Telerehabilitation System Research Articles

Development of telerehabilitation application with designated consultation categories.

Telerehabilitation (TR) is getting ever more popular because it is effective in bringing rehabilitation services to rural populations by means of audiovisual systems and its initial implementation studies presented encouraging results. TR is proven to be helpful, with benefits in terms of reduced travel time, cost, and availability of specialists' support in local communities. However, TR systems that are usable under low-bandwidth network environments are rare. This article introduces the development of a TR system with customized consultation categories for users to choose from, depending on requirements. Each category, with its preset parameter values, is discussed in detail by demonstrating relevant rehabilitation exercises. A novel bandwidth adaptation algorithm is also presented for optimal utilization of the dynamic network conditions, which ensures the system functionality even under narrow-bandwidth environments. Experiment results show that the system is able to perform effectively in each consultation category while the rehabilitation exercises are being performed. The proposed algorithm is also verified for its ability to adapt the content quality and effectively utilize the network under constrained conditions. A survey conducted on the video quality of the system under low-bandwidth conditions shows encouraging results for a large scale deployment of the application.

Ghostman: augmented reality application for telerehabilitation and remote instruction of a novel motor skill.

This paper describes a pilot study using a prototype telerehabilitation system (Ghostman). Ghostman is a visual augmentation system designed to allow a physical therapist and patient to inhabit each other's viewpoint in an augmented real-world environment. This allows the therapist to deliver instruction remotely and observe performance of a motor skill through the patient's point of view. In a pilot study, we investigated the efficacy of Ghostman by using it to teach participants to use chopsticks. Participants were randomized to a single training session, receiving either Ghostman or face-to-face instructions by the same skilled instructor. Learning was assessed by measuring retention of skills at 24-hour and 7-day post instruction. As hypothesised, there were no differences in reduction of error or time to completion between participants using Ghostman compared to those receiving face-to-face instruction. These initial results in a healthy population are promising and demonstrate the potential application of this technology to patients requiring learning or relearning of motor skills as may be required following a stroke or brain injury.

A Cloud-Based Tele-Rehabilitation System for Frozen Shoulder

A home-based motion-sensing tele-rehabilitation system that incorporated motion-sensing technology and cloud technology was developed for improving the rehabilitation mode of patients with frozen shoulder. The system will enable the patients to carry out motion-sensing rehabilitation at home and its rehabilitation results can be calculated and analyzed instantly in terms of motion effect index with cloud computing technology. The system will also enable medical professionals to find out patients rehabilitation status via a cloud system and issue personalized prescriptions of home-based rehabilitation system for individual patients.

Teaching self-management skills in persons with chronic lower limb swelling and limited mobility: evidence for usability of telerehabilitation.

The purpose of this study was to evaluate the usability of telerehabilitation as a method of teaching self-management for chronic swelling of the lower limbs in persons with limited mobility. An in-home telerehabilitation self-management education protocol for chronic swelling of the lower limbs, termed Telerehabilitation to Empower You to Manage and Prevent Swelling (TR-PUMPS), was implemented using the Versatile and Integrated System for Telerehabilitation (VISYTER) software platform. Participants (n=11) were 36–79 years old, predominately female (72.7%) and diagnosed with a variety of health conditions. Participants’ perceived usability scores of the remote delivery of TR-PUMPS was high with a median score of 6.67 (range 4.90 – 7.00) on a Likert scale: 1= disagree to 7= agree. There was no correlation between participants’ familiarity with information technology and their perception of telerehabilitation usability. These results support telerehabilitation as a viable method for teaching a home-based, self-management protocol for chronic swelling.

