Telerehabilitation:
Lessons learned from
two examples
William Durfee
Department of Mechanical Engineering
University of Minnesota
Minneapolis, USA
MINNEAPOLIS, MINNESOTA
MINNESOTA,
Land of 10,000 Lakes
Roadside “Art”
in Minnesota
MINNEAPOLIS, City of Lakes
HUMAN/MACHINE DESIGN LAB
Department of Mechanical Engineering
University of Minnesota
(www.me.umn.edu/labs/hmd/)
u
F
• Stimulated Muscles = Power
• Brace = Trajectory guidance
T
• Brake = Control, stability
Haptic interfaces for virtual product prototyping,
smart knobs for cars
Active Element
u
IRC
Activation Dynamics
(2nd order)
X
CE Force-Length
V
CE Force-Velocity
X
Force
Fscale
Rehabilitation engineering
-Tele-rehabilitation
-Stroke rehab
-Driving simulators
•
Passive Element
X
PE Force-Length
V
PE Force-Velocity
•
Muscle mechanics
Human assist machines
-Compact power sources
-Powered exoskeletons
-Natural control
Medical device design
-Evaluation of surgical tools
x,v
Smart orthotics +
electrical stimulation
for gait restoration
OUTLINE
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Overview of telerehabilitation
Example 1: Tele-assessment
Example 2: Home stroke trainer
Conclusions and lessons learned
Overview of Telerehabilitation
Clinic
Home
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?
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Clients in rural locations
Clients in urban locations, but have
transportation challenges
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No car
Poor public transportation
Eliminates transportation time
Tele Locations
Local clinic
Central clinic
Patient
+
Local clinician
Expert clinician
Home
Central clinic
Patient
+
Caregiver
Expert clinician
Telerehabilitation Applications
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Consultation
Home and activity monitoring
Assessment
Motor relearning (robot, biofeedback)
Diagnosis and evaluation
Education and training
Tele-consultations: A Success Story ?
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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?
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Possibly adds cost
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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
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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
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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
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Range of Motion (ROM)
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Manual Muscle Test (MMT)
Berg Balance Test
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Shoulder abduction, shoulder rotation, knee
flexion
Item 1: Sit-to-Stand
Item 8: Forward Reach
Timed Up and Go Test (TUG)
Approximations
ClinicHome
Room #1
Central
clinic
Clinic
Room
#2
Simulated
patient
Patient
+
Simulated
caregiver
Caregiver
Expert clinician
Simulated impairments
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MMT: added weights
Berg: stand on Dynadisk
TUG: walk a balance beam
Technology Layout
camera
camera
TV
video out
Polycom
ViewStation
net
net
Video
capture
(USB-Live)
Polycom
video out
ViewStation
TV
network
PC
PC
USB
serial
net
LOCAL (PT)
net
REMOTE (P and CG)
Interface
dig dyna
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
Manual Muscle Test
Biceps, Quadriceps
With and w/o digital dynamometer
Berg Forward Reach, TUG
Experiment Design
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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
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Communication bandwitdh
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ROM
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Dynamometer not needed, but still could aid
Sit-Stand and TUG
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Caregivers could place goniometer
Snapshot + virtual goniometer
Need clear camera view
MMT
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High quality audio link essential, requirements for video not
known
No difficulties for tele-implementation
Forward reach
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Need zoom camera
Measurement technology would help
Limitations
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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
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Post-stroke paralysis: dead cells + reduced excitability in
surviving cells
Chu et al., Stroke v.33, 2002
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“Learned nonuse”, compensatory use of non-impaired
muscles, hinders recovery
Taub, 1980
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Constraint induced movement therapy (CIMT) targets
learned nonuse
Taub et al., Arch Phys Med Rehab, 1993; Liepert, Taub, Stroke, 2000
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Question: Is it forced use or forced learning?
Animal studies show repetitive movement is not enough
Plautz et al., Neurobiol Learn Mem, 2000
Strategy
Provide patients with a movement
task that requires learning. A task
that requires concentration. A thinkbefore-move task.
Tracking task
Pilot study: finger tracking in the clinic
Carey et al., Brain, 2002.
Lesion
on left
Pre
Post
Home-based tracking
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Eliminate need for patients to travel to
clinic
Patients can track on own schedule
Lower cost
Primary science question: can tracking training be
transferred to the home?
Secondary science question: compare tracking training
(learning) with movement training (no learning)
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 Screens
Tracking
Feedback
Pause and Shutdown Screens
Pausing
Auto shutdown
Analysis Software
Task Variants
Wave shapes
Wave parameters
Hand Position: Pronated, Mid, Supinated
Joint: Finger, Wrist
Hand: Ipsi, Contra
Visual feedback: On, Off
Frequency
0.2, 0.4, 0.8 Hz
Amplitude
0-50%, 30-70%,
50-100%, 0-125%
of active range
Duration
5, 10, 15, 20 sec
100 combinations selected
Experiment
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Placed in homes of 24 subjects with
stroke, 20 included in study results
2 to 305 miles from clinic
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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
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Box and Block
Jebsen Taylor Hand Function
Finger Range of Motion
Finger Tracking Performance
fMRI (cortical activation intensity and
location)
Lesion
on right
Key Results
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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
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Longer treatment (4 weeks, 1 hr/day)
Improved technology
Conclusions & Lessons Learned
Tele Technology
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High quality audio essential
Video quality requirements open
Clients have surprising tolerance for
technology…if motivated
More technology = more training
Tele Applications
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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
Teleassessment
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Lynda Savard
Samantha Weinstein
Stroke Rehab
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Project funded by the
Sister Kenny Foundation,
Minneapolis
James Carey
Samantha Weinstein
Ela Bhatt
Ashima Nagpal
Project funded by NIDRR,
H133G020145