The feasibility of delivering constraint-induced language therapy via the Internet

Objective

This study is designed to determine the feasibility of the provision of an evidenced-based aphasia therapy, constraint-induced language therapy, via telerehabilitation. It describes the computer software that was developed specifically for the delivery of constraint-induced language therapy in the online environment and presents two case studies.

Methods

Two participants with chronic aphasia were assessed before and after a two-week intensive treatment block of constraint-induced language therapy delivered via Web-based videoconferencing. The group-based, dual card request game utilized in face-to-face constraint-induced language therapy was transformed into an innovative and user-friendly Web-based game - Internet constraint-induced language therapy (iCILT). Participants accessed iCILT via the Internet from their own home every weekday for two weeks. Language and quality of life measures were administered pre- and post-therapy in order to detect treatment effects. Participant satisfaction information was also recorded.

Results

Online delivery of iCILT was technically feasible and participant satisfaction was high with a number of benefits associated with telerehabilitation identified by participants. Post-treatment performance for language functioning and communication-related quality of life was variable for each participant, however improvements in naming were noted.

Conclusions

Constraint-induced language therapy delivered via telerehabilitation may be a feasible alternative to traditional face-to-face therapy for people with chronic aphasia.

Developing quality indicators for the care of patients with musculoskeletal injuries in the Emergency Department: study protocol

BACKGROUND

Musculoskeletal injuries are a common presentation to the Emergency Department (ED). The quality of care provided is important to the patients, clinicians, organisations and purchasers of care. In the context of the increasing burden of musculoskeletal disease, quality of care needs to occur despite financial impacts, variations in care, and pressure to reach time-based performance measures. This study aims to develop a suite of evidence-based quality indicators (QI) which will provide a measure of the quality of care for patients with musculoskeletal injuries in the ED.

METHODS

This study will utilise a multi-phase mixed methods protocol, commencing with a systematic review of the literature to identify and critically appraise existing QIs for musculoskeletal injuries in the ED. The study will then build on the gaps identified in the review to develop a suite of preliminary QIs, in accordance with established research methodology under the governance of an expert panel. The developed QI set will then be field-tested for feasibility and validity in selected EDs. After field-testing, the suite will be refined in consultation with the expert panel and finalised using a formal voting process.

DISCUSSION

The assessment of performance against QIs provides a quantitative measure for the quality of care provided to patients, to identify and target quality improvement activities. The QIs developed through this study will be evidence-based and balanced across the areas of structures, processes and outcomes. The rigorous methodology used to develop and test the QIs will result in QIs that are meaningful, valid, feasible to collect and efficiently measurable, amenable to improvement, and selected by experts in the emergency medicine field. The final QI suite will have applications across EDs that affords comparison, benchmarking and optimisation of emergency care for patients.

Exploring patient experiences and perspectives of a heart failure telerehabilitation program: A mixed methods approach

OBJECTIVES

To describe patient experiences and perspectives of a group-based heart failure (HF) telerehabilitation program delivered to the homes via online video-conferencing.

BACKGROUND

Limited information currently exists on patient experiences of telerehabilitation for HF. Patient feedback and end-user perspectives provide important information regarding the acceptability of this new delivery model which may have a substantial impact on future uptake.

METHODS

We used mixed-methods design with purposive sampling of patients with HF. We used self-report surveys and semi-structured interviews to measure patient experiences and perspectives following a 12-week telerehabilitation program. The telerehabilitation program encompassed group-based exercise and education, and were delivered in real-time via videoconferencing. Interviews were transcribed and coded, with thematic analysis undertaken.

RESULTS

Seventeen participants with HF (mean age [SD] of 69 [12] years and 88% males) were recruited. Participants reported high visual clarity and ease of use for the monitoring equipment. Major themes included motivating and inhibiting influences related to telerehabilitation and improvement suggestions. Participants liked the health benefits, access to care and social support. Participants highlighted a need for improved audio clarity and connectivity as well computer training for those with limited computer experience. The majority of participants preferred a combined face-to-face and online delivery model.

CONCLUSION

Participants in this study reported high visual clarity and ease-of-use, but provided suggestions for further improvements in group-based video telerehabilitation for HF.

Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial

QUESTION

Is a 12-week, home-based telerehabilitation program conducted in small groups non-inferior to a traditional centre-based program in terms of the change in 6-minute walk distance? Is the telerehabilitation program also non-inferior to a centre-based program in terms of functional capacity, muscle strength, quality of life, urinary incontinence, patient satisfaction, attendance rates, and adverse events?

DESIGN

Randomised, parallel, non-inferiority trial with concealed allocation, intention-to-treat analysis and assessor blinding.

PARTICIPANTS

Patients with stable chronic heart failure (including heart failure with reduced or preserved ejection fraction) were recruited from two tertiary hospitals in Brisbane, Australia.

INTERVENTION

The experimental group received a 12-week, real-time exercise and education intervention delivered into the participant's home twice weekly, using online videoconferencing software. The control group received a traditional hospital outpatient-based program of the same duration and frequency. Both groups received similar exercise prescription.

OUTCOME MEASURES

Participants were assessed by independent assessors at baseline (Week 0), at the end of the intervention (Week 12) and at follow-up (Week 24). The primary outcome was a between-group comparison of the change in 6-minute walk distance, with a non-inferiority margin of 28m. Secondary outcomes included other functional measures, quality of life, patient satisfaction, program attendance rates and adverse events.

RESULTS

In 53 participants (mean age 67 years, 75% males), there were no significant between-group differences on 6-minute walk distance gains, with a mean difference of 15m (95% CI -28 to 59) at Week 12. The confidence intervals were within the predetermined non-inferiority range. The secondary outcomes indicated that the experimental intervention was at least as effective as traditional rehabilitation. Significantly higher attendance rates were observed in the telerehabilitation group.

CONCLUSION

Telerehabilitation was not inferior to a hospital outpatient-based rehabilitation program in patients with chronic heart failure. Telerehabilitation appears to be an appropriate alternative because it promotes greater attendance at the rehabilitation sessions.

TRIAL REGISTRATION

ACTRN12613000390785. [Hwang R, Bruning J, Morris NR, Mandrusiak A, Russell T (2017) Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. Journal of Physiotherapy 63: 101-107].

A comparison of patient education practices and perceptions of novice and experienced physiotherapists in Australian physiotherapy settings

BACKGROUND

Patient education is an integral component of physiotherapy practice. Little is known about the differences in reported use and perception of patient education between experienced and novice physiotherapists. Understanding these differences has important implications for training approaches and physiotherapy practice.

OBJECTIVES

To compare how experienced and novice physiotherapists report frequency of patient education practices and their perceptions of the importance of these practices.

DESIGN AND METHODS

A web-based purpose-designed survey was developed, piloted and administered to practicing physiotherapists through direct email. Of 305 complete responses, two subgroups were explored for comparative analysis: 'novice' (≤5years' experience, n = 52); and 'experienced' (≥11 years' experience, n = 204).

RESULTS

The experienced group rated 14 of 15 educational items higher than the novice group in relation to frequency of use and perceived importance. Experienced physiotherapists reported a significantly higher frequency of using one-to-one discussion, personalised handouts and explicitly seeking patient understanding (p < 0.05). Novice physiotherapists perceived more barriers to patient education, particularly those related to characteristics of the patient (p < 0.05).

CONCLUSION

Experienced physiotherapists report higher use of self-management education and education content that is patient-centred. Experienced therapists report a higher frequency of seeking explicit patient understanding to evaluate their teaching than novice physiotherapists and perceive fewer patient-related barriers to their practice. These findings are important when considering teaching and learning of patient education skills. Students or novice physiotherapists may benefit from strategies to facilitate patient-centred education, self-management education, evaluation approaches and strategies to manage barriers.

Telerehabilitation Versus Traditional Care Following Total Hip Replacement: A Randomized Controlled Trial Protocol

Background

Total hip replacement (THR) is the gold standard treatment for severe hip osteoarthritis. Effectiveness of physical rehabilitation for THR patients following discharge from hospital is supported by evidence; however, barriers such as geographical location and transport can limit access to appropriate health care. One solution to this issue is using an alternative model of care using telerehabilitation technology to deliver rehabilitation programs directly into patients’ homes. A telerehabilitation model may also have potential health care cost savings for health care providers.

Objective

This study aims to determine if a telerehabilitation model of care delivered remotely is as effective as face-to-face rehabilitation in the THR population and cost effective for health care providers and patients.

