- Telerehabilitation
Telerehabilitation is the delivery of rehabilitation services over
telecommunication network s and the internet. Most types of services fall into two categories:clinical assessment (the patient’s functional abilities in his or her environment), andclinical therapy . Some fields of rehabilitation practice that have explored telerehabilitation are:neuropsychology ,speech-language pathology ,audiology ,occupational therapy , andphysical therapy . Telerehabilitation can deliver therapy to people who cannot travel to aclinic because the patient has adisability or because of travel time.Most telerehabilitation is very visual. The most widely used modalities, as of 2006, are
webcam s, tele-videoconferencing overphone line s,videophone s 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 forneuropsychological rehabilitation ; fitting of rehabilitation equipment such aswheelchair s, braces orartificial limb s; and in speech-language pathology.Rich internet applications for neuropsychological rehabilitation (akacognitive rehabilitation ) of cognitive impairment (from many etiologies) was first introduced in 2001. This endeavor has recently (2006) expanded as ateletherapy 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) [http://www.ed.gov/about/offices/list/osers/nidrr/index.html?src=mr] supports research and the development of methods, systems, and technologies that support telerehabilitation. NIDRR's grantees include the "Rehabilitation Engineering and Research Center" (RERC) at theUniversity 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 thattele-assessment s andtele-therapy are equivalent to clinical encounters, it is more likely thatinsurer s and Medicare will cover telerehabilitation services.History of telerehabilitation
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 oftelecommunications , theinternet andtelemedicine since the 1950s. The Department of Defense (DoD) and theNational Aeronautics and Space Administration (NASA) spearheaded the technology in theUnited States during theVietnam War and thespace program ; both agencies continue to fund advances intelemedicine .Three early adopters of telemedicine were
state penitentiary system s,rural health care system s, and theradiology profession. Telemedicine makes business sense for the states because they do not have to pay for security escorts to have aprison er 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 theDepartment of Commerce . Some stateuniversities have obtained state funding to operatetele-clinic s 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 stateMedicaid programs (for poor people and people with disabilities) have pilot programs using telecommunications to connect rural practitioners with subspecialty therapists. A fewschool district s inOklahoma andHawaii offer school-based rehabilitation therapy using therapy assistants who are directed by a remote therapist. TheNational Rehabilitation Hospital inWashington DC andSister Kenny Rehabilitation Institute inMinneapolis provided assessment and evaluations to patients living inGuam andAmerican 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 theEast Carolina University inNorth Carolina . TheState 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. The conference was attended by the incoming president of theAmerican 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 RERC on telerehabilitation in 2004, awarding it to theUniversity of Pittsburgh .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 afterhip-replacement surgery or people witharthritis ) can get the rehabilitative therapy they need. It is unethical to limit paymente 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.
Telerehabilitation technologies
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Plain old telephone service (POTS ) withvideophone s/Phones in telerehabilitation
#:There are several types of connections used with real time exchanges. Plain old telephone service (POTS) uses standard analogtelephone line s.Videophone s are used with POTS lines and include acamera ,display screen , andtelephone . Because they use telephone lines available in most homes, they are the easiest to set up and vary in cost from $500- $3000. After the initial cost of equipment, there may be long distance charges. Videophones have a display screen of 3.5 to 4.5 inches that might make it difficult for individuals with vision problems. Set-top videophones use a television as a display screen and range in cost from $300- $500. Using atelevision will make the display screen as big as themonitor . Resolution is better than videophones, but it is more difficult to connect and not all televisions have the necessary connectors.
#Video-conferencing /Video-conferencing in telerehabilitation
#Virtual reality /Virtual reality in telerehabilitation
#:Virtual reality in telerehabilitation is one of the newest tools available in that area. The computer technology that allows us to develop three-dimensional virtual environments consists of bothhardware andsoftware . The current popular, technical, and scientific interest in virtual environments is inspired, in large part, by the advent and availability of increasingly powerful and affordable visually oriented, interactive, graphical display systems and techniques.
#Motion technology /Motion technology in telerehabilitation
#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.
#Sensors and body monitoring /Sensors and body monitoring in telerehabilitation
#Haptic technology /Haptic technology in telerehabilitation
#Artificial intelligence /Artificial intelligence in telerehabilitation
#Wireless technology /Wireless technology in telerehabilitation
#PDA/PDA in telerehabilitation
#Cellular technologies /Cellular technologies in telerehabilitation
#Electronic case records /Electronic case records in telerehabilitation Clinical applications of telerehabilitation technology
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Review of telerehabilitation research on clinical populations
#Professional to professional (clinic to clinic applications)
#Telehealth –Information access
#Clinical approaches
##Assessment
##Monitoring
##Intervention
##Telesupervision (of licensed assistants)
##Telementoring
##Tele-education
##Telementoring 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, andswallowing dysfunction . The technology involved in these applications has ranged from the simple telephone (Plain Old Telephone System – POTS) to the use of dedicated Internet-basedvideoconferencing 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 aclosed-circuit television system to assess speech and language disorders (Wertz e tal, 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 dedicatedsoftware which enable the assessment of language disorders (Georgeadis, Brennan, Barker, & Baron, 2004, Brennan, Georgeadis, Baron & Barker, 2004) and the assessment and treatment of motor speech disorders (Hill, Theodoros, Russell, Cahill, Ward, Clark, 2006; Theodoros, Constantinescu, Russell, Ward, Wilson & Wootton, in press) followingbrain impairment andParkinson’s disease . 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 withoffline 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 forsingle-word articulation ,speech intelligibility , andoro-motor task s 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 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.
