Telerehabilitation

Telerehabilitation (or e-rehabilitation[1][2]) is the delivery of rehabilitation services over telecommunication networks and the internet. Most types of services fall into two categories: clinical assessment (the patient's functional abilities in his or her environment), and clinical therapy. Some fields of rehabilitation practice that have explored telerehabilitation are: neuropsychology, speech-language pathology, audiology, occupational therapy, and physical therapy. Telerehabilitation can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time. Telerehabilitation also allows experts in rehabilitation to engage in a clinical consultation at a distance.

Most telerehabilitation is highly visual. As of 2006 the most commonly used modalities are via webcams, videoconferencing, phone lines, videophones and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. It is most widely used for neuropsychological rehabilitation; fitting of rehabilitation equipment such as wheelchairs, braces or artificial limbs; and in speech-language pathology. Rich internet applications for neuropsychological rehabilitation (aka cognitive rehabilitation) of cognitive impairment (from many etiologies) was first introduced in 2001. This endeavor has recently (2006) expanded as a teletherapy application for cognitive skills enhancement programs for school children. Tele-audiology (hearing assessments) is a growing application. As of 2006, telerehabilitation in the practice of occupational therapy and physical therapy are very limited, perhaps because these two disciplines are more "hands on".

Two important areas of telerehabilitation research are (1) demonstrating equivalence of assessment and therapy to in-person assessment and therapy, and (2) building new data collection systems to digitize information that a therapist can use in practice. Ground-breaking research in telehaptics (the sense of touch) and virtual reality may broaden the scope of telerehabilitation practice, in the future.

In the United States, the National Institute on Disability and Rehabilitation Research's (NIDRR)[3] supports research and the development of telerehabilitation. NIDRR's grantees include the "Rehabilitation Engineering and Research Center" (RERC) at the University of Pittsburgh, the Rehabilitation Institute of Chicago, the State University of New York at Buffalo, and the National Rehabilitation Hospital in Washington DC. Other federal funders of research are the Veterans Administration, the Health Services Research Administration in the US Department of Health and Human Services, and the Department of Defense. Outside the United States, excellent research is conducted in Australia and Europe.

As of 2006, only a few health insurers in the United States will reimburse for telerehabilitation services. If the research shows that tele-assessments and tele-therapy are equivalent to clinical encounters, it is more likely that insurers and Medicare will cover telerehabilitation services.

History

In 1999, D.M. Angaran published "Telemedicine and Telepharmacy: Current Status and Future Implications" in the American Journal of Health-System Pharmacy. He provided a comprehensive history of telecommunications, the internet and telemedicine since the 1950s. The Department of Defense (DoD) and the National Aeronautics and Space Administration (NASA) spearheaded the technology in the United States during the Vietnam War and the space program; both agencies continue to fund advances in telemedicine.

Three early adopters of telemedicine were state penitentiary systems, rural health care systems, and the radiology profession. Telemedicine makes business sense for the states because they do not have to pay for security escorts to have a prisoner receive care outside the prison.

Rural telemedicine in the United States is heavily subsidized through federal agency grants for telecommunications operations. Most of this funding comes through the Health Services Research Administration and the Department of Commerce. Some state universities have obtained state funding to operate tele-clinics in rural areas. As of 2006, few (if any) of these programs are known to financially break-even, mostly because the Medicare program for people over age 65 (the largest payer) is very restrictive about paying for telehealth.

In contrast, the Veterans Administration is relatively active in using telemedicine for people with disabilities. There are several programs that provide annual physical exams or monitoring and consultation for veterans with spinal cord injuries. Similarly, some state Medicaid programs (for poor people and people with disabilities) have pilot programs using telecommunications to connect rural practitioners with subspecialty therapists. A few school districts in Oklahoma and Hawaii offer school-based rehabilitation therapy using therapy assistants who are directed by a remote therapist. The National Rehabilitation Hospital in Washington DC and Sister Kenny Rehabilitation Institute in Minneapolis provided assessment and evaluations to patients living in Guam and American Samoa. Cases included post-stroke, post-polio, autism, and wheel-chair fitting.

