Telerehabilitation.

Transcription

1 Telerehabilitation

2 HUMAN/MACHINE DESIGN LAB Stimulated Muscles = Power u F Brace = Trajectory guidance Brake = Control, stability x,v T Haptic interfaces for virtual product prototyping, smart knobs for cars u X IRC Activation Dynamics (2nd order) CE Force-Length Active Element X Rehabilitation engineering -Tele-rehabilitation -Stroke rehab -Driving simulators V X V CE Force-Velocity Fscale Passive Element PE Force-Length PE Force-Velocity Muscle mechanics Force Human assist machines -Compact power sources -Powered exoskeletons -Natural control Medical device design -Evaluation of surgical tools Smart orthotics + electrical stimulation for gait restoration

3 OUTLINE Overview of telerehabilitation Example 1: Tele-assessment Example 2: Home stroke trainer Conclusions and lessons learned

4 Overview of Telerehabilitation

5 Home Clinic TELE

6 Telehealth "Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration." HRSA Office for the Advancement of Telehealth

7 Telemedicine "Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status." American Telemedicine Association

8 Telerehabilitation "Telerehabilitation is the clinical application of consultative, preventative, diagnostic, and therapeutic services via two-way interactive telecommunication technology." American Association of Occupational Therapists Position Paper on Telerehabilitation

9 Why tele? Clients in rural locations Clients in urban locations, but have transportation challenges No car Poor public transportation Eliminates transportation time

10 Tele Locations Local clinic Patient + Local clinician Central clinic Expert clinician Home Patient + Caregiver Central clinic Expert clinician

11 Telerehabilitation Applications Consultation Home and activity monitoring Assessment Motor relearning (robot, biofeedback) Diagnosis and evaluation Education and training

12 Tele-consultations: A Success Story? Requires a 2-way video/audio link Only technical issue is bandwidth Most popular, and most successful form of telerehabilitation Cost, outcome benefits story remains uncertain

13 Telerehabilitation Flaws? Possibly adds cost Technology cost Extra prep time for provider May not eliminate face visits Technology growing pains Provider training Limited communications infrastructure Patient trust & familiarity Limited applications Unproven outcome benefits

14 Electrons Cannot Transmit Forces and Motions

15 Although rehab robots could migrate to the home

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17 Example project #1 Technical Feasibility of Teleassessment

18 Approach Standardized assessments essential Standard assessment instruments exist, and have long history of use Match technology to assessment rather than creating a new assessment to match the technology

19 Hypothesis Assessment instruments applied remotely are no different than assessment instruments applied locally Test hypothesis by implementing assessment locally and remotely on the same person, then look for differences in the results

20 Selection Criteria for Selection Instruments Published measurement tool Reliable and valid Used widely by physical therapists Supported by standardized instructions and scoring methods Likely to reveal strengths and weaknesses of tele approach

21 Assessment Instruments Range of Motion (ROM) Shoulder abduction, shoulder rotation, knee flexion Manual Muscle Test (MMT) Berg Balance Test Item 1: Sit-to-Stand Item 8: Forward Reach Timed Up and Go Test (TUG)

22 Approximations Clinic Home Room #1 Clinic Central Room clinic #2 Simulated Patient patient + Simulated Caregiver caregiver Expert clinician

23 Simulated impairments MMT: added weights Berg: stand on Dynadisk TUG: walk a balance beam

24 Technology Layout camera camera TV video out Video capture (USB-Live) Polycom ViewStation net network net Polycom ViewStation video out TV PC PC USB net net serial Interface dig dyna LOCAL (PT) REMOTE (P and CG)

25 Range of motion Knee flexion

26 Shoulder abduction Shoulder external rotation Televideo

27 ROM Tele Measuring Methods 1. Caregiver places & reads goniometer 2. Caregiver places goniometer, therapist reads by zooming camera 3. Photo snapped, therapist holds goniometer up to screen 4. Photo snapped, therapist uses virtual goniometer

28 Virtual Goniometer

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30 Manual Muscle Test Biceps, Quadriceps With and w/o digital dynamometer