Methods

A total of 70 people undergoing THR will be recruited to participate in a randomized, single-blind, controlled noninferiority clinical trial. The trial will compare a technology-based THR rehabilitation program to in-person care. On discharge from hospital, participants randomized to the in-person group will receive usual care, defined as a paper home exercise program (HEP) targeting strengthening exercises for quadriceps, hip abductors, extensors, and flexors; they will be advised to perform their HEP 3 times per day. At 2, 4, and 6 weeks postoperatively, they will receive a 30-minute in-person physiotherapy session with a focus on gait retraining and reviewing and progressing their HEP. The telerehabilitation protocol will involve a program similar in content to the in-person rehabilitation program, except delivery will be directly into the homes of the participants via telerehabilitation technology on an iPad. Outcomes will be evaluated preoperatively, day of discharge from in-patient physiotherapy, 6 weeks and 6 months postoperatively. The primary outcome will be the quality of life subscale of the hip disability and osteoarthritis outcome score, measured at 6 weeks. Both intention-to-treat and per-protocol analyses as recommended in the extension of the Consolidated Standards for Reporting Trials (CONSORT) guideline for noninferiority trials will be performed.

Results

Recruitment commenced in September 2015 and is expected to be completed by June 2017. Data collection will be completed by December 2017. It is anticipated the results from this trial will be published by July 2018.

Conclusions

Previous research investigating telerehabilitation in postoperative orthopedic conditions has yielded promising results. If shown to be as effective as in-person care, telerehabilitation after THR could be helpful in addressing access issues in this population. Furthermore, it may help reduce the cost of health care provision by enabling patients to take a more independent approach to their rehabilitation.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615000824561; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364010 (Archived by WebCite at http://www.webcitation.org/6oWXweVfI)

Assessment of communication and swallowing function post laryngectomy: A telerehabilitation trial

We validated an Internet-based telerehabiliatation system designed to assess the oromotor, swallowing and communication outcomes of patients following laryngectomy. Simultaneous online and face-to-face (FTF) assessments were made of 20 patients. The online assessment was conducted using a videoconferencing system developed specifically for telerehabilitation. There was greater than 80% agreement between the online and FTF clinician for all variables relating to oromotor function, swallowing status and communication ability. However, visualization of the stoma was poor. Clinician satisfaction with the functionality of the system was low, although their ratings were high for ease of use and the potential for telerehabilitation as a service delivery method. Patients were 100% satisfied with the usability of the system and the quality of service received. The study suggests that online assessment is a potentially viable service delivery method for evaluating the speech and swallowing status of patients post laryngectomy.

Designing quantitative telemedicine research

When designing quantitative trials and evaluation of telehealth interventions, researchers should think ahead to the intended way that the intervention could be implemented in routine care and consider how trial participants with similar characteristics to the target population can be included. The telehealth intervention and the context in which it is placed should be clearly described, and consideration given to conducting pragmatic trials in order to show the effect of telehealth in complex environments with rapidly changing technology. Types of research designs, comparators and outcome measures are discussed and common statistical issues are introduced.

Heritability and prevalence of selected osteochondrosis lesions in yearling Thoroughbred horses

BACKGROUND

Osteochondrosis is considered multifactorial in origin, with factors such as nutrition, conformation, body size, trauma and genetics thought to contribute to its pathogenesis. Few studies have investigated the effects of genetic variability of osteochondrosis in Thoroughbreds.

OBJECTIVES

To describe the prevalence and genetic variability of a subset of osteochondrosis lesions in a group of Thoroughbred yearlings.

STUDY DESIGN

Retrospective cohort study.

METHODS

Radiographs of 1962 Thoroughbred yearlings were retrieved from clinical records obtained between 2005 and 2013. Pedigree information was obtained from the Australian Stud Book. Osteochondrosis lesions were documented in selected joints and estimates of heritability were obtained by fitting linear mixed models in ASREML software.

RESULTS

The overall prevalence of osteochondrosis was 23%. Osteochondrosis was identified in 10% of stifle joints, 6% of hock joints and 8% of fetlock joints. The heritability estimates ranged from 0 to 0.21. The largest estimates were 0.10, 0.14, 0.16 and 0.21 for lesions of the distal intermediate ridge of the tibia, dorso-proximal proximal phalanx (P1), any stifle osteochondrosis, and lesions of the lateral trochlear ridge of the distal femur, respectively. Although calculated heritability estimates had high standard errors, meta-analyses combining the present results with published estimates were significant at 0.10, 0.17, 0.15 and 0.20 for stifle, tarsal, fetlock and these joints combined, respectively. In addition, there was a permanent environment attributable to the dam effect.

