RERC on Telerehabilitation

3. Study Partners Professional Association American Physical Therapy Association (APTA) American Physical Therapy Association (APTA) Rehabilitation Hospitals INTEGRIS/Jim Thorpe (Oklahoma) INTEGRIS/Jim Thorpe (Oklahoma) Sister Kinney Institute (Minnesota) Sister Kinney Institute (Minnesota)

4. Goal Determine if post-stroke functional assessments tendered by a remote therapist are equivalent to a face-to-face assessment. Move beyond “proof of concept” study; design and execute an equivalence trial

5. Criteria for Selecting Measures (1) Be appropriate and relevant to people with stroke. (2) Have known psychometric properties (validity and reliability) published in peer- reviewed literature. (3) Wide use in research and clinical practice. (4) Be visually based (that is, the therapist can measure using televideo without touching the patient). (5) All measures can be completed within 30 minutes.

6. Design Issues for Measuring Equivalence Serial correlation bias Measure simultaneously, not serially Measure simultaneously, not serially Inter-rater reliability Use measurement tools with published reliability values Use measurement tools with published reliability values Training Training Bias in administration Switch off the therapist conducting the assessment Switch off the therapist conducting the assessment

7. Subject Randomization Total: 26 paired observations

8. Measures Functional reach European stroke scale 1. Level of consciousness 2. Comprehension 3. Speech 4. Visual field 5. Gaze 6. Facial movement 7. Arm – maintain position when outstretched

9. Measures, con’t. 8. Arm – raising 9. Wrist extension 10. Fingers 11. Leg – maintain position 12. Leg – flex 13. Dorsiflexion of foot 14. Gait

10. Equipment and Methods Large monitor video-conferencing equipment Transmission speed of 384 kbs Therapists recorded their scores simultaneously Therapists were blind to each other’s scoring Recorded level of confidence in their scores

11. Recruitment, Inclusion, Exclusion Convenience sample $5 honorarium $5 honorarium Patients with a history of stroke Outpatients Outpatients Inpatients Inpatients Cognitive ability to comprehend informed consent No visual field cuts

12. Measuring Agreement Kappa Have to have both raters assign rankings over the same range Have to have both raters assign rankings over the same range Lin’s rho Only for continuous measures; OK for functional reach, but not interval scales such as ESS Only for continuous measures; OK for functional reach, but not interval scales such as ESS Raw percentage agreement

13. Results Functional reach: Lin’s rho – 0.98 Percent agreement:ExactOne-level Comprehension0.961.00 Gaze0.96 Gait0.951.00 Fingers0.921.00 Level of Consciousness0.921.00 Leg (maintain position)0.92 Arm (raising)0.840.96 Wrist extension0.811.00 Speech0.801.00 Leg (flex)0.761.00 Facial movement.0.751.00 Dorsiflexion of foot0.721.00 Arm (maintain outstretched)0.720.96 Visual field0.72

14. Conclusions and Future Research Televideo assessments are worth pursuing Need to look at POTS videophones Need to look at POTS videophones Need to develop clinical protocols (positioning camera; patient safety; appropriate candidates) Need to identify more continuous measurement scales and demonstrate equivalence Maintain movement toward RCTs of teletherapy