telerehabilitation applications for cognitive and …...3/29/11 1 dept. of rehabilitation science...

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Dept. of Rehabilitation Science and Technology

Telerehabilitation Applications for Cognitive and Vocational Rehabilitation

Michael McCue, PhD, April 1, 2011

School of Health and Rehabilitation Sciences Department of Rehabilitation Science and Technology


Collaborators, Affiliations and Acknowledgments

ASERT Regional Center on Autism. Pennsylvania Department of Public Welfare.

Interagency Agreement for Assistive Technology and Cognitive Rehabilitation. Contract funded by Pennsylvania OVR

Rehabilitation Engineering Research Center (RERC) on Telerehabilitation, NIDRR, # H133E090002

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Tele-Continuum (Parmanto & Saptono, 2008)


Evidence for Telerehabilitation Practice

•  General emphasis has been on equivalence or non-inferiority with face to face/traditional services

•  Efforts to document equivalent or reduced costs:

–  client travel time

–  clinician time

•  Satisfaction and usability

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Extending the Model: Naturalistic Rehabilitation •  Evidence for “in-vivo” home and work-based

rehabilitation widespread:

– Behavioral interventions for anxiety, pain, and phobias

– Supported Employment

– Stroke rehabilitation

–  ICF encourages exploration of contextual factors in environment


Rehabilitation Considerations

•  In defining process and outcomes, what works for telemedicine may not work for telerehabilitation . . .

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Rehabilitation Characteristics

•  Encounters with professionals are often repetitive, with established relationships

•  Client need for services often escalates as recovery continues

•  Needs and problems often most evident out in the community (shopping, at work) rather than in clinical settings

•  Rehab prescribes and enables clients to “practice” extensively between sessions in real-life activities


Rehabilitation Characteristics

•  Multitude of professional disciplines

•  Need for carryover of clinical evaluations and recommendations from one service network/team to another

•  Coupled with stubborn and chronic poor employment rates, evidence points to need for new and expanded models of community-based and vocational rehabilitation

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Contextual Factors in Rehabilitation •  Limited or difficulty generalizing from clinic to

natural environment

•  “place and train” model of supported employment

•  Use of strategies in environment to facilitate employment success – Assistive technology

– Cognitive rehabilitation

– Adjustment to disability counseling


Contextual Factors in Rehabilitation •  Rehab process requires:

– Education about injury/disability

– Detail about the environment

– Spontaneous compensatory strategies tried out in everyday life

– Increasing self-awareness and incorporating new info about self

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Contextual Factors •  Complex follow-up needs, often

escalating over time: – Emotional

– Psychosocial

– Family/relationship issues

– Return to work issues

– Return to home community, making face-to-face follow-up difficult or impossible


Contextual Factors: Conducting TR •  Obtain info about environment (pictures,

sounds) •  Implement real-time therapy while individual

faces environmental problems (“in vivo”) •  Provide education and feedback at pace

tolerable to individual •  Provide system of tracking progress/changes •  Anticipate long-term case management and

system carryover needs

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TR Applied to Vocational Rehabilitation •  Samples of TR in the VR Field (Summit

Group Survey)

•  Clinical Research and Demonstration Projects – University of Pittsburgh


Summit Group* Informal Survey of Telerehabilitation in VR •  Common for state agencies to utilize VC and other

technologies for staffing, training and administration

•  Several state VR agencies support and promote TR for consultation (Oregon, Virginia, WWRC)

•  Many state VR agencies implement client services via TR - deaf and interpreter services (e.g., South Dakota, Maryland, Oregon)

*Region 8 TACE; NCRTM; Utah VR

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Summit Group Survey •  Selected states identified direct client services via TR

–  Montana: client counseling sessions

–  WWRC: AAC training, NP test interpretation

–  Oregon: Client-counselor follow-along using text messaging

•  Nebraska: Researching iPad for client services

•  RTC – Rural Telecommunications and Individuals with Disability


Illustrations of Telerehabilitation Applications in Vocational Rehabilitation

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Modalities Used During 15 Week Study

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Week

Freq

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Face-to Face TrainingPhoneText MessagingInstant Messaging

E-mail Correspondence

TR Employment Supports – Mobile and Internet Applications


Experimental TR Job Coaching Supports

•  Sensors –  Collect information about what

the person is doing •  Machine Learning Software –  Identify a physical movement

(e.g. flipping a hamburger) •  Cueing Software –  Deliver a cue if the physical

movement is not correct for this step in the task (or offer praise)

•  Remote Job Coach Support

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Accuracy Matrix– Sensors

Action Flipping Picking Placing Pressing Salting

Flipping 94.12% 3.32% 1.04% 1.07% 0.45%

Picking 5.56% 91.09% 0.40% 2.95% 0.00%

Placing 1.75% 0.75% 95.75% 0.30% 1.45%

Pressing 7.02% 5.98% 3.51% 81.92% 1.56%

Salting 1.88% 0.00% 6.35% 1.30% 90.48%


Developing an Infrastructure for TR Applications in the VR Setting

•  A telerehabilitation portal enables ongoing real time, secure collaboration across program staff in different locations. The portal includes multiple features to emulate clinical workflow (e.g., medical records, progress notes, program materials, calendars, referral database, program evaluation and EBP tracking).

•  Incorporates VISyTER technology for integrated HD video conferencing (morning rounds, clinical assessment, counseling, consultation, staffings)

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Portal to Facilitate VR – State Operated Rehabilitation Center (HGAC - Johnstown)


•  Research protocols for remote autism (ADOS) and neuropsychological testing (usability, reliability and validity of remote standardized psychometric assessments)

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Cognitive and Vocational Rehabilitation Mobile TR Applications •  Remote Cognitive Rehabilitation (16 week ecologically

oriented memory rehabilitation program incorporating everyday demands and applications; structured protocol, homework, synchronous and asynchronous contact with therapist via portal/mobile tablet device)

•  Remote Job Coaching (8 week trial of mobile job supports including synchronous and asynchronous interactions with coach)


Portal Features TeleNP TeleCR TeleJC

Interactive Video ✔ ✔ ✔

Medical record ✔ ✔ ✔

Clinical Workflow ✔ ✔ ✔

Calendar ✔ ✔

Imbedded automated test protocols ✔

Test Stimuli ✔

White board response capability ✔

SMS text chat ✔ ✔

Customizable data collection forms ✔ ✔ ✔

Task guidance videos ✔

Therapeutic scripts (e.g., problem solving)

✔ ✔

Bibliotherapy resources ✔ ✔

Database/AV capture ✔ ✔ ✔

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Mobile Device Applications SMS text chat with coach

Video task guidance library

Problem solving script

Live interacJve video with coach

CBA -‐ Self-‐evaluaJon

Camera for recording/ forwarding to coach

Link to JAN accommodaJons

Worksite daily task list

Work schedule


TR Challenge for Vocational Rehabilitation •  Community based rehabilitation, including VR, has

traditionally been under funded, less rigorously researched, therefore underutilized and untested

•  TR already recognized as a tool to address rural accessibility

•  TR enables extension and expansion of services beyond clinic, face to face models; consistent with rehabilitation model of intervening in natural environment

•  Interventions that promote and result in employment and self-management are examples of the extension and expansion of services

•  Need new models for expanding TR applications to VR – Encourage support for Model demonstrations, University-State VR collaborations, Industry-VR collaborations

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Contact Information

Michael McCue, PhD

[email protected]

www.rerctr.pitt.edu

telerehabilitation applications for cognitive and …...3/29/11 1 dept. of rehabilitation science...

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