eHealthcare and eHealthcare and Rehabilitation:Rehabilitation:

What is the Evidence?What is the Evidence?

Sue Palsbo, PhD

Center for Health Policy, Research and Ethics

Need for TelerehabilitationNeed for Telerehabilitation

People with chronic or acute People with chronic or acute disabilitiesdisabilities Cognitive (impaired way-finding; Cognitive (impaired way-finding;

executive dysfunction)executive dysfunction) Physical (impaired mobility)Physical (impaired mobility)

Areas with shortages of therapistsAreas with shortages of therapists Transportation barriersTransportation barriers

Stance on TelerehabilitationStance on Telerehabilitation

Varies by payerVaries by payer Medicare Medicare MedicaidMedicaid Major insurersMajor insurers

Varies by professional associationVaries by professional association ASHAASHA APTAAPTA AOTAAOTA

What is Telerehabilitation?What is Telerehabilitation?

Assessment (client and Assessment (client and environmental status)environmental status)

Intervention (treatment, Intervention (treatment, management)management)

Consultation and peer support of Consultation and peer support of other cliniciansother clinicians

Patient education, supervisionPatient education, supervision

Examples - OTExamples - OT

Diagnosis and ConsultationDiagnosis and Consultation Home accessibility assessmentsHome accessibility assessments

Examples - PTExamples - PT

Wheelchair seating clinics Wheelchair seating clinics Minnesota Minnesota American Samoa American Samoa NYC (pressure pad mapping)NYC (pressure pad mapping)

Diagnosis & consultation Diagnosis & consultation (Washington DC (Washington DC American Samoa American Samoa and Guam)and Guam)

Pre-surgical exercise (Norway)Pre-surgical exercise (Norway)

Examples - SLPExamples - SLP

Speech therapySpeech therapy National Rehabilitation Hospital (stroke National Rehabilitation Hospital (stroke

rehab) rehab) Voice rehab (Hawaii Voice rehab (Hawaii military bases) military bases) Queensland, Australia (assessment)Queensland, Australia (assessment) Nova Scotia, Canada (swallowing)Nova Scotia, Canada (swallowing)

AudiologyAudiology Utah State; Mayo Clinic; Santa Rosa, CAUtah State; Mayo Clinic; Santa Rosa, CA

How Telepractice Is Being How Telepractice Is Being Used...Used...

Audiologists:Audiologists: Hearing screening Hearing screening Hearing aid programming and counseling Hearing aid programming and counseling Auditory brainstem response (ABR) Auditory brainstem response (ABR) Otoacoustic emissions (OAEs) Otoacoustic emissions (OAEs) Audiologic rehabilitation Audiologic rehabilitation

Speech-Language Pathologists:Speech-Language Pathologists: School-based service in remote/underserved areas School-based service in remote/underserved areas Voice, aphasia, or cognitive-communication treatment to Voice, aphasia, or cognitive-communication treatment to

satellite clinics from hospitals satellite clinics from hospitals Adjunct to home health visits Adjunct to home health visits Specialized services such as laryngectomy rehabilitation Specialized services such as laryngectomy rehabilitation

and augmentative and alternative communication and augmentative and alternative communication

Face-to-Face Interaction Face-to-Face Interaction ModelModel

Face-to-Face SLP treatment sessionsFace-to-Face SLP treatment sessions Verbal & visual communicationVerbal & visual communication Treatment WorkspaceTreatment Workspace – collaborative – collaborative

use of use of physicalphysical materials (e.g. materials (e.g. workbooks, flashcards, etc.)workbooks, flashcards, etc.)

ClientSLP Clinician

Verbal & VisualCommunication

TreatmentWorkspace

CS

RESPECT: RERESPECT: REmotemote SPE SPEech-ech-language andlanguage and C Cognitiveognitive

TTreatmentreatment

RESPECT: Client User RESPECT: Client User InterfaceInterface

Functional reading task with Functional reading task with video windowvideo window

Following directions task Following directions task (shared whiteboard) with (shared whiteboard) with video windowvideo window

The Peer-Reviewed EvidenceThe Peer-Reviewed Evidence

Proof-of-concept or equivalence trialsProof-of-concept or equivalence trials Consultation and peer therapist Consultation and peer therapist

supportsupport Patient assessment, not therapyPatient assessment, not therapy Care supplementation, not care Care supplementation, not care

substitutionsubstitution

Equivalence of Face-to-face and Equivalence of Face-to-face and Videoconference Administration of the ESS Videoconference Administration of the ESS

and Functional Reach for Post-Stroke and Functional Reach for Post-Stroke PatientsPatients

