Telerehabilitation Assessment Research Articles

Machine learning for automating subjective clinical assessment of gait impairment in people with acquired brain injury – a comparison of an image extraction and classification system to expert scoring

BackgroundWalking impairment is a common disability post acquired brain injury (ABI), with visually evident arm movement abnormality identified as negatively impacting a multitude of psychological factors. The International Classification of Functioning, Disability and Health (ICF) qualifiers scale has been used to subjectively assess arm movement abnormality, showing strong intra-rater and test-retest reliability, however, only moderate inter-rater reliability. This impacts clinical utility, limiting its use as a measurement tool. To both automate the analysis and overcome these errors, the primary aim of this study was to evaluate the ability of a novel two-level machine learning model to assess arm movement abnormality during walking in people with ABI.MethodsFrontal plane gait videos were used to train four networks with 50%, 75%, 90%, and 100% of participants (ABI: n = 42, healthy controls: n = 34) to automatically identify anatomical landmarks using DeepLabCut™ and calculate two-dimensional kinematic joint angles. Assessment scores from three experienced neurorehabilitation clinicians were used with these joint angles to train random forest networks with nested cross-validation to predict assessor scores for all videos. Agreement between unseen participant (i.e. test group participants that were not used to train the model) predictions and each individual assessor’s scores were compared using quadratic weighted kappa. One sample t-tests (to determine over/underprediction against clinician ratings) and one-way ANOVA (to determine differences between networks) were applied to the four networks.ResultsThe machine learning predictions have similar agreement to experienced human assessors, with no statistically significant (p < 0.05) difference for any match contingency. There was no statistically significant difference between the predictions from the four networks (F = 0.119; p = 0.949). The four networks did however under-predict scores with small effect sizes (p range = 0.007 to 0.040; Cohen’s d range = 0.156 to 0.217).ConclusionsThis study demonstrated that machine learning can perform similarly to experienced clinicians when subjectively assessing arm movement abnormality in people with ABI. The relatively small sample size may have resulted in under-prediction of some scores, albeit with small effect sizes. Studies with larger sample sizes that objectively and automatically assess dynamic movement in both local and telerehabilitation assessments, for example using smartphones and edge-based machine learning, to reduce measurement error and healthcare access inequality are needed.

Identification and description of telerehabilitation assessments for individuals with neurological conditions: A scoping review.

The clinical adoption of telerehabilitation accelerated rapidly over the last few years, creating opportunities for clinicians and researchers to explore the use of digital technologies and telerehabilitation in the assessment of deficits related to neurological conditions. The objectives of this scoping review were to identify outcome measures used to remotely assess the motor function and participation in people with neurological conditions and report, when available, the psychometric data of these remote outcome measures. MEDLINE (Ovid), CINAHL, PubMed, PsychINFO, EMBASE, and Cochrane databases were searched between December 13, 2020, and January 4, 2021, for studies investigating the use of remote assessments to evaluate motor function and participation in people with neurological conditions. An updated search was completed on May 9, 2022, using the same databases and search terms. Two reviewers independently screened each title and abstract, followed by full-text screening. Data extraction was completed using a pre-piloted data extraction sheet where outcome measures were reported as per the International Classification of Functioning, Disability and Health. Fifty studies were included in this review. Eighteen studies targeted outcomes related to body structures and 32 targeted those related to activity limitation and participation restriction. Seventeen studies reported psychometric data; of these, most included reliability and validity data. Clinical assessments of motor function of people living with neurological conditions can be completed in a telerehabilitation or remote context using validated and reliable remote assessment measures.

Telerehabilitation system construction: design of a comprehensive rehabilitation training assessment software

During the COVID-19 pandemic, people in lockdown areas are unable to go to hospitals or rehabilitation institutions for face-to-face rehabilitation treatment, which also brings more inconvenience to people in remote and developing countries. The telerehabilitation is a good solution. As the core of rehabilitation treatment, the degree of informationization of the rehabilitation assessment directly determines the efficiency of telerehabilitation treatment. This paper proposes a telerehabilitation assessment software based on the C/S architecture, which can complete six different rehabilitation assessment schemes (including Manual Muscle Test, Berg Balance Scale, Barthel Index, Functional Independent Measure, Boston Diagnostic Aphasia Examination and Hamilton Depression Scale) to further develop patient-centred and home-based telerehabilitation programmes.

