Telerehabilitation Research Articles

Exercise Telemonitoring and Telerehabilitation Compared with Traditional Cardiac and Pulmonary Rehabilitation: A Systematic Review and Meta-Analysis.

Background: Despite exercise capacity and quality-of-life benefits, pulmonary rehabilitation (PR) and cardiac rehabilitation (CR) programmes are not easily accessed because of several barriers. A solution may be telerehabilitation (TR), in which patients exercise in their communities while they are monitored via teletechnology. However, the benefits of TR for the purposes of PR and CR have not been systematically reviewed. Objective: To determine whether the benefits of the exercise component of PR and CR using TR are comparable to usual-care (UC) programmes. Methods: A comprehensive literature search was performed of the Medline, Embase, and CINAHL databases up to July 13, 2015. Meta-analyses were performed for peak oxygen consumption, peak workload, exercise test duration, and 6-minute walk test (6MWT) distance using the I2 statistic and forest plots displaying standardized mean difference (SMD). Results: Of 1,431 citations found, 8 CR studies met the inclusion criteria. No differences were found in exercise outcomes between UC and TR groups for CR studies, except in exercise test duration, which slightly favoured UC (SMD 0.268, 95% CI: 0.002, 0.534, p<0.05). Only 1 PR study was included, and it showed similar improvements on the 6MWT between the UC and TR groups. Conclusion: TR for patients with cardiac conditions provided benefits similar to UC with no adverse effects reported. Similar studies of TR for patients with pulmonary conditions need to be conducted.

Scoping review of outcome measures used in telerehabilitation and virtual reality for post-stroke rehabilitation

Introduction Despite the increased interest in telerehabilitation (TR), virtual reality (VR) and outcome measures for stroke rehabilitation, surprisingly little research has been done to map and identify the most common outcome measures used in TR. For this review, we conducted a systematic search of the literature that reports outcome measures used in TR or VR for stroke rehabilitation. Our specific objectives included: 1) to identify the outcome measures used in TR and VR studies; and 2) to describe which parts of the International Classification of Functioning are measured in the studies. Methods We conducted a comprehensive search of relevant electronic databases (e.g. PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, PSYCOINFO, The Cochrane Central Register of Controlled Trial and the Physiotherapy Evidence Database). The scoping review included all study designs. Two reviewers conducted pilot testing of the data extraction forms and independently screened all the studies and extracted the data. Disagreements about inclusion or exclusion were resolved by consensus or by consulting a third reviewer. Results In total, 28 studies were included in this scoping review. The results were synthesized and reported considering the implications of the findings within the clinical practice and policy context. Discussion This scoping review identified a wide range of outcome measures used in VR and TR studies and helped identify gaps in current use of outcome measures in the literature. The review also informs researchers and end users (i.e. clinicians, policymakers and researchers) regarding the most appropriate outcome measures for TR or VR.

Telerehabilitation after total knee replacement in Italy: cost-effectiveness and cost-utility analysis of a mixed telerehabilitation-standard rehabilitation programme compared with usual care

ObjectivesTo assess cost-effectiveness and cost utility of telerehabilitation (TR) versus standard rehabilitation (SR) after total knee replacement (TKR).DesignMarkov decision modelling of cost-effectiveness and cost-utility analysis based on patient-level and secondary...

HRV Analysis to Identify Stages of Home-based Telerehabilitation Exercise.

Spectral analysis of heart rate variability (HRV) has been widely used to investigate activity of autonomous nervous system. Previous studies demonstrated potential of analysis of short-term sequences of heart rate data in a time domain for continuous monitoring of levels of physiological stress however the value of HRV parameters in frequency domain for monitoring cycling exercise has not been established. The goal of this study was to assess whether HRV parameters in frequency domain differ depending on a stage of cycling exercise. We compared major HRV parameters in high, low and very low frequency ranges during rest, height of exercise, and recovery during cycling exercise. Our results indicated responsiveness of frequency-domain indices to different phases of cycling exercise program and their potential in monitoring autonomic balance and stress levels as a part of a tailored home-based telerehabilitation program.

Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review

Purpose The purpose of this review is to systematically explore and summarise the validity and reliability of telerehabilitation (TR)-based physiotherapy assessment for musculoskeletal disorders. Method A comprehensive systematic literature review was conducted using a number of electronic databases: PubMed, EMBASE, PsycINFO, Cochrane Library and CINAHL, published between January 2000 and May 2015. The studies examined the validity, inter- and intra-rater reliabilities of TR-based physiotherapy assessment for musculoskeletal conditions were included. Two independent reviewers used the Quality Appraisal Tool for studies of diagnostic Reliability (QAREL) and the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool to assess the methodological quality of reliability and validity studies respectively. Results A total of 898 hits were achieved, of which 11 articles based on inclusion criteria were reviewed. Nine studies explored the concurrent validity, inter- and intra-rater reliabilities, while two studies examined only the concurrent validity. Reviewed studies were moderate to good in methodological quality. The physiotherapy assessments such as pain, swelling, range of motion, muscle strength, balance, gait and functional assessment demonstrated good concurrent validity. However, the reported concurrent validity of lumbar spine posture, special orthopaedic tests, neurodynamic tests and scar assessments ranged from low to moderate. Conclusion TR-based physiotherapy assessment was technically feasible with overall good concurrent validity and excellent reliability, except for lumbar spine posture, orthopaedic special tests, neurodynamic testa and scar assessment.

Telerehabilitation approach for patients with hand impairment.

Telerehabilitation is one of the newest branches of telemedicine which has been developed because patients need regular trainings outside the medical institution but still under specialist supervision. It helps maintain regularity of exercises and reduces costs. The professional and advanced systems for telerehabilitation are presented in papers, however, there is still lack of development of minor systems which provide therapeutic values and are more accessible to people. Therefore we focus on a solution for hand telerehabilitation of poststroke patients, based solely on a personal computer and camera. We focused on the manipulative hand (fingers, metacarpus, wrist) movements trainings for patients with cerebral palsy. The contact between patient and physiotherapist is provided by using web cameras and web service. Additionally, the camera can be used to monitor the effectiveness of performed exercises. Computer vision system keeps track of the patient's hand movement. The digital image processing is used to detect if the patient performs exercises correctly. We created web service and software application TeleReh that provides therapeutic values for the hand impaired people. The system created was evaluated by three physiotherapists, one doctor and a cerebral palsy patient. Our solution applies to all patients who have undergone basic rehabilitation in hospital and need to continue hand rehabilitation at home. The main advantages are: easy adaptation to the individual needs and abilities, monitoring the progress by using automatically generated reports after each training session. It is worth noticing that discussion between IT specialists, rehabilitants and patients was necessary to achieve good results.

Use of video communication technology in the light of everyday and/or tele rehabilitation

Use of video communication technology in the light of everyday and/or tele rehabilitation

Consumer Satisfaction with Telerehabilitation Service Provision of Alternative Computer Access and Augmentative and Alternative Communication.

Telerehabilitation (TR) services for assistive technology evaluation and training have the potential to reduce travel demands for consumers and assistive technology professionals while allowing evaluation in more familiar, salient environments for the consumer. Sixty-five consumers received TR services for augmentative and alternative communication or alternative computer access, and consumer satisfaction was compared with twenty-eight consumers who received exclusively in-person services. TR recipients rated their TR services at a median of 6 on a 6-point Likert scale TR satisfaction questionnaire, although individual responses did indicate room for improvement in the technology. Overall satisfaction with AT services was rated highly by both in-person (100% satisfaction) and TR (99% satisfaction) service recipients.

Telerehabilitation – is connecting with your patient still meaningful?

Telerehabilitation – is connecting with your patient still meaningful?

Cost analysis of in-home telerehabilitation for post-knee arthroplasty.

BackgroundRehabilitation provided through home visits is part of the continuum of care after discharge from hospital following total knee arthroplasty (TKA). As demands for rehabilitation at home are growing and becoming more difficult to meet, in-home telerehabilitation has been proposed as an alternate service delivery method. However, there is a need for robust data concerning both the effectiveness and the cost of dispensing in-home telerehabilitation.ObjectiveThe objective of this study was to document, analyze, and compare real costs of two service delivery methods: in-home telerehabilitation and conventional home visits.MethodsThe economic analysis was conducted as part of a multicenter randomized controlled trial (RCT) on telerehabilitation for TKA, and involved data from 197 patients, post-TKA. Twice a week for 8 weeks, participants received supervised physiotherapy via two delivery methods, depending on their study group allocation: in-home telerehabilitation (TELE) and home-visit rehabilitation (VISIT). Patients were recruited from eight hospitals in the province of Quebec, Canada. The TELE group intervention was delivered by videoconferencing over high-speed Internet. The VISIT group received the same intervention at home. Costs related to the delivery of the two services (TELE and VISIT) were calculated. Student’s t tests were used to compare costs per treatment between the two groups. To take distance into account, the two treatment groups were compared within distance strata using two-way analyses of variance (ANOVAs).ResultsThe mean cost of a single session was Can $93.08 for the VISIT group (SD $35.70) and $80.99 for the TELE group (SD $26.60). When comparing both groups, real total cost analysis showed a cost differential in favor of the TELE group (TELE minus VISIT: -$263, 95% CI -$382 to -$143). However, when the patient’s home was located less than 30 km round-trip from the health care center, the difference in costs between TELE and VISIT treatments was not significant (P=.25, .26, and .11 for the <10, 10-19, and 20-29 km strata, respectively). The cost of TELE treatments was lower than VISIT treatments when the distance was 30 km or more (30-49 km: $81<$103, P=.002; ≥50 km: $90<$152, P<.001).ConclusionsTo our knowledge, this is the first study of the actual costs of in-home telerehabilitation covering all subcosts of telerehabilitation and distance between the health care center and the patient’s home. The cost for a single session of in-home telerehabilitation compared to conventional home-visit rehabilitation was lower or about the same, depending on the distance between the patient’s home and health care center. Under the controlled conditions of an RCT, a favorable cost differential was observed when the patient was more than 30 km from the provider. Stakeholders and program planners can use these data to guide decisions regarding introducing telerehabilitation as a new service in their clinic.Trial RegistrationInternational Standard Registered Clinical Study Number (ISRCTN): 66285945; http://www.isrctn.com/ISRCTN66285945 (Archived by WebCite at http://www.webcitation.org/6WlT2nuX4).