Telerehabilitation

Telerehabilitation can offer prolonged rehabilitation for patients with stroke after being discharged from the hospital, whilst remote diagnostics may reduce the frequency of the outpatient services required. Here, we compared a novel telerehabilitation system for virtual reality-supported balance training with balance training with only a standing frame and with conventional therapy in the hospital. The proposed low-cost experimental system for balance training enabling multiple home systems, real-time tracking of task's performance and different views of captured data with balance training, consists of a standing frame equipped with a tilt sensor, a low-cost computer, display, and internet connection. Goal-based tasks for balance training in the virtual environment proved motivating for the participating individuals. The physiotherapist, located in the remote healthcare center, could remotely adjust the level of complexity and difficulty or preview the outcomes and instructions with the application on the mobile smartphone. Patients using the virtual reality-supported balance training showed an improvement in the task performance time of 45% and number of collisions of 68%, showing significant improvements in the Berg Balance Scale, Timed 'Up and Go', and 10 m Walk Test. The clinical outcomes were not significantly different from balance training with only the standing frame or conventional therapy. The proposed telerehabilitation can facilitate the physiotherapists' work and thus enable rehabilitation to a larger number of patients after release from the hospital because it requires less time and infrequent presence of the clinical staff. However, a comprehensive clinical evaluation is required to confirm the applicability of the concept.

Agreement Between Telerehabilitation and Face-to-Face Clinical Outcome Assessments for Low Back Pain in Primary Care

A descriptive study of repeated measures using a crossover design. To determine the level of agreement between assessments obtained via telerehabilitation and those obtained by traditional face-to-face method in a population of individuals with chronic low back pain (LBP) in a primary care setting. Musculoskeletal assessment using telerehabilitation has shown adequate inter- and intrarater agreement and concordance with face-to-face clinical assessment in different diseases. There have been no published studies on the reliability of a telerehabilitation system to assess LBP. Fifteen individuals (6 males; mean age, 37 yr) with chronic LBP attended a session for a clinical interview, followed by face-to-face and real-time online telerehabilitation evaluations. There was a 30-minute interval between the 2 assessments, the order of which was randomly selected for each patient. The telerehabilitation system used an Internet application conducted via Internet connection (17 kB/s) between 2 personal computers. Real-time video connection facilitated communication between the therapist and the subject. Outcome measures included lumbar spine mobility, Sorensen test, anterior straight leg raise test, Oswestry Disability Index, visual analogue scale for pain, 12-Item Short Form Health Survey questionnaire, and Tampa Kinesiophobia Scale. The α reliability between face-to-face and telerehabilitation evaluations was more than 0.80 for 7 of the 9 outcome measures. Lowest reliability was for lateral flexion range of motion (α= 0.75). Very good inter- and intrarater intraclass correlation coefficients (ρ) were obtained (0.92-0.96). The findings of our pilot study suggest that this telerehabilitation system may be useful to assess individuals with chronic LBP, providing initial support for its implementation in primary care. 2.

Telehealth system (e-CUIDATE) to improve quality of life in breast cancer survivors: rationale and study protocol for a randomized clinical trial

BackgroundBreast cancer survivors suffer physical impairment after oncology treatment. This impairment reduces quality of life (QoL) and increase the prevalence of handicaps associated to unhealthy lifestyle (for example, decreased aerobic capacity and strength, weight gain, and fatigue). Recent work has shown that exercise adapted to individual characteristics of patients is related to improved overall and disease-free survival. Nowadays, technological support using telerehabilitation systems is a promising strategy with great advantage of a quick and efficient contact with the health professional. It is not known the role of telerehabilitation through therapeutic exercise as a support tool to implement an active lifestyle which has been shown as an effective resource to improve fitness and reduce musculoskeletal disorders of these women.Methods / DesignThis study will use a two-arm, assessor blinded, parallel randomized controlled trial design. People will be eligible if: their diagnosis is of stages I, II, or IIIA breast cancer; they are without chronic disease or orthopedic issues that would interfere with ability to participate in a physical activity program; they had access to the Internet and basic knowledge of computer use or living with a relative who has this knowledge; they had completed adjuvant therapy except for hormone therapy and not have a history of cancer recurrence; and they have an interest in improving lifestyle. Participants will be randomized into e-CUIDATE or usual care groups. E-CUIDATE give participants access to a range of contents: planning exercise arranged in series with breathing exercises, mobility, strength, and stretching. All of these exercises will be assigned to women in the telerehabilitation group according to perceived needs. The control group will be asked to maintain their usual routine. Study endpoints will be assessed after 8 weeks (immediate effects) and after 6 months. The primary outcome will be QoL measured by The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 version 3.0 and breast module called The European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life questionnaire. The secondary outcomes: pain (algometry, Visual Analogue Scale, Brief Pain Inventory short form); body composition; physical measurement (abdominal test, handgrip strength, back muscle strength, and multiple sit-to-stand test); cardiorespiratory fitness (International Fitness Scale, 6-minute walk test, International Physical Activity Questionnaire-Short Form); fatigue (Piper Fatigue Scale and Borg Fatigue Scale); anxiety and depression (Hospital Anxiety and Depression Scale); cognitive function (Trail Making Test and Auditory Consonant Trigram); accelerometry; lymphedema; and anthropometric perimeters.DiscussionThis study investigates the feasibility and effectiveness of a telerehabilitation system during adjuvant treatment of patients with breast cancer. If this treatment option is effective, telehealth systems could offer a choice of supportive care to cancer patients during the survivorship phase.Trial registrationClinicalTrials.gov Identifier: NCT01801527