Patient and Clinician Reported Outcomes and Experiences Following Advanced Tele-Rehabilitation Assessments Conducted in Rural Alberta

<h3>Research Objectives</h3> To determine the feasibility of a clinic-to-clinic tele-rehabilitation model in rural Alberta. <h3>Design</h3> This pilot study employed a Plan-Do-Study-Act (PDSA) methodology. We focused on 4 clinical areas: Hip & Knee post-arthroplasty follow-up, Vestibular & Balance issues, Severe Shoulder Pain & Instability, and Wheelchair Seating. We co-developed assessment processes with non-physician experts that connected to a general physiotherapist using new technologies. After a series of in-house trials, these assessments were then deployed to 5 rural communities in Alberta. Technologies included Kinetisense Markerless Motion Capture and a telepresence robot. Patients were provided with a minimum of two clinical visits, with follow-up approximately 4 weeks after initial assessment. Experience and outcome measures centered on ICF principles were collected from both patients and clinicians. <h3>Setting</h3> The study took place in public and private rehabilitation settings and a primary care facility. <h3>Participants</h3> Participants were selected from a convenience sample by local practitioners. Initial and follow-up assessments for 16 patients in this pilot study were completed. <h3>Interventions</h3> A novel suite of technologies and processes were developed through close consultation with expert clinicians to enable complex rehabilitation assessments to be conducted remotely. <h3>Main Outcome Measures</h3> A mix of outcome and experience measures determined the effectiveness of this model. The COPM, and a study-specific Patient Reported Experience Measure, measured patient outcomes. Two study-specific Clinician Reported Experience Measures provided clinician data. <h3>Results</h3> Across our 4 modules, 14 out of 16 participants either agreed (3) or strongly agreed (11) that they enjoyed their Tele-Rehab session overall. No participants disagreed, and 2 were neutral. Based on COPM scores, overall patients saw improvements in both performance and satisfaction for their identified goals.The remote clinicians were all confident in the treatment plans prescribed by the hub clinician (n=13, 4 Agree, 9 Strongly Agree). Both hub and remote clinicians had confidence in each other, and all agreed (5) or strongly agreed (18) that the assessments were a success. <h3>Conclusions</h3> Preliminary results indicate that this is an effective way of delivering care, but additional study is required. <h3>Author(s) Disclosures</h3> N/A.

Development of a Home-Based Telerehabilitation Service Delivery Protocol for Wheelchair Seating and Mobility Within the Veterans Health Administration.

The provision of seating and wheeled mobility devices is a complex process that requires trained professionals and multiple appointments throughout the service delivery process. However, this can be inconvenient and burdensome for individuals with mobility limitations or for individuals who live in rural areas. Rural areas often present unique difficulties regarding the provision of healthcare services including lengthy travel times to medical facilities and lack of specialized providers and medical technology. The purpose of this article is to provide a comprehensive overview of the development and implementation of a service delivery protocol for a home-based telerehabilitation assessment for wheelchair seating and mobility. The telerehabilitation team consists of a trained wheelchair seating and mobility therapist and a telehealth clinical technician (TCT). In order to determine veterans that are appropriate for a home-based telerehabilitation assessment, a three-phase pre-assessment screening process was conducted by the therapist and TCT, including consult, chart, and phone review. Veterans that metall of the predetermined eligibility criteria were recommended for a telerehabilitation wheelchair assessment. The TCT traveled to the veteran's residence with necessary evaluation and safety equipment and connected with the therapist remotely using the VA Video Connect platform. Assessment and veteran data were collected during the initial evaluation and then during a 21-day follow-up. Forty-three veterans were successfully seen via telerehabilitation for a seating and wheeled mobility assessment between November, 2017 and July, 2018. The average travel distance between the veteran's residence and the clinic was 34.1 miles. The total telerehabilitation encounter times ranged from 45 min to 145 min. The implementation of this service delivery protocol for wheelchair seating and mobility assessments demonstrated the benefits of using telehealth services including reaching rural veterans, reducing distance traveled, maximizing efficiency of provider schedules, and conducting realistic assessments in veterans' home environments. Success can be attributed to being able to deliver best practice remotely and to the rapport of the TCT with the providers. Cultivating provider buy-in, selecting appropriate outcome measures, and restructuring workflows were additional lessons learned. The VA Video Connect platform is an accessible tool that can be easily learned by both veterans and providers and used beyond initial wheelchair seating evaluations for improved access to follow-up healthcare services.