Telerehabilitation: Policy Issues and Research Tools

A number of experts recognize the importance of public policy as a complementary framework for telehealth, telemedicine, and by association, telerehabilitation. The purpose of this paper is to report on the current state-of-the-science on telerehabilitation (TR) policy and research methodology and make recommendations about future research needs. We conducted an extensive search of the literature via search terms grouped into the main topics of telerehabilitation, policy, population of users, and policy specific issues such as cost and reimbursement.The availability of rigorous and valid evidence-based cost studies emerged as a major challenge to the field. Existing cost studies provide evidence that tele-homecare may be a promising application area for TR. Cost studies also indicate that tele-psychiatry is a promising telepractice area. Notably, the literature did not reference the International Classification on Functioning, Disability and Health (ICF).We concluded that outcome studies characterized by rigorous and comprehensive TR assessment and evaluation are required to generate confidence among providers, payers, clinicians, and end users. Study criteria must comprehensively assess consumer satisfaction and participation via medical, functional, and quality of life items such as assistive technology and environmental factors.

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.

Telerehabilitation in Aphasia Following a Stroke-DiaTrain

Telerehabilitation in Aphasia Following a Stroke-DiaTrain

Remote decision support for wheeled mobility and seating devices

Current wheelchair selection and evaluation processes are time-consuming, often requiring cumbersome review and re-review of frequently changing wheelchair products and manufacturers. Telerehabilitation (TR) is an emerging field that complements the current in-person assessment for selecting an appropriate wheeled mobility and seating device in underserved areas. One of TR’s core functions is remote wheelchair selection (RWS), which requires detailed information on wheelchair characteristics and specifications, policy knowledge, and patient medical conditions including mobility limitation. Stakeholders currently have limited means to access comprehensive, reliable, monitored, and up-to-date information relative to wheeled mobility and seating devices, including performance, coverage criteria, or research evidence as to their benefits and short-comings. Centers for Medicare and Medicaid Services (CMS) implemented significant changes to the Healthcare Common Procedures Coding System (HCPCS) for wheeled mobility devices (WMDs) that includes expansion from 4 to 64 unique codes to identify different types of physical mobility devices (PMDs). This 16-fold increase can make it difficult to fully understand where a given product falls within the new structure. In our work we review the current TR research, wheelchair coverage policy issues, and the modern remote wheelchair selection paradigm. We introduce a framework for a web-based decision support system for remote wheelchair selection. These outcomes improve the wheelchair selection and evaluation processes through the capabilities of remote investigation of in-person assessment process, appropriated wheelchair alternatives, advanced wheelchair query and selection, a reusable wheelchair information repository, and systematic wheelchair evaluation. We also discuss lessons learned from a focus group study regarding the user acceptance of RWS-Advisor and the future direction of research on remote wheelchair selection.

Virtual environment system for motor tele-rehabilitation.

The present cutting-edge communication technology applied to the rehabilitation may change the real possibility of providing therapeutic treatments to the patients at their home. In order to confirm this assertion a current study on motor telerehabilitation was undertaken. Through a virtual reality based system, and a complementary video conference apparatus, we supplied five post stroke patients with a motor rehabilitation therapy. The rehabilitation technique was based on the augmented feedback. Subjects underwent the telerehabilitation program for six weeks. Before and after the evaluated therapy, arm motor performance and the activities of daily living were evaluated by the means of clinical scales and measuring the affected arm velocity (end-effector). This pilot study suggested that telerehabilitation could promote the learning of arm motor abilities at distance from the health facilities. From an economic point of view, it could be proposed also as an opportune strategy for saving resources.

