Programme Summary

The Rehabilitation Engineering Research Center (RERC) on Telerehabilitation was established to probe the idea that distance need not be an impassable barrier between people with disabilities and those who have the rehab skills required to meet their needs. Telerehab is a new field that probes the possibilities multimedia communications and virtual reality technologies hold for extending rehab services to people for whom they are not available under the traditional, face-to-face service delivery model. The Telerehab RERC operates under a mandate from the National Institute on Disability and Rehabilitation Research (NIDRR) to carry out research and development and share their findings in the areas of Tele education, Tele monitoring, Tele therapy and Virtual Reality.

Summary of ICT Initiatives

The Telerehab RERC is in the Pacific to help put in place technologies that will function to bring services to people with disabilities who, otherwise, would not have access to them. Technology,is not necessarily the latest and most sophisticated, complex hardware, but appropriate technology that will be durable, economical, reliable and of real use to the people for whose benefit it is installed. In areas of the Pacific with more developed infrastructure, this technology might take the form of high-end, H-320 ISDN video conferencing for remote, specialist consultation. In areas with low bandwidth communications options, this technology might take the form of exchanged videotapes: tapes of individuals needing evaluation coming from the island area; instructional tapes being returned from the remote expert to the island area.

Examples of other low-bandwidth technologies would be the store-and-forward consultationsystem currently in use by Tripler Army Medical Center (TAMC): Pacific Island Health CareProject (PIHCP) or the CD aided prosthesis fitting and crafting instruction under development by PALM - Physicians Against Land Mines to be presented over the internet. Yet another example of an effective, low-bandwidth system would be the e-mail transmission of images of wounds made with a digital camera. One nurse in Guam uses such a system in her home care practice to consult with the attending physician and to acquire a visual record of patient healing.

Observations

Clinicians state side spoke with patients, their families and caregivers. Working as an inter disciplinary team, they examined such visual phenomena as hand oedema, gait and range of motion. Both adult and paediatric patients were seen. Because of the multi-point video connection, staff and patients in American Samoa were able to observe exercises and therapies recommended by the state side staff. They were then able to demonstrate on video that they had comprehended the exercises and were able to perform them. The medium for conferencing was broadband video conferencing, connecting American Samoa, National Rehabilitation Hospital(NRH) in Washington, DC and Sister Kenny Rehabilitation Services in Minneapolis, MN through the bridging capabilities of STAN, the State of Hawaii Telehealth Access Network.Communications speed were up to 384 kbps, virtually the quality one observes in television broadcast programming.

One patient was a 45-year-old man named Luis who had suffered a right CVA with correspondingleft side disability. Members of Luis' family were present for the teleclinic and were able to interact with the mainland team as well. The following narration of the consultation with Luis is provided to document how the clinicians adapted face-to-face exam techniques to work effectively in the virtual rehab environment broadband video conferencing provides.

• Assessment of voluntary movement - Assessment of voluntary movement proceeded as it would in a face-to-face consultation. The speed of transmission was more than adequate to determine that Luis was significantly impaired, with virtually no voluntary movement observed on the left side of his body.
• Assessment of sensation - Mark and Alan acted as the hands of the mainland clinicians.Dr. Brendan demonstrated an exam technique on Nurse Judie and then Alan on American Samoa repeated it with Luis.
• Locomotory Assessment - Luis was instructed to walk toward the camera. The transmission quality was good enough for clinicians to concur on the observation of a little Trendelenberg. Luis was asked to walk backwards. The experts were in conflict over whether swelling could be observed, the communications medium quality obviously being in question over this point. Pixelation was excessive, probably due to the speed with which Luis executed portions of this exercise.
• Cognitive Assessment - Luis was instructed to close eyes, stick out tongue and raise his right hand, then to show three fingers and touch his left ear. These commands needed to be interpreted by people at other end for Luis. Whether language, or transmission audio quality, or the patient's own processing abilities was the cause could not be determined.
• Subluxation - Dr. Brendan instructed Alan to feel for a gap in the left shoulder. He demonstrated how to check for this anomaly on Judie. Alan imitated the action on Luis and was confident that there was no gap.
• Left Neglect Assessment - Mainland clinicians debriefed Luis' family for signs of left neglect, signs of Luis forgetting about his left, bumping into things on the left, falls. The family was able to report “no” satisfying this portion of the evaluation.
• Assessment by family interview - With family present, clinicians were able to assess dysphagia, bowel and bladder control through direct inquiry.
• Recommendations - Weight bearing activities were prescribed and demonstrated. Dr.Brendan showed how to practice bearing weight by leaning into a table. He instructed the family to stretch out Luis' affected arm daily to maintain range of motion.
• Soliciting questions from family - The family had an opportunity to ask questions. They were unsure whether Luis could be taken swimming. That question was resolved for them with a hearty recommendation for swimming exercise from the mainland clinical staff.
• Perceptions of family, patients and staff - Mark and Alan shared their perspective that patients and family were “loving” this teleclinic interaction. They were delighted to be able to get second opinion and specialized treatment not available locally.

As far as adjustment to the technology was concerned, Mark reported that patients say it's“different” but are excited by it rather than doubtful and apprehensive. Alan and Mark commented that they have been learning a lot of therapies assisting on the Pago Pago side of the consultation and that what they learn carries over nicely into their day-to-day practice.Partners: National Rehabilitation Hospital (NRH) in Washington, DC and Sister Kenny Rehabilitation Services in Minneapolis, State of Hawaii Telehealth Access Network (STAN)

Source:RERC on Tele rehabilitation, National Rehabilitation Hospital site and Pacific Rim Initiative site.

For more information, contact:

Tim Bowman, MBA, Sister Kenny Institute (Admin, Project Lead)

612-863-5498

bowmant@allina.com

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