An argument can be made that "telerehabilitation" began in 1998 when NIDRR funded the first RERC on tele-rehabilitation. It was awarded to a consortium of biomedical engineering departments at the National Rehabilitation Hospital and The Catholic University of America, both located in Washington, DC; the Sister Kenny Rehabilitation Institute in Minnesota; and the East Carolina University in North Carolina. Some of this early research work, and its motivation, is reviewed in Winters (2002). The State of Science Conference held in 2002 convened most of military and civilian clinicians, engineers, and government officials interested in using telecommunications as a modality for rehabilitation assessment and therapy; a summary is provided in Rosen, Winters & Lauderdale (2002). The conference was attended by the incoming president of the American Telemedicine Association (ATA). This led to an invitation by ATA to the conference attendees to form a special interest group on telerehabilitation. NIDRR funded the second 5-year RERC on telerehabilitation in 2004, awarding it to the University of Pittsburgh. This RERC was renewed in 2010.

In 2001, O. Bracy, a neuropsychologist, introduced the first web based, rich internet application, for the telerehabilitation presentation of cognitive rehabilitation therapy. This system first provides the subscriber clinician with an economical means of treating their own patients over the internet. Secondly, the system then provides, directly to the patient, the therapy prescription set up and controlled by the member clinician. All applications and response data are transported via the internet in real time. The patient can login to do their therapy from home, the library or anywhere they have access to an internet computer. In 2006, this system formed the basis of a new system designed as a cognitive skills enhancement program for school children. Individual children or whole classrooms can participate in this program over the internet.

In 2006, M.J. McCue and S.E. Palsbo published an article in the Journal of Telemedicine and Telecare that explored how telemedicine can become a profitable business for hospitals. They argue that telerehabilitation should be expanded so that people with disabilities and people in pain (perhaps after hip-replacement surgery or people with arthritis) can get the rehabilitative therapy they need. It is unethical to limit payments for telerehabilitation services only to patients in rural areas.

Research in telerehabilitation is in its infancy, with only a handful of equivalence trials. As of 2006, most peer-reviewed research in telemedicine are case reports of pilot programs or new equipment. Rehabilitation researchers need to conduct many more controlled experiments and present the evidence to clinicians (and payers) that telerehabilitation is clinically effective. The discipline of speech-language pathology is far head of occupational therapy and physical therapy in demonstrating equivalence over various types of telecommunications equipment.

Technologies
  1. Plain old telephone service (POTS) with videophones/phones in telerehabilitation
    There are several types of connections used with real time exchanges. Plain old telephone service (POTS) uses standard analog telephone lines. Videophones are used with POTS lines and include a camera, display screen, and telephone. Videophones use telephone lines that are available in most homes, so are easy to set up; however small display screens make them problematic for individuals with vision problems. This can be solved by using a large screen or television as a screen.
  2. Videotelephony/Videotelephony in telerehabilitation
    The use of improved quality video-assisted telecommunication devices, such as videoconferencing, webcams and telepresence to assist in treatments.
  3. Virtual reality/Virtual reality in telerehabilitation
    Virtual reality in telerehabilitation is one of the newest tools available in that area. This computer technology allows the development of three-dimensional virtual environments.
  4. Motion technology/Motion technology in telerehabilitation
  5. Web-based approaches/Web-based approaches in telerehabilitation
    Applications that run over the internet, just as if they were installed in your computer (called Rich Internet Applications), represent a new direction in software development. A person subscribes to the website rather than purchase the software. Any updates or changes to the software system are instantly available to all subscribers. The applications can be accessed from any location where one has access to an internet connected computer. Likewise, a patient's data is accessible from where ever the therapist is located. Neither the application nor the patient's data is tied to one computer.
  6. Sensors and body monitoring/Sensors and body monitoring in telerehabilitation
  7. Haptic technology/Haptic technology in telerehabilitation
  8. Artificial intelligence/Artificial intelligence in telerehabilitation
  9. Wireless technology/Wireless technology in telerehabilitation
  10. PDAs/PDA in telerehabilitation
  11. Mobile telephony/Mobile telephony in telerehabilitation
  12. Electronic medical records/Electronic medical record telerehabilitation
  13. Mobile apps/Mobile apps telerehabilitation