MAIN LIMITATIONS

Inclusion criteria were based on radiographic findings in specific joints at a specific age range in Thoroughbreds.

CONCLUSIONS

The present results indicate that only a proportion of osteochondrosis in Thoroughbreds is heritable. The permanent environment effects of the dam were observed to have effects on some categories of osteochondrosis.

Extraversion, Intelligence, and Ability to Draw a Person

Drawings of a person made by 50 girls and 54 boys were rated on the Harris Qualitative Scale by four independent raters; reliabilities were in the neighbourhood of .8. Ratings were correlated with the Extraversion scores on the Junior E.P.I.; extraverted children produced better drawings. Intelligence was correlated both with quality of drawing and with E, but even with intelligence partialled out positive but insignificant correlations between E and quality of drawing remained. The results tentatively support the hypothesis that in young children extraversion is related to drawing ability.

Assessing functional exercise capacity using telehealth: Is it valid and reliable in patients with chronic heart failure?

Introduction This study aimed to determine the validity and reliability of video-based telerehabilitation assessments in patients with heart failure. Methods Seventeen consecutive participants (mean age 69 years, SD 12 years and 88% males) undertook assessments of three functional tests via both telerehabilitation and face-to-face approaches, on the same day. The assessment order was randomised and conducted by independent assessors. Outcome measures included functional tests: timed up and go (time), six-minute walk (distance), grip strength (kilograms); system usability scale to rate participant experience with telerehabilitation assessment; and number of technical issues encountered. Validity and inter- and intra-rater reliability of telerehabilitation assessments were examined using limits of agreement, intra-class correlation coefficients (ICC), and paired t-tests. Results The limits of agreement for telerehabilitation assessments were within the clinically acceptable limits for timed up and go and grip strength. Telerehabilitation assessments for all functional tests were strongly associated with face-to-face assessments, with ICCs of between 0.85 and 0.96. Inter- and intra-rater reliability of telerehabilitation assessments for all functional tests were excellent (all ICC > 0.95). The mean (SD) system usability scale score was 85 (15)/100. Some incidences of Internet drop-outs, video freezing and auditory fading occurred. Discussion The use of telehealth for the assessment of functional exercise capacity appears to be valid and reliable in patients with heart failure.

Videophone support for an eight-year-old boy undergoing paediatric bone marrow transplantation

We report the use of an Internet-based videophone to support a child undergoing bone marrow transplantation (BMT). Over the Christmas period, an eight-year-old boy with an underlying diagnosis of attention-deficit/hyperactivity disorder (ADHD) and a history of absconding and aggressive non-compliant behaviour was treated by BMT. We installed an Internet-based videophone in the patient's hospital room two days post-transplant. A second videophone was installed in the patient's home and used the existing home telephone line. In all, 14 videophone calls were made over a nine-day period. The videophone improved interfamily social and emotional support, and appeared to reduce some of the inherent anxiety and distress resulting from paediatric bone marrow transplantation.

Factors shaping e-feedback utilization following electronic Objective Structured Clinical Examinations

The development of student-practitioners' practical clinical skills is essential in health professional education. Objective Structured Clinical Examinations are central to the assessment of students performing clinical procedures on simulated patients (actors). While feedback is considered core to learning providing timely, individualised student OSCE feedback is difficult. This study explored the perceptions of students about the multiple factors which shape the utility of e-feedback following an electronic Objective Structured Clinical Examinations, which utilized iPad and specialised software. The e-feedback was trialled in four courses within occupational therapy and physiotherapy pre-professional programs with a cohort of 204 students. Evaluation of student perceptions about feedback was collected using two surveys and eight focus groups. This data showed three factors shaped perceptions of the utility of e- Objective Structured Clinical Examinations feedback: 1) timely accessibility within one day of the assessment, 2) feedback demonstrating examiners' academic literacy and 3) feedback orientated to ways of improving future performance of clinical skills. The study found training in the provision of feedback using IPads and software is needed for examiners to ensure e-feedback meets students' needs for specific, future-oriented e-feedback and institutional requirements for justification of grades.

