Telerehabilitation: Review of the State-of-the-Art and Areas of Application

Teleassessment of Gait and Gait Aids: Validity and Interrater Reliability

BACKGROUND

Gait and mobility aid assessments are important components of rehabilitation. Given the increasing use of telehealth to meet rehabilitation needs, it is important to examine the feasibility of such assessments within the constraints of telerehabilitation.

OBJECTIVE

The objective of this study was to examine the reliability and validity of the Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) and cane height assessment under various video and transmission settings to demonstrate the feasibility of teleassessment.

DESIGN

This repeated-measures study compared the test performances of in-person, slow motion (SM) review, and normal-speed (NS) video ratings at various fixed frame rates (8, 15, and 30 frames per second) and bandwidth (128, 384, and 768 kB/s) configurations.

METHODS

Overall bias, validity, and interrater reliability were assessed for in-person, SM video, and NS video ratings, with SM video rating as the gold standard, as well as for different frame rate and bandwidth configurations within NS videos.

RESULTS

There was moderate to good interrater reliability for the POMA-G (intraclass correlation coefficient [ICC] = 0.66-0.77 across all configurations) and moderate validity for in-person (β = 0.62; 95% confidence interval [CI] = 0.37-0.87) and NS video (β = 0.74; 95% CI = 0.67-0.80) ratings compared with the SM video rating. For cane height, interrater reliability was good (ICC = 0.66-0.77), although it was significantly lower at the lowest frame rate (8 frames per second) (ICC = 0.66; 95% CI = 0.54-0.76) and bandwidth (128 kB/s) (ICC = 0.69; 95% CI = 0.57-0.78) configurations. Validity for cane height was good for both in-person (β = 0.80; 95% CI = 0.62-0.98) and NS video (β = 0.86; 95% CI = 0.81-0.90) ratings compared with SM video rating.

LIMITATIONS

Some lower frame rate and bandwidth configurations may limit the reliability of remote cane height assessments.

CONCLUSIONS

Teleassessment for POMA-G and cane height using typically available internet and video quality is feasible, valid, and reliable.

Hand Rehabilitation and Telemonitoring through Smart Toys

We describe here a platform for autonomous hand rehabilitation and telemonitoring of young patients. A toy embedding the electronics required to sense fingers pressure in different grasping modalities is the core element of this platform. The system has been realized following the user-centered design methodology taking into account stakeholder needs from start: clinicians require reliable measurements and the ability to get a picture remotely on rehabilitation progression; children have asked to interact with a pleasant and comfortable object that is easy to use, safe, and rewarding. These requirements are not antithetic, and considering both since the design phase has allowed the realization of a platform reliable to clinicians and keen to be used by young children.

Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of technology-assisted rehabilitation following total hip/knee replacement (THR/TKR).

METHODS

Six electronic databases were searched without language or time restrictions for relevant studies: MEDLINE, EMBASE, Cochrane Library, CINAHL, SPORTDiscus, Physiotherapy Evidence Database (PEDro); from inception to November 7th, 2018. Two reviewers independently applied inclusion criteria to select eligible randomised controlled trials (RCTs) that investigated the effectiveness of technology-based interventions, compared with usual care or no intervention for people undergoing THR/TKR. Two reviewers independently extracted trial details (e.g. patients' profile, intervention, outcomes, attrition and adverse events). Study methodological quality was assessed using the PEDro scale. Quality of evidence was critically appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

We identified 21 eligible studies assessing telerehabilitation, game- or web-based therapy. There were 17 studies (N = 2188) in post-TKR rehabilitation and 4 studies (N = 783) in post-THR rehabilitation. Compared to usual care, technology-based intervention was more effective in reducing pain (mean difference (MD): - 0.25; 95% confidence interval (CI): - 0.48, - 0.02; moderate evidence) and improving function measured with the timed up-and-go test (MD: -7.03; 95% CI: - 11.18, - 2.88) in people undergoing TKR. No between-group differences were observed in rates of hospital readmissions or treatment-related adverse events (AEs) in those studies.

CONCLUSION

There is moderate-quality of evidence showed technology-assisted rehabilitation, in particular, telerehabilitation, results in a statistically significant improvement in pain; and low-quality of evidence for the improvement in functional mobility in people undergoing TKR. The effects were however too small to be clinically significant. For THR, there is very limited low-quality evidence shows no significant effects.