Clinical applications
  1. Review of telerehabilitation research on clinical populations
  2. Professional to professional (clinic to clinic applications)
  3. Telehealth – Information access
  4. Clinical approaches
    1. Assessment
    2. Monitoring
    3. Intervention
    4. Telesupervision (of licensed assistants)
    5. Telementoring
    6. Tele-education
    7. Telementoring

Speech-language pathology

The clinical services provided by speech-language pathology readily lend themselves to telerehabilitation applications due to the emphasis on auditory and visual communicative interaction between the client and the clinician. As a result, the number of telerehabilitation applications in speech-language pathology tend to outnumber those in other allied health professions. To date, applications have been developed to assess and/or treat acquired adult speech and language disorders, stuttering, voice disorders, speech disorders in children, and swallowing dysfunction. The technology involved in these applications has ranged from the simple telephone (Plain Old Telephone System – POTS) to the use of dedicated Internet-based videoconferencing systems.

Early applications to assess and treat acquired adult speech and language disorders involved the use of the telephone to treat patients with aphasia and motor speech disorders (Vaughan, 1976, Wertz, et al., 1987), a computer controlled video laserdisc over the telephone and a closed-circuit television system to assess speech and language disorders (Wertz et al., 1987), and a satellite-based videoconferencing system to assess patients in rural areas (Duffy, Werven & Aronson, 1997). More recent applications have involved the use of sophisticated Internet-based videoconferencing systems with dedicated software which enable the assessment of language disorders [4][5](Georgeadis, Brennan, Barker, & Baron, 2004, Brennan, Georgeadis, Baron & Barker, 2004), the treatment of language disorders [6][7][8][9][10][11][12][13][14][15][16] and the assessment and treatment of motor speech disorders[17][18][19] (Hill, Theodoros, Russell, Cahill, Ward, Clark, 2006; Theodoros, Constantinescu, Russell, Ward, Wilson & Wootton, in press) following brain impairment and Parkinson's disease.[20][21][22][23][24] Collectively, these studies have revealed positive treatment outcomes, while assessment and diagnoses have been found to be comparable to face-to-face evaluations.

The treatment of stuttering has been adapted to a telerehabilitation environment with notable success. Two Australian studies (Harrison, Wilson & Onslow, 1999; Wilson, Onslow & Lincoln, 2004) involving the distance delivery of the Lidcombe program to children who stutter have utilized the telephone in conjunction with offline video recordings to successfully treat several children. Overall, the parents and children responded positively to the program delivered at a distant. Using a high speed videoconferencing system link, Sicotte, Lehoux, Fortier-Blanc and Leblanc (2003) assessed and treated six children and adolescents with a positive reduction in the frequency of dysfluency that was maintained six months later. In addition, a videoconferencing platform has been used successfully to provide follow-up treatment to an adult who had previously received intensive therapy (Kully, 200).

Reports of telerehabilitation applications in paediatric speech and language disorders are sparse. A recent Australian pilot study has investigated the feasibility of an Internet-based assessment of speech disorder in six children (Waite, Cahill, Theodoros, Russell, Busuttin, in press). High levels of agreement between the online and face-to-face clinicians for single-word articulation, speech intelligibility, and oro-motor tasks were obtained suggesting that the Internet-based protocol had the potential to be a reliable method for assessing paediatric speech disorders.

Voice therapy across a variety of types of voice disorders has been shown to be effectively delivered via a telerehabilitation application. Mashima et al. (2003) using PC based videoconferencing and speech analysis software compared 23 patients treated online with 28 persons treated face-to-face. The authors reported positive post treatment results with no significant difference in measures between the traditional and videoconferencing group, suggesting that the majority of traditional voice therapy techniques can be applied to distance treatment.

Although obvious limitations exist, telerehabilitation applications for the assessment of swallowing function have also been used with success. Lalor, Brown and Cranfield (2000) were able to obtain an initial assessment of the nature and extent of swallowing dysfunction in an adult via a videoconferencing link although a more complete evaluation was restricted due to the inability to physically determine the degree of laryngeal movement. A more sophisticated telerehabilitation application for the assessment of swallowing was developed by Perlman and Witthawaskul (2002) who described the use of real-time videofluoroscopic examination via the Internet. This system enabled the capture and display of images in real-time with only a three to five second delay.There has been considerable research into the assessment and treatment of dysphagia via telerehabilitation, including cost analyses, leading to the establishment of sustainable telerehabilitation services.[25][26][27][28][29][30][31][32][33][34][35][36][37][38]

There continues to be a need for ongoing research to develop and validate the use of telerehabilitation applications in speech-language pathology in a greater number and variety of adult and paediatric communication and swallowing disorders.