The relationship of foot and ankle mobility to the frontal plane projection angle in asymptomatic adults

Background

The frontal plane projection angle (FPPA) is frequently used as a measure of dynamic knee valgus during functional tasks, such as the single leg squat. Increased dynamic knee valgus is observed in people with knee pathologies including patellofemoral pain and anterior cruciate injury. As the foot is the primary interface with the support surface, foot and ankle mobility may affect the FPPA. This study investigated the relationship between foot and ankle mobility and the FPPA in asymptomatic adults.

Methods

Thirty healthy people (aged 18–50 years) performed 5 single leg squats. Peak FPPA and FPPA excursion were determined from digital video recordings. Foot mobility was quantified as the difference in dorsal midfoot height or midfoot width, between non-weightbearing and bilateral weightbearing positions. Ankle joint dorsiflexion range was measured as the maximum distance in centimetres between the longest toe and the wall during a knee-to-wall lunge. Linear regressions with generalised estimating equations were used to examine relationships between variables.

Results

Higher midfoot width mobility was associated with greater peak FPPA (β 0.90, p < 0.001, odds ratio [OR] 2.5), and FPPA excursion (β 0.67, p < 0.001, OR 1.9). Lower midfoot height mobility was associated with greater peak FPPA (β 0.37, p = 0.030, OR 1.4) and FPPA excursion (β 0.30, p = 0.020, OR 1.3). Lower ankle joint dorsiflexion was also associated with greater peak FPPA (β 0.61, p = 0.008, OR 1.8) and greater FPPA excursion (β 0.56, p < 0.001, OR 1.7).

Conclusions

Foot and ankle mobility was significantly related to the FPPA during the single leg squat in healthy individuals. Specifically, higher midfoot width mobility, or lower ankle joint dorsiflexion range and midfoot height mobility, were associated with a greater FPPA. These foot mobility factors should be considered in the clinical management of knee-related disorders that are associated with a high FPPA.

Validation of a Kinect-based telerehabilitation system with total hip replacement patients

The evolving telecommunications industry combined with medical information technology has been proposed as a solution to reduce health care cost and provide remote medical services. This paper aims to validate and show the feasibility and user acceptance of using a telerehabilitation system called Kinect Rehabilitation System (KiReS) in a real scenario, with patients attending repeated rehabilitation sessions after they had a Total Hip Replacement (THR). We present the main features of KiReS, how it was set up in the considered scenario and the experimental results obtained in relation to two different perspectives: patients' subjective perceptions (gathered through questionnaires) and the accuracy of the performed exercises (by analysing the data captured using KiReS). We made a full deployment of KiReS, defining step by step all the elements of a therapy: postures, movements, exercises and the therapy itself. Seven patients participated in this trial in a total of 19 sessions, and the system recorded 3865 exercise executions. The group showed general support for telerehabilitation and the possibilities that systems such as KiReS bring to physiotherapy treatment.

Quality indicators for musculoskeletal injury management in the emergency department: a systematic review

OBJECTIVES

There is increasing importance placed on quality of health care for musculoskeletal injuries in emergency departments (EDs). This systematic review aimed to identify existing musculoskeletal quality indicators (QIs) developed for ED use and to critically evaluate their methodological quality.

METHODS

MEDLINE, EMBASE, CINAHL, and the gray literature, including relevant organizational websites, were searched in 2013. English-language articles were included that described the development of at least one QI related to the ED care of musculoskeletal injuries. Data extraction of each included article was conducted. A quality assessment was then performed by rating each relevant QI against the Appraisal of Indicators through Research and Evaluation (AIRE) Instrument. QIs with similar definitions were grouped together and categorized according to the health care quality frameworks of Donabedian and the Institute of Medicine.

RESULTS

The search revealed 1,805 potentially relevant articles, of which 15 were finally included in the review. The number of relevant QIs per article ranged from one to 11, resulting in a total of 71 QIs overall. Pain (n = 17) and fracture management (n = 13) QIs were predominant. Ten QIs scored at least 50% across all AIRE Instrument domains, and these related to pain management and appropriate imaging of the spine.

CONCLUSIONS

Methodological quality of the development of most QIs is poor. Recommendations for a core set of QIs that address the complete spectrum of musculoskeletal injury management in emergency medicine is not possible, and more work is needed. Currently, QIs with highest methodological quality are in the areas of pain management and medical imaging.