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.

Effectiveness of an interactive virtual telerehabilitation system in patients after total knee arthoplasty: A randomized controlled trial

To compare the effectiveness of a new interactive virtual telerehabilitation system and a conventional programme following total knee arthroplasty. Randomized, controlled, single-blind clinical trial. A total of 142 total knee arthroplasty patients. Participants were randomly assigned to receive either: (i) conventional out-patient physical therapy; or (ii) interactive virtual telerehabilitation system. The main outcome was function assessed with active range of knee movement. Other variables, such as muscle strength, walk speed, pain and the Western Ontario and McMaster Universities osteoarthritis index, were also collected. Comparisons were made on the basis of data collected routinely before surgery, at the end of the rehabilitation programme, and at 3 months follow-up. Quantitative variables were compared by Mann-Whitney U test. The agreed alpha risk for all hypothesis testing was 0.05. Baseline characteristics between groups were comparable. All participants improved after the 2-week intervention on all outcome variables (p < 0.05). Patients in the interactive virtual telerehabilitation group achieved improvements in the functional variables similar to those achieved in the conventional therapy group. A 2-week interactive virtual telerehabilitation programme is at least as effective as conventional therapy. Telerehabilitation is a promising alternative to traditional face-to-face therapies after discharge from total knee arthroplasty, especially for those patients who have difficulty with transportation to rehabilitation centres.

IBalance-ABF: A Smartphone-Based Audio-Biofeedback Balance System

This paper proposes an implementation of a Kalman filter, using inertial sensors of a smartphone, to estimate 3-D angulation of the trunk. The developed system monitors the trunk angular evolution during bipedal stance and helps the user to improve balance through a configurable and integrated auditory-biofeedback (ABF) loop. A proof-of-concept study was performed to assess the effectiveness of this so-called iBalance-ABF--smartphone-based audio-biofeedback system--in improving balance during bipedal standing. Results showed that young healthy individuals were able to efficiently use ABF on sagittal trunk tilt to improve their balance in the medial-lateral direction. These findings suggest that the iBalance-ABF system as a telerehabilitation system could represent a suitable solution for ambient assisted living technologies.

Validity and reliability of the assessment and diagnosis of musculoskeletal elbow disorders using telerehabilitation

We examined the validity and reliability of a physiotherapy examination of the elbow, using telerehabilitation. The patho-anatomical diagnoses, systems diagnosis and physical examination findings of face-to-face physiotherapy examinations were compared with telerehabilitation examinations. Ten participants attended a single session, during which they were interviewed, a face-to-face physical examination was performed and a remote physical examination was conducted, guided by an examiner at a different location via a telerehabilitation system. Conventional face-to-face physiotherapy physical examination test results, diagnoses and systems diagnoses were compared to those produced by an examiner using the telerehabiliation system. There was substantial agreement for systems diagnosis (73%; P = 0.013) for validity and almost perfect agreement for intra-rater reliability (90%; P = 0.001). The inter-rater reliability had a weaker and non-significant agreement (64%; P = 0.11). Physical examination data demonstrated >68% agreement across all three datasets, between the examination methods. Performing a telerehabilitation physical examination to determine a musculoskeletal diagnosis of the elbow joint complex is both valid and reliable.