Telemedicine and telerehabilitation: current and forthcoming applications in haemophilia

In persons with haemophilia (PWH), the importance of comprehensive disease management to prevent bleeding, joint damage and secondary diseases has been well established. However, because haemophilia is a chronic disease, intervention programmes carried out for prolonged periods of time may create problems of patient adherence. Driven by continuous technological innovation, telemedicine is being increasingly proposed as a way to provide PWH with a range of services designed to improve their health, saving the time and cost involved in going to the treatment centre, and increasing therapeutic adherence. The aim of this article is to identify and discuss the tools available for the management of PWH by means of telemedicine and information technology. Video conferences are helpful to obtain a rapid evaluation at a distance of the occurrence and severity of bleeding episodes by the personnel of the treatment centre. Cell phones and associated applications (apps) help to improve the regular implementation of replacement therapy and monitor any ensuing adverse effect. Portable sensors help to improve lifestyle and to monitor the degree of physical activity through the fulfilment of a given number of daily walking steps and other physical activities. In the context of telerehabilitation, exergames have the potential to improve the musculoskeletal function of PWH by exploiting the recreational features of videogames. Thus, telemedicine and its multiple applications may be useful in the management of haemophilia, especially for patients living far from specialised centres. However, since this is a recent and rapidly evolving field, published studies are few and have, so far, involved only a limited number of cases. Therefore, additional evidence needs to be obtained by means of accrual of cumulative data from multiple centres specialised in haemophilia.

Home-based physiotherapy programmes for individuals with neurological diseases: systematic review

Abstract Introduction: Home-based programmes have received increasing attention in rehabilitation, providing an opportunity to continue aspects of therapy, benefiting the retention of established intervention effects. Objective: To describe the available home-based physiotherapy programmes in neurorehabilitation for people with neurological diseases. Method: MEDLINE, EMBASE, Cochrane Library, OTseeker and PEDro were searched, no restrictions regarding the date of publication or language restrictions for randomized controlled clinical trial. The quality of the selected studies using the PEDro scale and the Cochrane Collaboration’s tool for assessing the risk of bias. Results: Fifteen articles met the eligibility criteria and quality assessment and were selected for the present systematic review. The findings supports the positive impact of home-based intervention, finding evidence in the changes in activity level, improvement in the control and muscle strength, balance and walking in patients with neurological conditions who perform rehabilitation program at home, with a good adherence of participants in total. Conclusion: Models of rehabilitative such as home-based programmes can be an alternative efficient method to deliver rehabilitation, showing to be beneficial in improving different aspects of activities, and participation.

The Use of Telerehabilitation Technologies for Cardiac Patients to Improve Rehabilitation Activities and Unify Organizations: Qualitative Study

Background

Cardiovascular disease is a leading cause of death globally causing 31% of all deaths worldwide. The Danish health care system is characterized by fragmented delivery of services and rehabilitation activities. The Teledialog Telerehabilitation Program for cardiac patients was developed and tested to rectify fragmentation and improve the quality of care. The Teledialog program was based on the assumption that a common communication platform shared by health care professionals, patients, and relatives could reduce or eliminate the fragmentation in the rehabilitation process and improve cooperation between the health professionals.

Objective

This study aimed to assess the interorganizational cooperation between health care professionals across sectors (hospitals, municipal health care centers) in a cardiac telerehabilitation program.

Methods

Theories of networks between organizations, the sociology of professions, and the “community of practice” approach were used in a case study of a cardiac telerehabilitation program. A triangulation of data collection techniques were used including documents, participant observation (n=76 hours), and qualitative interviews with healthcare professionals (n=37). Data were analyzed using NVivo 11.0.

Results

The case study of cooperation in an interorganizational context of cardiac telerehabilitation program is characterized by the following key themes and patterns: (1) integrated workflows via a shared digital rehabilitation plan that help integrate workflow between health care professions and organizations, (2) joint clinical practice showed as a community of practice in telerehabilitation developed across professions and organizations, and (3) unifying the organizations as cooperation has advanced via a joint telerehabilitation program across municipalities and hospitals.

Conclusions

The Teledialog Telerehabilitation Program was a new innovative cardiac program tested on a large scale across hospitals, health care centers, and municipalities. Assessments showed that the Teledialog program and its associated technologies helped improve interorganizational cooperation and reduce fragmentation. The program helped integrate the organizations and led to the creation of a community of practice. Further research is needed to explore long-term effects of implementation of telerehabilitation technologies and programs.

Trial Registration

ClinicalTrials.gov NCT01752192; http://clinicaltrials.gov/ct2/show/NCT01752192 (Archived by WebCite at http://www.webcitation.org/6yR3tdEpb)

Remote Home-Based Virtual Training of Functional Living Skills for Adolescents and Young Adults With Intellectual Disability: Feasibility and Preliminary Results

Background: Virtual Reality (VR) is acquiring increasing credibility as a tool for teaching independent living skills to people with Intellectual Disability (ID). Generalization of skills acquired during VR training into real environment seems to be feasible.

Objective: To assess feasibility and verify effectiveness of a remote home-based rehabilitation, focused on functional living skills, for adolescents and young adults with ID, by using virtual apps installed on tablets. In particular, to assess if this tool can be managed independently, if it is enjoyable and simple to be used, and if the acquired skills can be generalized to the real environment of everyday life.

Subjects and method: A single group, pre- and post-test research design was used. Sixteen participants with ID were included. A digital system was arranged, with a server managing communication between the database and the apps installed on tablets. In vivo tests were performed before and after the eleven sessions of VR training. Satisfaction questionnaires were also administered.

