RESNA 26th International Annual Confence

Technology & Disability: Research, Design, Practice & Policy

June 19 to June 23, 2003
Atlanta, Georgia



Ana L.C.Allegretti, Shirley G. Fitzgerald, Michael L. Boninger, Rory A. Cooper, Rosemarie Cooper, Laura Cohen, Nigel Shapcott
Departments of Rehabilitation Science and Technology, Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA


Telerehabilitation shows the promise to be able to improve access to seating and mobility specialists for people living in rural and remote areas. The goal addressed in this research paper is to compare pelvic positioning evaluation findings in person (IP) and via telerehabilitation (TR) in wheelchair selection. The kappa measure for agreement was used to analyze the data. Findings showed agreement between in person and between IP to TR. These results indicate promise for TR to be a useful tool in wheelchair selection.


Telerehabilitation is the application of telecommunication technology to provide distance support, assessment, and intervention to individuals with disabilities (1). This technology may show promise in different areas, such as prevention and management of pressure ulcers in patients with spinal cord injuries. TR can also be used in rural settings where the delivery of rehabilitation and assistive technology is problematic and to improve access to seating and mobility specialists (1) (2).

At present, there is an absence of any large-scale randomized controlled trials demonstrating either clinical effectiveness or cost-effectiveness of TR in providing seating assessment for individuals who live in remote or underserved areas (2). Cooper at al showed that TR was promising in wheelchair recommendations (2). It was of interest to determine whether this was true for more specific aspects of seating.


When examining the pelvic position during a mat evaluation; what is the level of agreement between therapist via TR and IP?


Four licensed therapists with experience in seating and mobility evaluations conducted assessments, on 20 model patients. The group of model patients consisted of ten females and ten males with the mean age of 42.4 years (+ 13.1years). The primary diagnoses included Rheumatoid Arthritis, Engelman's disease, Cerebral Palsy, Spinal Cord Injury, Head Injury, Spinal Muscular Atrophy, severe Osteoporosis, Spina Bifida, Diabetes, Muscular Distrophy and Multiple Sclerosis. Two assessments were done, one week apart in person by different clinicians; two assessments were also completed via TR. IP assessment was compared to another IP assessment, and then one IP assessment was compared to TR assessment.

The evaluation protocol consisted of an interview, mat evaluation and functional evaluation. The purpose of the evaluation protocol was to have clinicians identify: 1) need for seating and mobility, 2) type of equipment, 3) therapeutic goal for assistive technology. Each clinician evaluated the same 20 model patients one time only either by TR or by IP. The TR assessment was conducted with an "assistant"(a student not in the field of physiotherapy or occupational therapy, monitored by an onsite licensed therapist) at the CAT under the supervision of one of the four therapists observing from a remote location. For this paper, pelvic assessment compared the efficacy of TR.

For this study mat evaluation was used to compare the efficacy of the TR pelvic positioning and trunk evaluation, as they are one KEY in the evaluation process to prescribe a good seating system/wheelchair. The mat evaluation is important to assess the pelvis, trunk, hip and knee, and ankle range of motion as they relate to wheelchair sitting posture. This evaluation was done by one therapist when it was an IP assessment and by one therapist and one assistant in a TR assessment, as cited above. Fixed deformities were examined and included fixed posterior pelvic tilt, thoracic kyphosis, hip joints limited to 90º of flexion or less, and knee joints that are limited due to tight hamstrings muscles. When a fixed deformity is found, the seating needs to accommodate, support and protect the fixed posture. If a flexible joint is found, the seating must support and maintain the most optimal position within the resident's tolerance. (4).

The two IP assessments and the IP and TR assessments were compared using Kappa statistics. A Kappa value of > .75 was interpreted as excellent agreement (3).


The results are summarized in tables 1 and 2 below. As can be seen, IP to IP were for the most part comparable. IP to TR were not as comparable.

Table 1: In person compared to in person.
IP x IP          

Anterior -Posterior Pelvic Tilt

Hip Flexion

Knee Flexion

Anterior Pelvic Tilt

Posterior Pelvic Tilt

Trunk Deformity

Kappa= 0.667

P= 0.006

Kappa= 0.444

p= 0.038

Kappa= 0.575

p= 0.031

Kappa= 0.612

p= 0.004

Kappa= 0.828

p= 0.000

Kappa= 0.100

p= 0.531


Table 2: In person compared to telerehabilitation.
IP x TR          

Anterior- Posterior Pelvic Tilt

Hip Flexion

Knee Flexion

Anterior Pelvic Tilt

Posterior Pelvic Tilt

Trunk Deformity

Kappa= 0.429

P= 0.86

Kappa= 0.767

p= 0.001

Kappa= 0.723


No agreement

Kappa= 0.477

p= 0.035

Kappa= 0.191

p=0. 156


Mat evaluation can be a challenging even for a skilled therapist. Our results showed that in a population of `model' patients, even IP to IP do not have perfect agreement. IP was also shown to be less comparable to TR in some of the pelvic positioning variables. Possible reasons why included limitations in the study design as well as the technology.

Within the study design, although the TR assistants were trained, they were not homogeneous group. None were therapists such as, OT or PT students. Therefore knowing terminology and specific items required, like stabilizing the pelvis during the hip and knee assessment could be difficult. In addition the training of the therapists, who completed the exams may have different ways of talking to the assistants or difference definitions of the variables in question. Other limitations include form design, resulting in the therapist not completing forms correctly.

There were also limitations include the technology. The mat assessment may simply rely too heavily as sensory-motor feedback to be viable with simple TR like, to examine the neurological influences as they relate to the seated posture. Also the camera view (1 dimension) for some positioning the therapist was limited to see clearly.

For future studies, the research methodology should be improved to better investigate the efficacy of IP and TR. Although our results were not promising, TR may still be useful tool in a clinical setting.


  1. Ricker, JH; Rosenthal, M; Garay, EBS, De Lucca, J; Germain, AMBA; Abraham- Fuchs,KMS.; Schmidt, K (2002) Telerehabilitation Needs: A survey of Persons with Acquired Brain Injury. Journal of Head Trauma Rehabilitation, Vol.17(3), p.242-250.

  2. Cooper R, Fitzgerald SG, Boninger ML, Cooper RA, Shapcott N, Cohen L, Thorman T, Schmeler MS. (2002) Using Telerehabilitation Aid in Selecting a Wheelchair. Proceedings of the RESNA 25 International Conference, p.327-329

  3. Gertsman BB (1998). Epidemiology Kept Simple, An Introduction to Classic and Modern Epidemiology, A John Wiley & Sons, Inc, Publication

  4. Jones D (1995) Real Solutions. TeamRehab Report, p. 14-16.


This study was supported in part by the U.S. Department of Veterans Affairs, Veterans Health Administration, Rehabilitation Research and Development Service (B2159TC).

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