Tele-Wobble: A Telerehabilitation Wobble Board for Lower Extremity Therapy

Ankle deficiencies occur quite often among poststroke patients and people working in physically demanding professions in general. Computerized telerehabilitation systems have emerged as promising assistive tools for effective diagnosis and rehabilitation interventions. Consequently, the process of recording and analyzing the medical data captured by such systems has become vital for the generation of efficient reports that can assist clinicians to assess their patient's health. In this paper, we present our telerehabilitation system called “Tele-Wobble” that consists of a modified version of a wobble board mounted with sensors and actuators, a software training game, and a web-service architecture that allows for remote monitoring of the patient's training progress. The system aims to provide clinicians with key performance measurements captured during the patient's training session. Our evaluations showed that Tele-Wobble may offer an efficient and cost-effective home-based rehabilitation for patients with ankle deficiencies.

Evaluation of a telerehabilitation system for community-based rehabilitation.

The use of web-based portals, while increasing in popularity in the fields of medicine and research, are rarely reported on in community-based rehabilitation programs. A program within the Pennsylvania Office of Vocational Rehabilitation’s Hiram G. Andrews Center, the Cognitive Skills Enhancement Program (CSEP), sought to enhance organization of program and participant information and communication between part- and full-time employees, supervisors and consultants. A telerehabilitation system was developed consisting of (1) a web-based portal to support a variety of clinical activities, and (2) the Versatile Integrated System for Telerehabilitation (VISYTER) video-conferencing system to support the collaboration and delivery of rehabilitation services remotely. This descriptive evaluation examines the usability of the telerehabilitation system incorporating both the portal and VISYTER. Telerehabilitation system users include CSEP staff members from three geographical locations and employed by two institutions. The IBM After-Scenario Questionnaire (ASQ) and Post-Study System Usability Questionnaire (PSSUQ), the Telehealth Usability Questionnaire (TUQ), and two demographic surveys were administered to gather both objective and subjective information. Results showed generally high levels of usability. Users commented that the telerehabilitation system improved communication, increased access to information, improved speed of completing tasks, and had an appealing interface. Areas where users would like to see improvements, including ease of accessing/editing documents and searching for information, are discussed.

Editors' note: volume overview.

The current issue of the International Journal of Telerehabilitation (IJT) contains original research evaluating the efficacy of telerehabilitation; an evaluation of a telerehabilitation system for community based research; and work that examines users’ perceptions of the privacy and security of the three top used consumer-based, free Voice and video over the Internet Protocol (VoIP) software systems (e.g., Skype and others) used by health care providers to deliver therapeutic services via telerehabilitation. Two Brief Communications authored by speech-language pathologists present the possibilities for significant telehealth related cost-savings when telepractice is implemented in clinical practice. Finally, this issue presents a report generated by a working group within the American Telemedicine Association’s Telerehabilitation Special Interest Group, and announcements from the American Telemedicine Association and the International Society for Augmentative and Alternative Communication (ISAAC).

Validity of Conducting Clinical Dysphagia Assessments for Patients with Normal to Mild Cognitive Impairment via Telerehabilitation

To assess the validity of conducting clinical dysphagia assessments via telerehabilitation, 40 individuals with dysphagia from various etiologies were assessed simultaneously by a face-to-face speech-language pathologist (FTF-SLP) and a telerehabilitation SLP (T-SLP) via an Internet-based videoconferencing telerehabilitation system. Dysphagia status was assessed using a Clinical Swallowing Examination (CSE) protocol, delivered via a specialized telerehabilitation videoconferencing system and involving the use of an assistant at the patient's end of the consultation to facilitate the assessment. Levels of agreement between the FTF-SLP and T-SLP revealed that the majority of parameters reached set levels of clinically acceptable levels of agreement. Specifically, agreement between the T-SLP and FTF-SLP ratings for the oral, oromotor, and laryngeal function tasks revealed levels of exact agreement ranging from 75 to 100% (kappa=0.36-1.0), while the parameters relating to food and fluid trials ranged in exact agreement from 79 to 100% (kappa=0.61-1.0). Across the parameters related to aspiration risk and clinical management, exact agreement ranged between 79 and 100% (kappa=0.49-1.0). The data show that a CSE conducted via telerehabilitation can provide valid and reliable outcomes comparable to clinical decisions made in the FTF environment.

Shared virtual environments for telerehabilitation.