Results: Statistically significant improvements were found between the pre- and post-in vivo tests, as well as between the VR training sessions, in almost all the parameters taken into account, for each app. Final questionnaires showed a good satisfaction level for both the participants and their families.

Conclusion: The highly technological system was managed independently by participants with ID, who found it simple to be used, useful and even fun; generalization across settings was obtained. Results obtained require to be confirmed by future controlled studies, with larger samples.

Virtual Reality for Neurorehabilitation: Insights From 3 European Clinics

Virtual reality for the treatment of motor impairment is a burgeoning application of digital technology in neurorehabilitation. Virtual reality systems pose an opportunity for health care providers to augment the dose of task-oriented exercises delivered both in the clinic, and via telerehabilitation models in the home. The technology is almost exclusively applied as an adjunct to traditional approaches and is typically characterized by the use of gamified exergames which feature task-oriented physiotherapy exercises. At present, evidence for the efficacy of this technology is sparse, with some reviews suggesting it is the same or no better than conventional approaches. The purpose of this article is to provide real-world insights on the adoption of a virtual reality by 3 European clinics in 3 different service delivery models. These include an inpatient setting for Parkinson disease, a kiosk model for pediatric neurorehabilitation, and a home-based telerehabilitation model for neurologic patients. Motivations, settings, requirements for the pathology, outcomes, and challenges encountered during this process are reported with the objective of priming clinicians on what to expect when implementing virtual reality in neurorehabilitation.

Smart Web-Based Platform to Support Physical Rehabilitation

The enhancement of ubiquitous and pervasive computing brings new perspectives in medical rehabilitation. In that sense, the present study proposes a smart, web-based platform to promote the reeducation of patients after hip replacement surgery. This project focuses on two fundamental aspects in the development of a suitable tele-rehabilitation application, which are: (i) being based on an affordable technology, and (ii) providing the patients with a real-time assessment of the correctness of their movements. A probabilistic approach based on the development and training of ten Hidden Markov Models (HMMs) is used to discriminate in real time the main faults in the execution of the therapeutic exercises. Two experiments are designed to evaluate the precision of the algorithm for classifying movements performed in the laboratory and clinical settings, respectively. A comparative analysis of the data shows that the models are as reliable as the physiotherapists to discriminate and identify the motion errors. The results are discussed in terms of the required setup for a successful application in the field and further implementations to improve the accuracy and usability of the system.

Development and Implementation of a New Telerehabilitation System for Audiovisual Stimulation Training in Hemianopia

Telerehabilitation, defined as the method by which communication technologies are used to provide remote rehabilitation, although still underused, could be as efficient and effective as the conventional clinical rehabilitation practices. In the literature, there are descriptions of the use of telerehabilitation in adult patients with various diseases, whereas it is seldom used in clinical practice with child and adolescent patients. We have developed a new audiovisual telerehabilitation (AVT) system, based on the multisensory capabilities of the human brain, to provide a new tool for adults and children with visual field defects in order to improve ocular movements toward the blind hemifield. The apparatus consists of a semicircular structure in which visual and acoustic stimuli are positioned. A camera is integrated into the mechanical structure in the center of the panel to control eye and head movements. Patients can use this training system with a customized software on a tablet. From hospital, the therapist has complete control over the training process, and the results of the training sessions are automatically available within a few minutes on the hospital website. In this paper, we report the AVT system protocol and the preliminary results on its use by three adult patients. All three showed improvements in visual detection abilities with long-term effects. In the future, we will test this apparatus with children and their families. Since interventions for impairments in the visual field have a substantial cost for individuals and for the welfare system, we expect that our research could have a profound socio-economic impact avoiding prolonged and intensive hospital stays.

Cognitive telerehabilitation in mild cognitive impairment, Alzheimer's disease and frontotemporal dementia: A systematic review

INTRODUCTION

Given the limited effectiveness of pharmacological treatments, non-pharmacological interventions in neurodegenerative diseases have gained increasing attention in recent years and telerehabilitation has been proposed as a cognitive rehabilitation strategy. The purpose of this systematic review is to examine the evidence for the efficacy of cognitive telerehabilitation interventions compared with face-to-face rehabilitation in patients with mild cognitive impairment, Alzheimer's disease and frontotemporal dementia.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of the Medline database was conducted. Out of 14 articles assessed for eligibility, five studies were identified, three in participants with mild cognitive impairment or Alzheimer's disease, two in patients with primary progressive aphasia.

RESULTS

The Physiotherapy Evidence Database scale was used to assess the methodological quality of four out of five studies included in this systematic review, with only one report receiving a high-quality rating. Effect-size analysis evidenced positive effects of telerehabilitation interventions, comparable with those reported for face-to-face rehabilitation.

DISCUSSION

The available evidence for the effectiveness of cognitive telerehabilitation is limited, and the quality of the evidence needs to be improved. The systematic review provides preliminary evidence suggesting that cognitive telerehabilitation for neurodegenerative disease may have comparable effects as conventional in-person cognitive rehabilitation.