Sue Palsbo, PhDSue Palsbo, PhD National Rehabilitation Hospital / George Mason UniversityNational Rehabilitation Hospital / George Mason University

Stephen J. Dawson, PTStephen J. Dawson, PT INTEGRIS/Jim ThorpeINTEGRIS/Jim Thorpe

Lynda Savard, PTLynda Savard, PT Sister Kinney Rehabilitation InstituteSister Kinney Rehabilitation Institute

Marc Goldstein, EdDMarc Goldstein, EdD American Physical Therapy AssociationAmerican Physical Therapy Association

Why is it so hard?Why is it so hard?

(1) Be appropriate and relevant to people with stroke. (1) Be appropriate and relevant to people with stroke.

(2) Have known psychometric properties (validity and (2) Have known psychometric properties (validity and reliability) published in peer-reviewed literature. reliability) published in peer-reviewed literature.

(3) Wide use in research and clinical practice.(3) Wide use in research and clinical practice.

(4) Be visually based (that is, the therapist can (4) Be visually based (that is, the therapist can measure using televideo without touching the measure using televideo without touching the patient).patient).

(5) All measures can be completed within 30 minutes.(5) All measures can be completed within 30 minutes.

Design Issues for Measuring Design Issues for Measuring Equivalence Equivalence

Serial correlation biasSerial correlation bias Measure simultaneously, not seriallyMeasure simultaneously, not serially

Inter-rater reliabilityInter-rater reliability Use measurement tools with published Use measurement tools with published

reliability valuesreliability values TrainingTraining

Bias in administrationBias in administration Switch off the therapist conducting the Switch off the therapist conducting the

assessmentassessment

MeasuresMeasures

Functional reachFunctional reach European stroke scaleEuropean stroke scale

1.1. Level of consciousnessLevel of consciousness

2.2. ComprehensionComprehension

3.3. SpeechSpeech

4.4. Visual fieldVisual field

5.5. GazeGaze

6.6. Facial movementFacial movement

7.7. Arm – maintain position when outstretchedArm – maintain position when outstretched

Measures, con’t.Measures, con’t.

8.8. Arm – raisingArm – raising

9.9. Wrist extensionWrist extension

10.10. FingersFingers

11.11. Leg – maintain positionLeg – maintain position

12.12. Leg – flexLeg – flex

13.13. Dorsiflexion of footDorsiflexion of foot

14.14. GaitGait

ResultsResults Functional reach: Lin’s rho – 0.98Functional reach: Lin’s rho – 0.98

Percent agreement: Exact One-level

Comprehension 0.96 1.00

Gaze 0.96 0.96

Gait 0.95 1.00

Fingers 0.92 1.00

Level of Consciousness 0.92 1.00

Leg (maintain position) 0.92 0.92

Arm (raising) 0.84 0.96

Wrist extension 0.81 1.00

Speech 0.80 1.00

Leg (flex) 0.76 1.00

Facial movement. 0.75 1.00

Dorsiflexion of foot 0.72 1.00

Arm (maintain outstretched) 0.72 0.96

Visual field 0.72 0.72

ConclusionsConclusions

Evidence for eHealth and Rehabilitation assement Evidence for eHealth and Rehabilitation assement and management are skimpy – at the moment!and management are skimpy – at the moment!

Growing interest in post-stroke rehabilitationGrowing interest in post-stroke rehabilitation SLP is most conducive to e-therapy using SLP is most conducive to e-therapy using

televideo & things that can be digitized televideo & things that can be digitized (swallowing)(swallowing)

PT will have more limited visual therapy PT will have more limited visual therapy applications (but growing use with e-robotics)applications (but growing use with e-robotics)

Rapid growth in telerehabilitation e-therapy over Rapid growth in telerehabilitation e-therapy over next 5 yearsnext 5 years

FundingFunding

Robert Wood Johnson Foundation, Robert Wood Johnson Foundation, Methodologies Grant, #49143Methodologies Grant, #49143

US Department of Education, National US Department of Education, National Institute on Disability and Rehabilitation Institute on Disability and Rehabilitation Research (NIDRR), Rehabilitation Research (NIDRR), Rehabilitation Engineering and Research Center (RERC) Engineering and Research Center (RERC) on Telerehabilitation #H133E990007-00Con Telerehabilitation #H133E990007-00C