Telerehabilitation: Lessons learned

from two examples

William DurfeeDepartment of Mechanical

EngineeringUniversity of Minnesota

Minneapolis, USA

MINNEAPOLIS, MINNESOTA

MINNESOTA, Land of 10,000 Lakes

Roadside “Art”in Minnesota

MINNEAPOLIS, City of Lakes

• Stimulated Muscles = Power • Brace = Trajectory guidance • Brake = Control, stability

HUMAN/MACHINE DESIGN LABDepartment of Mechanical EngineeringUniversity of Minnesota(www.me.umn.edu/labs/hmd/)

Fu

x,vT

X

PE Force-Velocity

CE Force-Velocity

Fscale

IRC

CE Force-Length

Activation Dynamics (2nd order)

PE Force-Length

u

V

X

V

X

Force

Passive Element

Active Element

Muscle mechanics

Smart orthotics + electrical stimulation for gait restoration

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

Medical device design-Evaluation of surgical tools

OUTLINE

Overview of telerehabilitation Example 1: Tele-assessment Example 2: Home stroke trainer Conclusions and lessons learned

Overview of Telerehabilitation

Home Clinic

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

Tele Locations

Patient+

Local clinicianExpert clinician

Local clinic Central clinic

Patient+

CaregiverExpert clinician

Home Central clinic

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

Electrons Cannot Transmit Forces and Motions

Although rehab robots could migrate to the home

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)

Approximations

Patient+

CaregiverExpert clinician

Home Central clinicClinic Room #1 Clinic Room #2

Simulated patient+

Simulated caregiver

Simulated impairments

MMT: added weights Berg: stand on Dynadisk TUG: walk a balance beam

Technology Layout

network

dig dyna

Polycom ViewStatio

n

TV

PC

Interface

serial

video outPolycom

ViewStation

TV

PC

USB

video out netnet

net net

Video capture (USB-Live)

LOCAL (PT) REMOTE (P and CG)

cameracamera

Range of motion

Knee flexion

Shoulder abduction

Shoulder external rotation

Televideo

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

Virtual Goniometer

C:\Documents and Settings\user\Desktop\VT TALKS\TELE\VirtualGoniometer.exe

Manual Muscle Test

Biceps, Quadriceps With and w/o digital dynamometer

Berg Forward Reach, TUG

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 recovery

Taub, 1980

Constraint induced movement therapy (CIMT) targets learned nonuse

Taub 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.

Tracking task

Pilot study: finger tracking in the clinic

Carey et al., Brain, 2002.

Pre Post

Lesionon left

Home-based tracking

Eliminate need for patients to travel to clinic

Patients can track on own schedule Lower cost

Secondary science question: compare tracking training (learning) with movement training (no learning)

Primary science question: can tracking training be transferred to the home?

Primary technology question: is home based tracking training feasible?

Track train system

Sensing Brace

1-Button Operation

Simplify Setup with Instructions

Pre-Trial Screens

Calibration Trial prep

Trial ScreensFeedbackTracking

Pause and Shutdown Screens

Auto shutdownPausing

Analysis Software

Task Variants

5, 10, 15, 20 secDuration

0-50%, 30-70%, 50-100%, 0-125% of

active range Amplitude

0.2, 0.4, 0.8 HzFrequency

Hand Position: Pronated, Mid, SupinatedJoint: Finger, WristHand: Ipsi, ContraVisual feedback: On, Off

Wave parameters

Wave shapes

100 combinations selected

Experiment

Placed in homes of 24 subjects with stroke, 20 included in study results

2 to 305 miles from clinic Plus one at 1,057 mi

180 trials/day x 10 days = 1800 total trials (some took 14 days to complete)

Periodic teleconferencing sessions Tracking group and Move (control)

group

Pre-Post Evaluations

Box and Block Jebsen Taylor Hand Function Finger Range of Motion Finger Tracking Performance fMRI (cortical activation intensity

and location)

Lesionon right

Key Results Tracking group improved in tracking

accuracy and finger ROM Both groups improved on functional tests Both groups had cortical reorganization,

but Tracking group showed more shift towards lesioned side

Subjects could self-install system and don/doff sensors

Conclusion: Tracking training at home is feasible and effective. Need to explore why Tracking and Move groups were similar

Next steps

Longer treatment (4 weeks, 1 hr/day) Improved technology

Conclusions & Lessons Learned

Tele Technology

High quality audio essential Video quality requirements open Clients have surprising tolerance for

technology…if motivated More technology = more training

Tele Applications

Tele-consultation: a winner Self-administered home treatment

with periodic tele-checkups: promising Interactions requiring touch: not yet,

but rehab robots promising

Cost and outcome benefits of telerehabilitation unknown which means research is only path to progress

Collaborators

Lynda Savard Samantha

Weinstein

James Carey Samantha Weinstein Ela Bhatt Ashima Nagpal

Project funded by NIDRR, H133G020145

Project funded by the Sister Kenny Foundation, Minneapolis

Teleassessment Stroke Rehab