RESNA 28th Annual Conference - Atlanta, Georgia
An ongoing randomized controlled trial is being conducted to evaluate the efficacy of interactive video teleconferencing technology to provide remote in-home rehabilitation interventions aimed at improving mobility and transfer ability of mobility aid users. Specific objectives are to determine if interventions delivered via telecare is as effective as in-home care in diagnosing problems, prescribing interventions, and implementing solutions. The intervention groups receive weekly, one-hour therapy sessions with six mobility and transfer tasks for four consecutive weeks. To date, there are n o significant differences between the two intervention groups for the number of environmental barriers and personal limitations diagnosed; number of recommendations for equipment , home modification, or adaptive strategies prescribed; or the number of recommendations implemented .
Keywords: telerehabilitation, telecare, assistive technology, home modification, adaptive strategies
Rehabilitation services in the home environment can be an important intervention strategy to manage chronic health care conditions, maintain or improve functioning, increase independence, ensure safety, and minimize the cost of personal care services [(1), (2), (3)]. However, for many individuals, and particularly those living in remote areas, in-home rehabilitation services can be hard to find and obtain due to travel distances, time constraints, and availability of personnel. Whereas interactive video teleconferencing has great potential to overcome some of these barriers, there has been little investigation of this technology for this purpose. In fact, few telehealth applications have investigated the use of real time, interactive communication between the patient and health care provider that is characteristic of rehabilitation therapy. Rather, they have relied on most applications have used store and forward technologies that transmit data, still images, or video recordings related to physical condition and physiological status [(4), (5)]. Studies have monitored and evaluated ultrasound testing for high risk pregnancies, dermatological conditions, congestive heart failure and electrocardiogram data, and psychiatric conditions [(6), (7), (8)] .
The ongoing study reported here builds upon previous pilot investigations [(10)] to extend the use of interactive video teleconferencing technology to deliver rehabilitation services to individuals in their own homes. Specifically, the study will assess the efficacy of the technology to provide remote rehabilitation therapy aimed at improving mobility and transfer abilities. The specific aim is to demonstrate that patients receiving telecare will achieve functional gains comparable to those receiving in-home care and greater than those who receive usual care . The study is undertaking to address three research questions: Q1) Does teleconferencing technology effectively enable remote therapists to diagnose problems and prescribe interventions to improve patients’ functioning? Q2) Do patients who receive therapy via teleconferencing technology implement an equivalent number of interventions as those who receive therapy via home visit? and Q3) Does remote telecare result in greater improvements in function as compared to the usual model of care and show a similar amount of improvement as those who receive in-home care. Results reported in this paper will address the first two questions only.
Experimental Design. Prospective subjects who have recently been prescribed a mobility aid are screened, consented, and randomized to the control group (usual care group) or one of two intervention groups (in-home care group and telecare group). The two intervention groups receive hour long weekly therapy sessions for four consecutive weeks. The control group receives no therapy as part of the study. Task performance is evaluated for all three groups within one week of discharge (baseline), at the end of the four week intervention period (week six), and at six months post-discharge (week 26). The mobile, wireless televideo system used in this study consists of “off-the-shelf” technology that uses POTS lines to transmit real-time, two-way audio and video between the patient’s home and the therapist in a clinic. The basic system, developed for a previous study, is described elsewhere [(10)].
Variables. Data regarding perceived dependency and difficulty with ADLs and mobility tasks, mobility aid usage and health status are collected through chart review and telephone interviews with subjects. Outcome variables include the number of adaptive prescriptions made by the therapist (Q1) and implemented by the patient (Q2), and level of independence in ADLs, and maneuverability and safety of mobility device use (Q3).
Procedures. Subjects in the intervention groups undertake a standardized protocol that includes three transfer tasks (getting on and off toilet, in and out of shower, and in and out of bed) and three locomotion/mobility tasks (moving from room to room, maneuvering the mobility aid while removing items from the refrigerator, and getting in and out of the house). Each week the therapist observes and assesses the patient to identify problems, provides instruction for adaptive methods/transfer techniques and makes recommendations for adaptive equipment and home modifications.
Sample . To date 50 individuals, mostly from a VA hospital have been enrolled in the study. Almost nine out of ten participants are male with an average age of 62 years. The majority of the sample (57%) is African American, 39% is Caucasian, and 4% is Hispanic. Over three-quarters reported earning a minimum of a high school diploma. At week 1 baseline, there were no significant differences in self-reported task difficulty and dependence between the two intervention groups.
Problems Identified . Across the 6 tasks, 195 (mean = 16.3 per subject) and 136 (mean = 12.4 per subject) problems were identified in the in-home and televideo groups, respectively. Almost three-fourths of the total number problems reported (74%) in each group were due to environmental barriers. There were no significant differences in the number of environmental barriers ( p = .358), personal limitations ( p = .510), or total number of problems identified as a function of intervention group ( p = .373). Similarly there were no significant differences the groups by mobility and transfer task, with the exception of environmental barriers for moving from room to room ( p = .023).
Recommendations . A total of 326 adaptive prescriptions (185 in-home and 141 tele) were made for the two intervention groups. Although Thet here were no significant differences between the two intervention groups for in any of the specific types of recommendations made for equipment(i.e., equipment and assistive technologies, home modifications, o r adaptive strategies), there were strong trends toward a greater number of recommendations for home modifications in the in-home care therapy group in all but two of four of the mobility and transfer tasks , (i.e., getting on and off the toilet and in/out of the tub), with two of the four remaining tasks (getting in and out of bed and moving room to room) approaching significance ( p = .055 and .052, respectively).
Implementation . The groups did not differ in the average number of recommendations implemented. For both intervention groups, getting in and out of the shower/tub had the highest frequency of implementation of recommendations with a mean number of 2.17 for the in-home group and 2.09 for the televideo group. For the in-home group, 91% of the recommendations were implemented for equipment and AT; yet only 39% of the home modifications and 79% of the adaptive strategies were implemented. For the televideo group, 100% of the adaptive strategies were implemented in contrast to 56% for each of equipment and AT and home modification categories.
Preliminary data suggest that providing in-home rehabilitation via tele-visit is as effective for the as a traditional in-home visit, at least for the six mobility and transfer tasks examined in the study . However, the modest sample sizes at this point in the project may over state inflate this finding. T herapists identified 20 more problems environmental barriers through the in-home visit than were identified in the tele video care group. This represents, on average, one problem per task per person more for subjects in the in-home group for these mobility tasks. These differences are worthy of w arrant further examination discussion as there were strong trends toward diagnosing identifying a greater number of environmental problems (which, in turn, affect the number of recommendations and implementations) for the in-home group.
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Jon A. Sanford, M.Arch.
Rehabilitation R&D Center (151R) , Atlanta VA
Decatur, GA 30033 USA
Email: jasanf@yahoo.com
Phone: 404-321-6111, x 6788
This project was funded by the Rehabilitation R&D Service, Department of Veterans Affairs, Grant #E2806T.