Physical and occupational therapy

Disciplines and therapies
    1. Speech-language pathology
    2. Audiology
    3. Physical therapy
    4. Occupational therapy
    5. Psychology
    6. Nursing
    7. Social work
    8. Rehabilitation counseling/Vocational rehabilitation

Standards and training requirements
  1. Telerehabilitation standards
  2. Reimbursement policies/Reimbursement in telerehabilitation
  3. Legislative activities/Legislative activities in telerehabilitation
  4. Ethics and privacy issues/Ethics and privacy issues in telerehabilitation
  5. Clinical and technology training issues

See also

References
  1. E-health care information systems: an introduction for students and professionals, John Wiley and Sons, 2005, p. 219, ISBN 978-0-7879-6618-8
  2. Lisa Keaton; Linda L. Pierce; Victoria Steiner; Karen Lance (October 2004). "An E-rehabilitation Team Helps Caregivers Deal with Stroke". The Internet Journal of Allied Health Sciences and Practice. Ijahsp.nova.edu. 2 (4). ISSN 1540-580X. Retrieved 2011-03-26.
  3. National Institute on Disability and Rehabilitation Research Archived 2003-10-11 at the Wayback Machine
  4. Hill, Anne J.; Theodoros, Deborah G.; Russell, Trevor G.; Ward, Elizabeth C.; Wootton, Richard (2009). "The effects of aphasia severity on the ability to assess language disorders via telerehabilitation". Aphasiology. 23 (5): 627–642. doi:10.1080/02687030801909659.
  5. Theodoros, Deborah; Hill, Anne; Russell, Trevor; Ward, Elizabeth; Wootton, Richard (August 2008). "Assessing Acquired Language Disorders in Adults via the Internet". Telemedicine and E-Health. 14 (6): 552–559. doi:10.1089/tmj.2007.0091. PMID 18729754.
  6. Nichol, Leana; Hill, Annie J.; Wallace, Sarah J.; Pitt, Rachelle; Baker, Caroline; Rodriguez, Amy D. (23 February 2019). "Self-management of aphasia: a scoping review". Aphasiology. 33 (8): 903–942. doi:10.1080/02687038.2019.1575065.
  7. Pitt, Rachelle; Theodoros, Deborah; Hill, Anne J.; Russell, Trevor (10 September 2018). "The impact of the telerehabilitation group aphasia intervention and networking programme on communication, participation, and quality of life in people with aphasia". International Journal of Speech-Language Pathology: 1–11. doi:10.1080/17549507.2018.1488990. PMID 30200788.
  8. Pitt, Rachelle; Hill, Anne J.; Theodoros, Deborah; Russell, Trevor (8 June 2018). ""I definitely think it's a feasible and worthwhile option": perspectives of speech-language pathologists providing online aphasia group therapy". Aphasiology. 32 (9): 1031–1053. doi:10.1080/02687038.2018.1482403.
  9. Nichol, Leana; Hill, Annie J.; Wallace, Sarah J.; Pitt, Rachelle; Rodriguez, Amy D. (28 May 2018). "Exploring speech-language pathologists' perspectives of aphasia self-management: a qualitative study". Aphasiology. 32 (sup1): 159–161. doi:10.1080/02687038.2018.1470603.
  10. Clunne, Stephanie Jane; Ryan, Brooke Jade; Hill, Annie Jane; Brandenburg, Caitlin; Kneebone, Ian (4 December 2018). "Accessibility and Applicability of Currently Available e-Mental Health Programs for Depression for People With Poststroke Aphasia: Scoping Review". Journal of Medical Internet Research. 20 (12): e291. doi:10.2196/jmir.9864. PMID 30514696.
  11. Hill, Annie J; Breslin, Hugh M (16 June 2018). "Asynchronous telepractice in aphasia rehabilitation: outcomes from a pilot study". Aphasiology. 32 (sup1): 90–92. doi:10.1080/02687038.2018.1484877.