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.

Evidence of benefit from telerehabilitation in routine care: a systematic review

We systematically reviewed the evidence on the effectiveness of telerehabilitation (TR) applications. The review included reports on rehabilitation for any disability, other than mental health conditions, and drug or alcohol addiction. All forms of telecommunications technology for TR and all types of study design were considered. Study quality was assessed using an approach that considered both study performance and study design. Judgements were made on whether each TR application had been successful, whether reported outcomes were clinically significant, and whether further data were needed to establish the application as suitable for routine use. Sixty-one scientifically credible studies that reported patient outcomes or administrative changes were identified through computerized literature searches on five databases. Twelve clinical categories were covered by the studies. Those dealing with cardiac or neurological rehabilitation were the most numerous. Thirty-one of the studies (51%) were of high or good quality. Study results showed that 71% of the TR applications were successful, 18% were unsuccessful and for 11% the status was unclear. The reported outcomes for 51% of the applications appeared to be clinically significant. Poorer-quality studies tended to have worse outcomes than those from high- or good-quality studies. We judged that further study was required for 62% of the TR applications and desirable for 23%. TR shows promise in many fields, but compelling evidence of benefit and of impact on routine rehabilitation programmes is still limited. There is a need for more detailed, better-quality studies and for studies on the use of TR in routine care.

Interaction between COPD patients and healthcare professionals in a cross-sector tele-rehabilitation programme.

This paper explores how technology affects the interaction between chronic obstructive pulmonary disease (COPD) patients and healthcare professionals in a cross-sector tele-rehabilitation programme. The qualitative analysis has shown that a community of rehabilitation can be created despite the presence of long-distance technology. In the tele-rehabilitation programme, the interaction between the COPD patients at home and the healthcare professionals at the clinic has evolved with dialogue as the basis for mutual learning processes and new relationships. Managed properly, rehabilitation at a distance can be both effective and satisfying.

VOIP for Telerehabilitation: A Risk Analysis for Privacy, Security and HIPAA Compliance: Part II.

In a previous publication the authors developed a privacy and security checklist to evaluate Voice over Internet Protocol (VoIP) videoconferencing software used between patients and therapists to provide telerehabilitation (TR) therapy. In this paper, the privacy and security checklist that was previously developed is used to perform a risk analysis of the top ten VoIP videoconferencing software to determine if their policies provide answers to the privacy and security checklist. Sixty percent of the companies claimed they do not listen into video-therapy calls unless maintenance is needed. Only 50% of the companies assessed use some form of encryption, and some did not specify what type of encryption was used. Seventy percent of the companies assessed did not specify any form of auditing on their servers. Statistically significant differences across company websites were found for sharing information outside of the country (p=0.010), encryption (p=0.006), and security evaluation (p=0.005). Healthcare providers considering use of VoIP software for TR services may consider using this privacy and security checklist before deciding to incorporate a VoIP software system for TR. Other videoconferencing software that is specific for TR with strong encryption, good access controls, and hardware that meets privacy and security standards should be considered for use with TR.

Telemonitoring in Heart Failure Rehabilitation

Exercise training (ET) is now recommended as an important component of a comprehensive approach to patients with heart failure (HF). Despite the existence of proven benefits of ET, many HF patients remain physically inactive. Introducing telerehabilitation (TR) may eliminate most of the factors that result in the currently low number of patients undergoing outpatient-based rehabilitation programmes and thus increase the percentage of those who will undergo cardiac rehabilitation. Despite the fact that TR is highly applicable and effective, there are few papers dedicated to the study of TR in HF patients. Until recently, only a couple of home rehabilitation-monitoring models have been presented, from the simplest, i.e. heart rate monitoring and transtelephonic electrocardiographic monitoring, through to the more advanced tele-electocardiogram (tele-ECG) monitoring (via a remote device) and realtime electrocardiographic and voice transtelephonic monitoring. It seems the last two are the most useful and reliable. Based on published studies, TR in HF patients could be equally effective as and provide similar improvements in health-related quality of life to standard outpatient cardiac rehabilitation. In addition, adherence to cardiac rehabilitation seems to be better during TR. Due to disease-related limitations, TR seems to be a viable alternative for comprehensive cardiac rehabilitation in HF patients. Further studies are needed to confirm the utility of this type of rehabilitation in routine clinical practice, including its cost-effectiveness. Because of the diversity of technological systems, it is necessary to create a platform to ensure compatibility between the devices used in telemedicine.