Current VR telerehabilitation systems use offline remote monitoring from the clinic and patient-therapist videoconferencing. Such "store and forward" and video-based systems cannot implement medical services involving patient therapist direct interaction. Real-time telerehabilitation applications (including remote therapy) can be developed using a shared Virtual Environment (VE) architecture. We developed a two-user shared VE for hand telerehabilitation. Each site has a telerehabilitation workstation with a videocamera and a Rutgers Master II (RMII) force feedback glove. Each user can control a virtual hand and interact hapticly with virtual objects. Simulated physical interactions between therapist and patient are implemented using hand force feedback. The therapist's graphic interface contains several virtual panels, which allow control over the rehabilitation process. These controls start a videoconferencing session, collect patient data, or apply therapy. Several experimental telerehabilitation scenarios were successfully tested on a LAN. A Web-based approach to "real-time" patient telemonitoring--the monitoring portal for hand telerehabilitation--was also developed. The therapist interface is implemented as a Java3D applet that monitors patient hand movement. The monitoring portal gives real-time performance on off-the-shelf desktop workstations.

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.

Design and development of a telerehabilitation self-management program for persons with chronic lower limb swelling and mobility limitations: preliminary evidence.

This paper describes design and development of a self-management program, delivered by telerehabilitation (TR), to address the problem of chronic lower limb swelling in persons with limited mobility. The 18.6 million persons with limited mobility in the USA are at increased risk for chronic lower limb swelling and related secondary complications, including cellulitis and skin ulcers. Over time, chronic swelling often progresses to lymphedema, an incurable condition requiring lifelong care. Without successful self-management, lymphedema and its related complications inevitably worsen. Access and adherence to appropriate treatment are challenging for persons with limited mobility. Program development involved a structured process to establish content validity (videos and manuals), readability, suitability, and selection of a TR platform to deliver the educational program. Our goal was to develop a program that would engage patients in self-management skills. The TR software platform chosen, Versatile and Integrated System for Telerehabilitation (VISYTER) was designed to facilitate face-to-face delivery of an interactive home-based self-management program via the internet in real time. Results demonstrated validity of the educational program and ease of use with TR. Future plans are to evaluate ability of this approach to promote self-management skills, home monitoring, and improved management of persons with lymphedema and limited mobility.

The VISYTER Telerehabilitation System for Globalizing Physical Therapy Consultation: Issues and Challenges for Telehealth Implementation

Background and Purpose. There are substantive issues to address in physical therapist education programs facing obstacles related to faculty funding for educational endeavors, identification of optimal pedagogies, and consideration of global and national health concerns. Educational technologies may serve as tools to expand the delivery of high-quality, efficient health care education to address current, evolving, and future needs of physical therapist students and the patients they will serve. The purpose of this case report is to describe the Versatile and Integrated System for Telerehabilitation (VISYTER) and its use for physical therapy telehealth consultation in an international setting, as well as its use to measure patient satisfaction and explore provider perspectives on the experience. Case Description. Three pediatric patients, 1 male and 2 females, with a mean age of 5 years (SD=3), and located in Mexico, participated in a telehealth session with academic and clinical faculty in the United States using the VISYTER telerehabilitation system. A patient satisfaction survey and user perspectives were collected and analyzed. Key themes were identified from semi-structured interviews with patients, family members, and health care providers. Outcomes. Patient satisfaction was high for utilizing the VISYTER telerehabilitation system. A key theme was that technology-assisted collaboration between the health care team members and patients may further education, research, and practice in Mexico and the United States. Discussion and Conclusion. Several challenges must be addressed when considering telehealth implementation internationally. Overall, the VISYTER telerehabilitation software, using lowbandwidth Internet connections (384 kbps) and aggressive compression with low resolution (320 x 240), allowed for a stable telehealth physical therapy consultation between Mexico to the United States.

A Fully Immersive Set-Up for Remote Interaction and Neurorehabilitation Based on Virtual Body Ownership

Although telerehabilitation systems represent one of the most technologically appealing clinical solutions for the immediate future, they still present limitations that prevent their standardization. Here we propose an integrated approach that includes three key and novel factors: (a) fully immersive virtual environments, including virtual body representation and ownership; (b) multimodal interaction with remote people and virtual objects including haptic interaction; and (c) a physical representation of the patient at the hospital through embodiment agents (e.g., as a physical robot). The importance of secure and rapid communication between the nodes is also stressed and an example implemented solution is described. Finally, we discuss the proposed approach with reference to the existing literature and systems.