Disciplines and therapies
##
Speech-language pathology
##Audiology
##Physical therapy
##Occupational therapy
##Psychology
##Nursing
##Social work
##Rehabilitation counseling /Vocational rehabilitation tandards and training requirements
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Telerehabilitation standards
#Reimbursement policies/Reimbursement in telerehabilitation
#Legislative activities/Legislative activities in telerehabilitation
#Ethics andprivacy issues /Ethics and privacy issues in telerehabilitation
#Clinical and technology training issuesResearch
Related organizations
*
American Telemedicine Association (ATA)
*American Speech-Language-Hearing Association (ASHA)
*Association of Telehealth Service Providers (ATSP)
*National Institute on Disability and Rehabilitation Research (NIDRR)
*Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)
*Special Interest Group on Telerehabilitation (SIGOT)See also
*
Telehealth
*Telemedicine
*Rehabilitation (neuropsychology)
*Rehabilitation Engineering and Research Center s (RERC)References
*Brennan, D.M., Georgeadis, A.C., Baron, C.R., & Barker, L.M. (2004). The effect of videoconferencing-based telerehabilitation on story retelling performance by brain-injured subjects and its implications for remote speech-language therapy. Telemedicine Journal and e-Health, 10, 147-154.
*Duffy, J.R., Werven, G.W., & Aronson, A.E. (1997). Telemedicine and the diagnosis of speech and language disorders. Mayo Clinic Proceedings, 72, 1116-1122.
*Georgeadis, A.C., Brennan, D.M., Barker, L.M., & Baron, C.R. (2004). Telerehabilitation and its effect on story retelling by adults with neurogenic impairments. Aphasiology, 18, 639-652.
*Harrison, E., Wilson, L., & Onsow, M. (1999). Distance intervention for early stuttering with the Lidcombe program. Advances in Speech Language Pathology, 1, 31-36.
*Hill, A.J., Theodoros, D.G., Russell, T.G., Cahill, L.M., Ward, E.C., & Clark, K (2006). An Internet-based telerehabilitation system for the assessment of motor speech disorders: A pilot study. American Journal of Speech Language Pathology, 15 1-12.
*Kully, D. (2000). Telehealth in speech pathology: Applications in the treatment of stuttering. Journal of Telemedicine and Telecare, 6 (Suppl 2), S39-41.
*Lalor, E., Brown, M., & Cranfield, E. (2000). Telemedicine: Its role in speech and language management for rural and remote patients. Australian Communication Quarterly: Issues in Language, Speech and Hearing, 2, 54-55.
*Mashima, P.A., Birkmire-Peters, D.P., Syms, M.J., Holtel, M.R., Burgess, L.P.A., & Peters, L.J. (2003). Telehealth: Voice therapy using telecommunications technology. American Journal of Speech-Language Pathology, 12, 432-439.
*Perlman, A.L. & Witthawaskul, W. (2002). Real-time remote telefluoroscopic assessment of patients with dysphagia. Dysphagia, 17, 162-167.
*Sicotte, C., Lehoux, P., Fortier-Blanc, J., & Leblanc, Y. (2003). Feasibility and outcome evaluation of a telemedicine application in speech: language pathology. Journal of Telemedicine and Telecare, 9, 253-258.
*Theodoros, D.G., Constantinescu, G., Russell, T., Ward, E., Wilson, S. & Wootton, R. (In press). Treating the speech disorder in Parkinson’s disease online. Journal of Telemedicine and Telecare.
*Vaughn, G.R. (1976). Tel-communicology: Health care delivery system for persons wit communicative disorders. ASHA, 18, 13-17.
*Waite, M., Cahill, L., Theodoros, D., Russell, T., & Busuttin, S. (In press). Online assessment of childhood speech disorders. Journal of Telemedicine and Telecare.
*Wertz,R.T., Dronkers, N.F., Berstein-Ellis, E., Shubitowski, Y., Elman, R., Shenaut, G.K., & Knight, R.T. (1987). Appraisal and diagnosis of neurogenic communication disorders in remote settings. Clinical Aphasiology, 17, 117-123.
*Wilson, L., Onslow, M., & Lincoln, M. (2004). Telehealth adaptation of the Lidcombe program of early stuttering intervention: Five case studies. American Journal of Speech-Language Pathology, 13, 81-93.External links
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