Tele Rehabilitation Overview and Preliminary Results Nigel Shapcott

Tele. Rehabilitation 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 Beijing Conference October 2001

Institutional Acknowledgements n. US Dept. of Agriculture SBIR I and II. n. Center for Excellence in Rural Medically Underserved Areas, PA. n. Veteran’s Affairs Rehab Research & Development Service n. Dept of Rehab Science & Technology at the University of Pittsburgh n. UPMC Center for Assistive Tech. n. UPMC Spinal Injury Center n. HERL VA Medical Center Pittsburgh Beijing Conference October 2001

People Acknowledgements Michael Boninger MD n Laura Cohen PT n Rory Cooper Ph. D n Rosi Cooper PT n Shirley Fitzgerald Ph. D n Mark Schmeler OT n Tricia Thorman OT n Beijing Conference October 2001

Tele. Rehab- 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 Beijing Conference • Non Specialist OTR or PT • COTA or PTA • RTS Technician • LPN • Orthotist or Prosthetist • Visiting Nurse October 2001

Tele. Rehab- The Need u Resources and Distances u. Not enough skilled people u. Large numbers of underserved u. Too many miles u. Earlier discharge u. Mortality rates u. Disability rates u. AT Approx 200 miles Pennsylvania- West/Central Beijing Conference October 2001

Tele. Rehab- Why Are We Using Telephone Based Systems Now? u AT&T, top picture 1994 ($1500) poor performance u Via. TV, 1998 u 1998, same widespread infrastructure (POTS)- better performance with lower costs e. g. Via. TV, Starview u. New units cost $300 + Beijing Conference October 2001

Potential Benefits of Tele. Rehab u Better access to health care for those living outside metropolitan areas u Fewer trips to clinics and hospitals for both patients and clinicians u More specialists can take part in an evaluation u Follow-up with clients after discharge Beijing Conference October 2001

Tele. Rehabilitation Part II- Technologies and Nomenclature Beijing Conference October 2001

BANDWIDTH- (Rate of Information) Available/Developing Technologies u Hard wired-T/4 Fiber optic Lines- high u Hard wired-ISDN Digital Phone Lines- medium u Hard wired-POTS- Plain Old Telephone Service- low u Hard wired-Cable- medium/high u Hard wired- Power Utilities- not known u Hard wired- *DSL Technologies- medium/high u Wireless- Cell Phone 3 G- medium/high u Wireless- 2 Way Satellite (0. 5 m)- medium/high Beijing Conference October 2001

Connection Technologies. Summary u Rapid changes in these u Huge potential market u Rural areas likely to be last in line u Bandwidth will increase u Video quality will improve u Data capability will be further developed Beijing Conference October 2001

Tele. Rehabilitation Part III- Results Beijing Conference October 2001

Clinical Issues u Injury- Handover of responsibility n Transfer n ROM u Training n Qualifications at both ends n Specialized training requirements u Recognition of current limits n No feel (ROM) n Tremors (not picked up) n More quantitative tools needed (Pressure etc) n Multiple view issues Beijing Conference October 2001

Efficacy of Wheelchair System Prescription Using POTS Tele. Rehab u Aims and Method n 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. n 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. n Tele. Rehab (TR) systems are used to evaluate individuals for their wheelchair & seating needs and compared to the findings of In Person (IP) evaluations. Beijing Conference October 2001

Efficacy of Wheelchair System Prescription Using POTS Tele. Rehab u RESEARCH QUESTIONS u Can experienced Clinicians using TR technologies, with defined operational protocols: u 1. Reliably determine if the TR process is appropriate and safe for a specific individual? u 2. Reliably provide accurate decisions regarding the need for a wheelchair, at a detailed level? u 3. Reliably obtain accurate assessments of medical history and physical examination? Beijing Conference October 2001

Efficacy of Wheelchair System Prescription Using POTS Tele. Rehab u Assessment/Evaluation n 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. Beijing Conference October 2001

Efficacy of Wheelchair System Prescription Using POTS Tele. Rehab u 20 subjects acting as “model patients” u 4 evaluations/subject n Crossover study v v v n n u 9 2 Locations 2 In Person (IP) 2 Tele. Rehab (TR) Detailed Protocol Data Collection (Forms) 4 Clinicians (2 OT, 2 PT) “Assistants” Trained n n Tele. Rehab evaluation Transfer ROM Dimensions Beijing Conference October 2001

2 Locations UPMC u 2 Center for Assistive Technology Locations Pittsburgh VA Medical Center. Highland Drive Pittsburgh Beijing Conference October 2001

Experimental Schematic DAY 2 Clinician 3 evaluation CAT TR Clinician 1 evaluation CAT IP VA IP Clinician 2 evaluation DAY 1 3 -7 DAY DELAY BETWEEN SESSIONS Beijing Conference October 2001 Clinician 4 evaluation VA TR

Efficacy of Wheelchair System Prescription Using POTS Tele. Rehab u 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. Beijing Conference October 2001

Data Collection- Form 1 Beijing Conference October 2001

Data Collection- Form 2 Beijing Conference October 2001

Data Collection- Form 3 Beijing Conference October 2001

Data Collection- Form 3 Beijing Conference October 2001

Data Collection- Form 4 Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Qu. 1. Further evaluation v 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% v (Weighted Kappa issue) v v v Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Question. v v v Wheelchair Type Manual Wheelchair- simple agreement 100% (n=4) Powered Wheelchair- simple agreement 100% (n=4) Scooter- simple agreement 100% (n=1) Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Question. v v 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% Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Question. v v Seating Dimensions Overall Seat width: (<16”, 18”, >18”)simple agreement 61% Overall seat width In Person : (<16”, 18”, >18”)simple agreement 66% Overall Seat length: (<16”, 18”, >18”)simple agreement 75% Overall seat length In Person : (<16”, 18”, >18”)simple agreement 44% Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Question. v v v 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% Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Question. v v v Seating/Backrest Features Back Lateral Supports: (left, none)agreement 83% Back Lateral Supports: (right, none)simple agreement 83% Back customization required : (yes, no)simple agreement 80% Beijing Conference October 2001 simple

Preliminary Estimations (9 of 20 subjects) n Question. v v Headrest and Armrest Headrest required: (yes, no)simple agreement 94% Armrest required: (yes, no)simple agreement 94% Beijing Conference October 2001

Preliminary Estimations (9 of 20 subjects) n Conclusions: v v Simple to set up and use Good quality audio is essential Experienced clinicians required Linear measurement results diabolicalsupports rationel for simple measurement rigs (Logan et al 1998) Beijing Conference October 2001

Tele. Rehabilitation Part IV- Future Technical Issues Beijing Conference October 2001

Tele. Rehab- Future Needs u. Data Acquisition with video n Pressure n Dimensional Beijing Conference October 2001

Tele. Rehab- Future Needs u. Data Acquisition with video n Wound Care Beijing Conference October 2001

Tele. Rehab- Future Needs u. Data Acquisition with video n Temperature Beijing Conference October 2001

u. Data Acquisition with video n Shear n Humidity Beijing Conference October 2001

Tele. Rehab- Future Needs u. Data Acquisition with video n Data Glove Beijing Conference October 2001

Tele. Rehabilitation Future Service Delivery ISDN or Other High Bandwidth Systems High bandwidth link to center in Texas followed up with POTS link into home. Tele. Rehab services are limited by funding to special cases and demonstrations at this time. Beijing Conference October 2001