  12. Pitt, Rachelle; Theodoros, Deborah; Hill, Anne J.; Russell, Trevor (4 September 2017). "The development and feasibility of an online aphasia group intervention and networking program – TeleGAIN". International Journal of Speech-Language Pathology. 21 (1): 23–36. doi:10.1080/17549507.2017.1369567. PMID 28868932.
  13. Pitt, Rachelle; Theodoros, Deborah; Hill, Anne J; Rodriguez, Amy D; Russell, Trevor (2 July 2017). "The feasibility of delivering constraint-induced language therapy via the Internet". Digital Health. 3: 205520761771876. doi:10.1177/2055207617718767. PMC 6001182. PMID 29942607.
  14. Hill, Annie J.; Breslin, Hugh M. (20 December 2016). "Refining an Asynchronous Telerehabilitation Platform for Speech-Language Pathology: Engaging End-Users in the Process". Frontiers in Human Neuroscience. 10: 640. doi:10.3389/fnhum.2016.00640. PMC 5168427. PMID 28066211.
  15. Swales, Megan A.; Hill, Anne J; Finch, Emma (15 September 2015). "Feature rich, but user-friendly: Speech pathologists' preferences for computer-based aphasia therapy". International Journal of Speech-Language Pathology. 18 (4): 315–328. doi:10.3109/17549507.2015.1081283. PMID 27063672.
  16. Finch, Emma; Hill, Anne J. (18 September 2014). "Computer use by People with Aphasia: A Survey Investigation". Brain Impairment. 15 (2): 107–119. doi:10.1017/BrImp.2014.17.
  17. Hill, Anne J.; Theodoros, Deborah G.; Russell, Trevor G.; Ward, Elizabeth C. (November 2009). "The Redesign and Re-evaluation of an Internet-Based Telerehabilitation System for the Assessment of Dysarthria in Adults" (PDF). Telemedicine and E-Health. 15 (9): 840–850. doi:10.1089/tmj.2009.0015. PMID 19919190.
  18. Hill, Anne Jane; Theodoros, Deborah; Russell, Trevor; Ward, Elizabeth (January 2009). "Using telerehabilitation to assess apraxia of speech in adults". International Journal of Language & Communication Disorders. 44 (5): 731–747. doi:10.1080/13682820802350537. PMID 18821157.
  19. Hill, Anne J.; Theodoros, Deborah G.; Russell, Trevor G.; Cahill, Louise M.; Ward, Elizabeth C.; Clark, Kathy M. (February 2006). "An Internet-Based Telerehabilitation System for the Assessment of Motor Speech Disorders: A Pilot Study". American Journal of Speech-Language Pathology. 15 (1): 45–56. doi:10.1044/1058-0360(2006/006). PMID 16533092.
  20. Swales, Megan; Theodoros, Deborah; Hill, Anne J.; Russell, Trevor (29 November 2018). "Communication service provision and access for people with Parkinson's disease in Australia: A national survey of speech-language pathologists". International Journal of Speech-Language Pathology: 1–12. doi:10.1080/17549507.2018.1537372. PMID 30496696.
  21. Swales, Megan; Theodoros, Deborah; Hill, Anne J.; Russell, Trevor (15 August 2019). "Speech-language pathologists' perceptions of the use of telepractice in the delivery of services to people with Parkinson's disease: A national pilot survey". International Journal of Speech-Language Pathology: 1–12. doi:10.1080/17549507.2019.1650110. PMID 31416341.
  22. Theodoros, Deborah; Aldridge, Danielle; Hill, Anne J.; Russell, Trevor (March 2019). "Technology-enabled management of communication and swallowing disorders in Parkinson's disease: a systematic scoping review". International Journal of Language & Communication Disorders. 54 (2): 170–188. doi:10.1111/1460-6984.12400. PMID 29923267.
  23. Quinn, Rachel; Park, Stacie; Theodoros, Deborah; Hill, Anne J (7 June 2018). "Delivering group speech maintenance therapy via telerehabilitation to people with Parkinson's disease: A pilot study". International Journal of Speech-Language Pathology. 21 (4): 385–394. doi:10.1080/17549507.2018.1476918. PMID 29879854.
