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eHealthcare and Rehabilitation: What is the Evidence?. Sue Palsbo, PhD. Center for Health Policy, Research and Ethics. Need for Telerehabilitation. People with chronic or acute disabilities Cognitive (impaired way-finding; executive dysfunction) Physical (impaired mobility) - PowerPoint PPT Presentation
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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