RESNA 26th International Annual Confence
Constraint Induced Movement Therapy (CIMT) is a relatively new therapy that's not widely available. The majority of cases are not covered by third party payers, which can cost the patient thousands of dollars. Therefore, it's important to carefully screen potential participants to make sure they would benefit from CIMT. In most cases, if the patient lives near a facility that provides this therapy, he or she can be seen for a CIMT screening with minimal travel. However, this is not true for the rural patient. This paper describes how a potential CIMT patient from American Samoa was screened using video conferencing. This paper also considers providing actual CIMT therapy, not just the screening, using video conferencing.
Telerehabilitation has been defined as the "delivery of rehabilitation services at a distance by means of electronic information and communication technologies." (1) Sister Kenny Institute (SKI) in Minneapolis is part of a Rehabilitation Engineering and Research Center (RERC) on telerehabilitation. Collaborators include National Rehabilitation Hospital (NRH) and Catholic University of America, both in Washington, DC.
For over two years, SKI and NRH have been delivering telerehabilitation services to the L.B.J. Tropical Medical Center in Pago Pago, American Samoa. Bridging the three sites together is the State of Hawaii Telehealth Access Network (STAN) located in Honolulu. Using a combination of ISDN (mainland sites) and satellite telecommunication, real-time audio and video can be transmitted and received at a rate of 384 kbps. All three sites use a Polycom? ViewStation with the capabilities of transmitting and receiving 30 frames per second (close to TV quality).
The tele-clinics are held bi-weekly and typically include a physiatrist and nurse practitioner from NRH, a physical therapist at L.B.J., and a physical and occupational therapist from SKI. Referrals for telerehabilitation usually come from the physical therapist at L.B.J. Typical tele-encounters result in setting up or advancing a patient's treatment plan.
SKI has also been delivering Constraint Induced Movement Therapy (CIMT) since spring of 2001. CIMT is a form of therapy that "induce[s] stroke patients to greatly increase the use of a more affected upper extremity for many hours a day over a 10-14 consecutive-day period."(2) Many patients who complete this rigorous program report much improvement in their affected extremity. As the typical patient gets more proactive in his or her treatment, he or she is seeking new techniques and asking for this treatment, even in America Samoa.
One patient in American Samoa sought information regarding this relatively new technique and questioned if he was an appropriate candidate. His physical therapist at L.B.J. recommended he participate in a tele-clinic to be screened by a therapist trained in CIMT. The patient was a 59 year old Caucasian male who had a right cerebrovascular accident (stroke) in August of 1997, resulting in left-sided weakness. The patient participated in a 30-minute tele-clinic in December of 2001. During the screening the patient was asked to mimic the movements performed by the occupational therapist at SKI. The patient mimicked the following active range of motion movements from a seated position: shoulder flexion to 45 degrees, shoulder abduction to 45 degrees, elbow extension (shoulder at 90 degrees in abduction) of 30 degrees, wrist extension by 20 degrees, and digit extension of each joint by 10 degrees. The patient passed the above CIMT inclusion criteria, including the ability to follow simple 1-2 step commands which is necessary when following the CIMT exercise program. The video component for the session was essential in observing the desired movements.
The patient could have been mailed a questionnaire asking if he could perform the motions (see above section) needed to meet the CIMT criteria, but he would still be required to attend an in-person assessment to verify that the patient met the minimum movement requirement.
The patient's movements could have been videotaped. The SKI therapist could have taped the desired motions for potential patients to mimic. Then the therapist in American Samoa could have videotaped the mimicked movements and mailed it to SKI for analysis.
The above solutions weren't used because the tele-clinics were already in place, and the L.B.J. therapist referred this patient specifically for a CIMT consult. In addition, it was obviously an advantage to have real time interaction with the patient to accurately screen him.
A data collection tool was administered at the end of the tele-clinic to measure the effectiveness of the tele-clinic session. Questions addressed the referring and consulting therapists' satisfaction with the tele-clinic. The referring therapist reported a score of "excellent" on a scale of "poor", "fair", "good", and "excellent" when responding to the question of helpfulness of the tele-encounter. The consulting (SKI) therapist also responded with "excellent" on the same scale regarding the effectiveness of the tele-encounter
Although the use of high-end video conferencing equipment is expensive, in this case it was readily available and accessible for the patient and covered under the grant. Questions have arisen from our exposure to this CIMT screen and telerehabilitation encounters. Could others be effectively screened using simple and inexpensive video phones using standard telephone connections? Maybe another more intriguing possibility would be delivering the actual treatment sessions of CIMT to rural patients over video conferencing technologies. These are questions we may investigate in the near future.
Matthew W. White
Advanced Rehabilitative Technologies
Sister Kenny Institute, Mail Route 12210,
800 East 28th Street
Minneapolis, MN 55407-3799