31 Berg Forward Reach, TUG

32 Experiment Design 10 subjects + 10 caregivers 5 assessment instruments Trained PTs Co-located and remote testing

33 Key result No significant difference between any of the measurement methods

34 Discussion Communication bandwitdh High quality audio link essential, requirements for video not known ROM Caregivers could place goniometer Snapshot + virtual goniometer Need clear camera view MMT Dynamometer not needed, but still could aid Sit-Stand and TUG No difficulties for tele-implementation Forward reach Need zoom camera Measurement technology would help

35 Limitations Simulated patients Simulated caregivers Performance variation No inter-rater reliability

36 Conclusion Some assessment methods are suitable for tele implementation with modest technology. Proof of clinical efficacy requires a home study with real patients.

37 Example project #2 Telerehabilitation for Training Recovery of Hand Function Following Stroke

38 Background Post-stroke paralysis: dead cells + reduced excitability in surviving cells Chu et al., Stroke v.33, 2002 Learned nonuse, compensatory use of non-impaired muscles, hinders recovery Taub, 1980 Constraint induced movement therapy (CIMT) targets learned nonuse Taub et al., Arch Phys Med Rehab, 1993; Liepert, Taub, Stroke, 2000 Question: Is it forced use or forced learning? Animal studies show repetitive movement is not enough Plautz et al., Neurobiol Learn Mem, 2000

39 Strategy Provide patients with a movement task that requires learning. A task that requires concentration. A thinkbefore-move task.

40 Tracking task

41 Pilot study: finger tracking in the clinic Carey et al., Brain, 2002.

42 Lesion on left Pre Post

43 Home-based tracking Eliminate need for patients to travel to clinic Patients can track on own schedule Lower cost Primary science question: can tracking training be transferred to the home? Secondary science question: compare tracking training (learning) with movement training (no learning) Primary technology question: is home based tracking training feasible?

44 Track train system

45 Sensing Brace

46 1-Button Operation

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49 Simplify Setup with Instructions

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51 Pre-Trial Screens Calibration Trial prep

52 Trial Screens Tracking Feedback

53 Pause and Shutdown Screens Pausing Auto shutdown

54 Analysis Software

55 Task Variants Wave shapes Wave parameters Frequency Amplitude Duration 0.2, 0.4, 0.8 Hz 0-50%, 30-70%, %, 0-125% of active range 5, 10, 15, 20 sec Hand Position: Pronated, Mid, Supinated Joint: Finger, Wrist Hand: Ipsi, Contra Visual feedback: On, Off 100 combinations selected

56 Experiment Placed in homes of 24 subjects with stroke, 20 included in study results 2 to 305 miles from clinic Plus one at 1,057 mi 180 trials/day x 10 days = 1800 total trials (some took 14 days to complete) Periodic teleconferencing sessions Tracking group and Move (control) group

57 Pre-Post Evaluations Box and Block Jebsen Taylor Hand Function Finger Range of Motion Finger Tracking Performance fmri (cortical activation intensity and location)

58 Lesion on right

59 Key Results Tracking group improved in tracking accuracy and finger ROM Both groups improved on functional tests Both groups had cortical reorganization, but Tracking group showed more shift towards lesioned side Subjects could self-install system and don/doff sensors Conclusion: Tracking training at home is feasible and effective. Need to explore why Tracking and Move groups were similar

60 Next steps Longer treatment (4 weeks, 1 hr/day) Improved technology

61 Conclusions & Lessons Learned

62 Tele Technology High quality audio essential Video quality requirements open Clients have surprising tolerance for technology if motivated More technology = more training

63 Tele Applications Tele-consultation: a winner Self-administered home treatment with periodic tele-checkups: promising Interactions requiring touch: not yet, but rehab robots promising Cost and outcome benefits of telerehabilitation unknown which means research is only path to progress

64 Collaborators Teleassessment Lynda Savard Samantha Weinstein Stroke Rehab James Carey Samantha Weinstein Ela Bhatt Ashima Nagpal Project funded by the Sister Kenny Foundation, Minneapolis Project funded by NIDRR, H133G020145

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