Veteran and Provider Satisfaction with a Home-Based Telerehabilitation Assessment for Wheelchair Seating and Mobility.

The objective of this project was to measure Veteran and provider satisfaction with a home-based telerehabilitation assessment for wheelchair seating and mobility. Forty-three Veterans were seen remotely at their place of residence by a provider, using a VA Video Connect synchronous videoconferencing system. Veteran and provider satisfaction were collected using the Telerehabilitation Questionnaire (TRQ). Mean individual TRQ scores for both Veterans and providers were significantly higher than the scale midpoint of 3.5. Veterans had higher scores than providers for five individual items on the TRQ. Higher scores by Veterans on the technology and quality and clarity of the video and audio likely correspond to the differences in environmental settings in which the visit occurred for the Veteran compared with the provider. High satisfaction scores with the telerehabilitation assessments are likely attributed to the positive working relationship between the provider and the rehabilitation technician, who provided in-person technical support to the Veteran in the home during the wheeled mobility evaluation. Overall, the results indicate a high level of Veteran and provider satisfaction using telerehabilitation for wheelchair seating and mobility evaluations.

Tele rehabilitation: two-year experience in conducting medical assessments via tele link

Introduction: Telemedicine has been practised for many decades since initial documentation in 1940s when radiology images were sent between two townships in Pennsylvania via telephone lines. Bioinstrumentation and transmission of astronauts’ vital parameters to ground based flight surgeons came to forefront during NASA’s space programme in 1960s. During following decades, telemedicine was used in multiple medical specialties as a mode of patient assessment. Use of telemedicine in Rehabilitation Medicine is relatively recent. As multidisciplinary coordinated care led by rehabilitation physicians and allied clinicians is required, proformas are used in tele rehabilitation assessments. Proformas help to generate a clinical document with medical and allied health assessments in one clinical record. Currently, delivery of rehabilitation services is further empowered, enhanced and in evolution with the installation of dedicated software programmes for use by allied health clinicians. Most units operating tele medicine for rehabilitation medical services use trained proctor with the client/patient to enable more comprehensive examination to aid clinical decision when the physician is stationed in a distant site.

Design and Trial Operation of Tele-rehabilitation Gradient Motor Function Self-evaluating System for Stroke Patients

In order to overcome the defects of the motor function evaluation systems contained in current tele-rehabilitation devices, such as inconvenient, incomplete of measurement position, nonstandard and lacking of humanized design, we designed and developed a tele-rehabilitation gradient motor function self-evaluating system in this paper. Based on Brunnstrom stage, this system which was competitive comparing to manual evaluations, common tele-rehabilitation assessments and similar nonmedical products, realized the quantitative motor assessment for both limbs of stroke patients using the self-developed algorithms. The clinical trials proved that the system was feasible and accurate.

Assessing functional exercise capacity using telehealth: Is it valid and reliable in patients with chronic heart failure?

Introduction This study aimed to determine the validity and reliability of video-based telerehabilitation assessments in patients with heart failure. Methods Seventeen consecutive participants (mean age 69 years, SD 12 years and 88% males) undertook assessments of three functional tests via both telerehabilitation and face-to-face approaches, on the same day. The assessment order was randomised and conducted by independent assessors. Outcome measures included functional tests: timed up and go (time), six-minute walk (distance), grip strength (kilograms); system usability scale to rate participant experience with telerehabilitation assessment; and number of technical issues encountered. Validity and inter- and intra-rater reliability of telerehabilitation assessments were examined using limits of agreement, intra-class correlation coefficients (ICC), and paired t-tests. Results The limits of agreement for telerehabilitation assessments were within the clinically acceptable limits for timed up and go and grip strength. Telerehabilitation assessments for all functional tests were strongly associated with face-to-face assessments, with ICCs of between 0.85 and 0.96. Inter- and intra-rater reliability of telerehabilitation assessments for all functional tests were excellent (all ICC > 0.95). The mean (SD) system usability scale score was 85 (15)/100. Some incidences of Internet drop-outs, video freezing and auditory fading occurred. Discussion The use of telehealth for the assessment of functional exercise capacity appears to be valid and reliable in patients with heart failure.