  24. Theodoros, Deborah G.; Hill, Anne J.; Russell, Trevor G. (May 2016). "Clinical and Quality of Life Outcomes of Speech Treatment for Parkinson's Disease Delivered to the Home Via Telerehabilitation: A Noninferiority Randomized Controlled Trial". American Journal of Speech-Language Pathology. 25 (2): 214–232. doi:10.1044/2015_AJSLP-15-0005. PMID 27145396.
  25. Wall, Laurelie R.; Kularatna, Sanjeewa; Ward, Elizabeth C.; Cartmill, Bena; Hill, Anne J.; Isenring, Elizabeth; Byrnes, Joshua; Porceddu, Sandro V. (4 December 2018). "Economic Analysis of a Three-Arm RCT Exploring the Delivery of Intensive, Prophylactic Swallowing Therapy to Patients with Head and Neck Cancer During (Chemo)Radiotherapy". Dysphagia. 34 (5): 627–639. doi:10.1007/s00455-018-9960-1. PMID 30515560.
  26. Burns, Clare L.; Kularatna, Sanjeewa; Ward, Elizabeth C.; Hill, Anne J.; Byrnes, Joshua; Kenny, Lizbeth M. (December 2017). "Cost analysis of a speech pathology synchronous telepractice service for patients with head and neck cancer". Head & Neck. 39 (12): 2470–2480. doi:10.1002/hed.24916. PMID 28963804.
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  29. Cartmill, Bena; Wall, Laurelie R.; Ward, Elizabeth C.; Hill, Anne J.; Porceddu, Sandro V. (15 December 2016). "Computer Literacy and Health Locus of Control as Determinants for Readiness and Acceptability of Telepractice in a Head and Neck Cancer Population". International Journal of Telerehabilitation. 8 (2): 49–60. doi:10.5195/ijt.2016.6203. PMID 28775801.
  30. Wall, Laurelie R.; Ward, Elizabeth C.; Cartmill, Bena; Hill, Anne J.; Porceddu, Sandro V. (14 November 2016). "Adherence to a Prophylactic Swallowing Therapy Program During (Chemo) Radiotherapy: Impact of Service-Delivery Model and Patient Factors". Dysphagia. 32 (2): 279–292. doi:10.1007/s00455-016-9757-z. PMID 27844152.
  31. Burns, Clare L.; Ward, Elizabeth C.; Hill, Anne J.; Phillips, Nick; Porter, Linda (15 March 2016). "Conducting Real-Time Videofluoroscopic Swallow Study via Telepractice: A Preliminary Feasibility and Reliability Study". Dysphagia. 31 (3): 473–483. doi:10.1007/s00455-016-9701-2. PMID 26979971.
  32. Wall, Laurelie R.; Cartmill, Bena; Ward, Elizabeth C.; Hill, Anne J.; Isenring, Elizabeth; Byrnes, Joshua; Chambers, Suzanne; Dunn, Jeff; Nixon, Jodie; Whelan, Jane; Porceddu, Sandro V. (March 2016). ""ScreenIT": Computerized screening of swallowing, nutrition and distress in head and neck cancer patients during (chemo)radiotherapy". Oral Oncology. 54: 47–53. doi:10.1016/j.oraloncology.2016.01.004. PMID 26803342.
  33. Wall, Laurelie R; Ward, Elizabeth C; Cartmill, Bena; Hill, Anne J; Porceddu, Sandro V (9 July 2016). "Examining user perceptions of : A pilot study of a new telepractice application for delivering intensive swallowing therapy to head and neck cancer patients". Journal of Telemedicine and Telecare. 23 (1): 53–59. doi:10.1177/1357633X15617887. PMID 26670210.
  34. Wall, Laurelie R.; Cartmill, Bena; Ward, Elizabeth C.; Hill, Anne J.; Isenring, Elizabeth; Porceddu, Sandro V. (25 August 2015). "Evaluation of a weekly speech pathology/dietetic service model for providing supportive care intervention to head and neck cancer patients and their carers during (chemo)radiotherapy". Supportive Care in Cancer. 24 (3): 1227–1234. doi:10.1007/s00520-015-2912-5. PMID 26304158.
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