Physiotherapy assessment and diagnosis of musculoskeletal disorders of the knee via telerehabilitation

Introduction Lower limb musculoskeletal disorders place a heavy burden on healthcare systems. Appropriate management of these conditions is critical, however access to appropriate physiotherapy services is difficult for those in geographically remote areas or those with mobility or transport difficulties. The aim of this study was to evaluate the accuracy and reliability of an online musculoskeletal physiotherapy assessment of the knee complex using telerehabilitation compared to traditional face-to-face assessment. Methods In a repeated-measures design, 18 subjects who sought treatment for knee pain underwent a traditional face-to-face assessment and a remote telerehabilitation assessment. Telerehabilitation assessments were conducted with participants performing facilitated self-palpation, self-applied modified orthopaedic tests, active movements and functional tasks. Results Primary pathoanatomical diagnoses were in exact agreement in 67% of cases and were similar in 89% of cases. The system of pathology was found to be in agreement in 17 out of 18 cases (94%). Comparisons of objective findings from the two physical assessments demonstrated substantial agreement (kappa = 0.635) for categorical data and binary data (chi-squared = 400.36; p < 0.001). A high level of intra-rater (89%) and moderate level of inter-rater (67%) reliability was evident for telerehabilitation assessments. Discussion Telerehabilitation assessment of the knee complex appears to be feasible and reliable. This study has implications for clinical practice and the development of physiotherapy services to address the burden of lower limb musculoskeletal pain and disability.

Extraction of spatial information for low-bandwidth telerehabilitation applications.

Telemedicine applications, based on two-dimensional (2D) video conferencing technology, have been around for the past 15 to 20 yr. They have been demonstrated to be acceptable for face-to-face consultations and useful for visual examination of wounds and abrasions. However, certain telerehabilitation assessments need the use of spatial information in order to accurately assess the patient's condition and sending three-dimensional video data over low-bandwidth networks is extremely challenging. This article proposes an innovative way of extracting the key spatial information from the patient's movement during telerehabilitation assessment based on 2D video and then presenting the extracted data by using graph plots alongside the video to help physicians in assessments with minimum burden on existing video data transfer. Some common rehabilitation scenarios are chosen for illustrations, and experiments are conducted based on skeletal tracking and color detection algorithms using the Microsoft Kinect sensor. Extracted data are analyzed in detail and their usability discussed.

The Validity of Physical Therapy Assessment of Low Back Pain via Telerehabilitation in a Clinical Setting

Back pain is a common and disabling condition for people in rural and remote areas. In these areas, access to rehabilitation services is limited by service availability. Telerehabilitation is suggested as a solution for providing physical therapy services; however, the validity of clinical assessment is largely unproven. The aim of this study was to establish the validity of clinically pragmatic remote assessment of spinal posture, active movements of the lumbar spine, and the passive straight leg raise (SLR) test. Face-to-face physical therapist assessment was compared with telerehabilitation assessment of spinal posture, active movements of the lumbar spine, and the SLR test. Twenty-six participants recruited from a rural population with current or recent low back pain (LBP) were assessed by a face-to-face physical therapist and a remote physical therapist. Pain, disability, and clinical measurements were assessed. Outcomes were compared to establish agreement. High levels of agreement were found with detecting pain with specific lumbar movements, eliciting symptoms, and sensitizing the SLR test. Moderate agreement occurred with identifying the worst lumbar spine movement direction, SLR range of motion, and active lumbar spine range of motion. Poor agreement occurred with postural analysis and identifying reasons for limitations to lumbar movements. Conducted in a rural clinical setting, this study validates elements of the physical assessment of the lumbar spine and identifies technical and clinical issues to be addressed by future research. Important components of the standard musculoskeletal assessment of LBP are valid via telerehabilitation in a clinical setting.

Agreement between telerehabilitation involving caregivers and face-to-face clinical assessment of lymphedema in breast cancer survivors

Lymphedema is a lifetime complication of breast cancer survivors that can limit their participation in recreational or strenuous daily activities. Follow-up of lymphedema using an Internet application could help patients to determine the influence on their condition of these activities and adapt them accordingly. We aimed to determine the level of agreement between lymphedema assessment by telerehabilitation and by the traditional face-to-face method. Thirty breast cancer survivors participated in a descriptive study of repeated measures using a crossover design. Patients attended a session for clinical face-to-face and real-time online telerehabilitation assessments of lymphedema. There was a 120-min interval between these two sessions. The order of sessions was randomly selected for each patient. A caregiver (relative or friend) conducted the telerehabilitation assessment using a system that includes a specific tool based on an arm diagram for measuring the participant's arm circumferences via a telehealth application. All outcome measures showed reliability estimates (α) ≥ 0.90; the lowest reliability was obtained for the total volume on the non-affected side (α = 0.90). The diagnosis of lymphedema by the two methods also showed good inter-rater reliability (Rho = 0.89). These preliminary findings support the use of an Internet-based system to assess lymphedema in breast cancer survivors, offering carers a useful role in helping patients to follow up this lifetime health problem.

Internet-based physical assessment of people with Parkinson disease is accurate and reliable: A pilot study

Telerehabilitation may be an alternative service delivery model for people with Parkinson disease (PD) who live in areas where traditional rehabilitation services are not readily accessible. The aim of this study was to determine the accuracy and reliability of performing remote physical assessments of people with PD via telerehabilitation when compared with traditional face-to-face assessments. Twelve subjects were simultaneously examined by a face-to-face investigator and a remote investigator via the eHAB telerehabilitation system. The outcome measures evaluated included the timed stance test, Timed "Up and Go" test, step test, steps in 360 degree turn, Berg Balance Scale, and lateral and functional reach tests. Limits of agreements intervals and weighted kappa statistics demonstrated the telerehabilitation assessments to be accurate within clinically acceptable limits. A high level of inter- and intrarater reliability was demonstrated across all telerehabilitation assessments. This study indicates that it is possible to assess the physical ability of people with PD via telerehabilitation systems and provides support for the further development of telerehabilitation applications for patients with neurological disorders.

Training the allied health assistant for the telerehabilitation assessment of dysphagia

We examined the effect of knowledge and task specific training provided to an allied health assistant (AHA), prior to her involvement in facilitating assessments of dysphagia (swallowing disorders) via telerehabilitation. The AHA received four hours of training, which included basic theoretical information regarding dysphagia as well as hands-on training with simulated patients. A written test examining swallowing function and its evaluation was completed pre- and then immediately post-training, and then again after the 15th and 30th of 31 consecutive patient assessments. In addition, after each set of 5 clinical dysphagia assessments completed with patients following the training, two speech pathologists rated the AHA's competence in relation to performing the tasks and activities required of her during the telerehabilitation swallowing assessment. The AHA also self-rated the perceived level of confidence at these times. Before training, the assistant's knowledge of dysphagia theory was at 40%. Following training, all tests were above the 80% level. The AHA's performance was rated as competent on each evaluation post-training. The AHA also expressed overall satisfaction with the initial training provided and reported feeling confident after the initial sessions with patients. Thus for an AHA with previous clinical experience, competence and perceived comfort in providing assistance in the sessions was achieved with only a few hours of task specific training.

Assessing dysphagia via telerehabilitation: Patient perceptions and satisfaction

To gain insight into factors which may influence future acceptance of dysphagia management via telerehabilitation, patients’ perceptions were examined before and after a telerehabilitation assessment session. Forty adult patients with dysphagia (M =66 years, SD =16.25) completed pre- and post-session questionnaires which consisted of 14 matched questions worded to suit pre- and post-conditions. Questions explored comfort with the use of telerehabilitation, satisfaction with audio and video quality, benefits of telerehabilitation assessments and patients’ preferred assessment modality. Questions were rated on a 5-point scale (1 = strongly disagree, 3 = unsure, 5 = strongly agree). Patients’ comfort with assessment via telerehabilitation was high in over 80% of the group both pre- and post-assessment. Pre-assessment, patients were unsure what to expect with the auditory and visual aspects of the videoconference, however there were significant positive changes reported post-experience. In relation to perceived benefits of telerehabilitation services in general, most patients believed in the value of telerehabilitation and post-assessment this increased to 90–100% agreement. Although 92% felt they would be comfortable receiving services via telerehabilitation, 45% of patients indicated ultimate preference for a traditional face-to-face assessment. The data highlight that patients are interested in and willing to receive services via telerehabilitation; however, any concerns should be addressed pre-assessment.

Managing Patient Factors in the Assessment of Swallowing via Telerehabilitation

Undoubtedly, the identification of patient suitability for a telerehabilitation assessment should be carried out on a case-by-case basis. However, at present there is minimal discussion of how telerehabilitation systems can accommodate and adapt to various patient factors, which may pose challenges to successful service delivery. The current study examines a subgroup of 10 patients who underwent an online assessment of their swallowing difficulties. Although all assessments were completed successfully; there were certain patient factors, which complicated the delivery of the online assessment session. The paper presents a discussion of the main patient factors observed in this cohort including the presence of speech and/or voice disorders, hearing impairment, dyskinesia, and behavioural and/or emotional issues and examines how the assessment session, the telerehabilitation system, and the staff involved were manipulated to accommodate these patient factors. In order for telerehabilitation systems to be more widely incorporated into routine clinical care, systems need to have the flexibility and design capabilities to adjust and accommodate for patients with varying levels of function and physical and psychological comorbidities.

Telerehabilitation assessment using the Functioning Everyday with a Wheelchair-Capacity instrument

This study explored the interrater reliability between a generalist practitioner administering the Functioning Everyday with a Wheelchair-Capacity (FEW-C) in person (IP) and a remote expert practitioner observing via telerehabilitation (TR) from more than 100 miles away. Each of the 46 participants was simultaneously rated by both the IP and TR practitioner, who were masked to each other's results. The IP-TR raters demonstrated excellent interrater reliability, with an intraclass correlation coefficient of 0.91 for the total FEW-C and 0.96, 0.88, and 0.90 for the constructs of independence, safety, and quality, respectively. Internal consistency (Cronbach alpha) was 0.94 for the total FEW-C tool and 0.91, 0.83, and 0.82 for independence, safety, and quality, respectively, indicating good internal consistency without redundancy. Using TR and the FEW-C, an expert practitioner more than 100 miles away was able to accurately assess the functional mobility needs of clients being assessed for new wheeled mobility devices.

Patient Satisfaction with Telerehabilitation Assessments for Wheeled Mobility and Seating

ABSTRACT Wheeled mobility and seating assessments for individuals with mobility impairments living in rural or distant locations are problematic due to the lack of expertise and available resources. The objective of this study was to measure satisfaction based on one's evaluation and prescription as well as comfort level when being evaluated by telerehabilitation (TR). Patient satisfaction data from real-time interactive TR clinical consultations between an expert practitioner located at least 125 miles away and four remote wheelchair clinics set up by the research team were collected and evaluated. The results revealed that there was a statistically significant difference between participants' pre- and postevaluation scores, t(39) = −13.92, p < .05, as well as pre- and postprescription scores, t(39) = −13.15, p < .05. In addition, all mean scores were significantly higher than the scale midpoint of 3.5 on a TR survey. The study's findings are consistent with those of previous telemedicine satisfaction studies. Overall, the results indicate a high level of patient satisfaction using TR.

Telerehabilitation mediated physiotherapy assessment of ankle disorders

Musculoskeletal injuries are the most common source of chronic pain and disability. The ankle joint is the most common of these injuries and without adequate rehabilitation function can be severely impaired. Access to physiotherapy rehabilitation services can be limited due to geographical remoteness and a shortage of services in rural and remote areas. Telerehabilitation is a potential solution to bridge this service delivery gap. The aim of this study was to determine the criterion validity and reliability of conducting a remote musculoskeletal assessment of the ankle joint complex using telerehabilitation technologies compared with a face-to-face assessment. This study utilized a repeated measures design to assess 15 subjects (mean age 24.5, SD 10.8 years) presenting with ankle pain. Conventional face-to-face assessments were compared with assessments performed via a telerehabilitation system. A similar agreement of 93.3% in patho-anatomical diagnosis and an 80% exact agreement (chi(2) = 4.267; p < 0.04) in primary systems diagnosis was found between face-to-face and telerehabilitation assessments. Clinical observations were found to have very strong agreement (k = 0.92) for categorical data and significant agreement (93.3% agreement; chi(2) = 234.4; p < 0.001) for binary data. A high level of inter- and intrarater reliability was found for the telerehabilitation assessments. This study demonstrates the criterion validity and reliability of remote musculoskeletal assessments of the ankle joint complex using telerehabilitation.