eHealthcare and Rehabilitation:
What is the Evidence?
Sue Palsbo, PhD
Center for Health Policy,
Research and Ethics
Need for Telerehabilitation
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People with chronic or acute disabilities
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Cognitive (impaired way-finding; executive
dysfunction)
Physical (impaired mobility)
Areas with shortages of therapists
Transportation barriers
Stance on Telerehabilitation
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Varies by payer
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Medicare
Medicaid
Major insurers
Varies by professional association
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ASHA
APTA
AOTA
What is Telerehabilitation?
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Assessment (client and environmental
status)
Intervention (treatment, management)
Consultation and peer support of other
clinicians
Patient education, supervision
Examples - OT
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Diagnosis and Consultation
Home accessibility assessments
Examples - PT
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Wheelchair seating clinics
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Minnesota  American Samoa
NYC (pressure pad mapping)
Diagnosis & consultation (Washington DC
 American Samoa and Guam)
Pre-surgical exercise (Norway)
Examples - SLP
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Speech therapy
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National Rehabilitation Hospital (stroke rehab)
Voice rehab (Hawaii  military bases)
Queensland, Australia (assessment)
Nova Scotia, Canada (swallowing)
Audiology
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Utah State; Mayo Clinic; Santa Rosa, CA
How Telepractice Is Being
Used...
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Audiologists:
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Hearing screening
Hearing aid programming and counseling
Auditory brainstem response (ABR)
Otoacoustic emissions (OAEs)
Audiologic rehabilitation
Speech-Language Pathologists:
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School-based service in remote/underserved areas
Voice, aphasia, or cognitive-communication treatment to satellite
clinics from hospitals
Adjunct to home health visits
Specialized services such as laryngectomy rehabilitation and
augmentative and alternative communication
Face-to-Face Interaction Model
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Face-to-Face SLP treatment sessions
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Verbal & visual communication
Treatment Workspace – collaborative use
of physical materials (e.g. workbooks,
flashcards, etc.)
Verbal & Visual
Communication
S
C
Treatment
Workspace
SLP Clinician
Client
RESPECT: REmote SPEechlanguage and Cognitive
Treatment
RESPECT: Client User Interface
Functional reading task with
video window
Following directions task
(shared whiteboard) with
video window
The Peer-Reviewed Evidence
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Proof-of-concept or equivalence trials
Consultation and peer therapist support
Patient assessment, not therapy
Care supplementation, not care
substitution
Equivalence of Face-to-face and Videoconference
Administration of the ESS and Functional Reach for
Post-Stroke Patients

Sue Palsbo, PhD

National Rehabilitation Hospital / George Mason University

Stephen J. Dawson, PT
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INTEGRIS/Jim Thorpe
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Lynda Savard, PT
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Sister Kinney Rehabilitation Institute
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Marc Goldstein, EdD
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American Physical Therapy Association
Why is it so hard?
(1) Be appropriate and relevant to people
with stroke.
(2) Have known psychometric properties
(validity and reliability) published in peerreviewed literature.
(3) Wide use in research and clinical practice.
(4) Be visually based (that is, the therapist
can measure using televideo without
touching the patient).
(5) All measures can be completed within 30
Design Issues for Measuring
Equivalence
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Serial correlation bias
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Inter-rater reliability
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Measure simultaneously, not serially
Use measurement tools with published
reliability values
Training
Bias in administration
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Switch off the therapist conducting the
assessment
Measures
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Functional reach
European stroke scale
1.
2.
3.
4.
5.
6.
7.
Level of consciousness
Comprehension
Speech
Visual field
Gaze
Facial movement
Arm – maintain position when outstretched
Measures, con’t.
8.
9.
10.
11.
12.
13.
14.
Arm – raising
Wrist extension
Fingers
Leg – maintain position
Leg – flex
Dorsiflexion of foot
Gait
Results

Functional reach: Lin’s rho – 0.98
Percent agreement:
Exact
One-level
Comprehension
0.96
1.00
Gaze
0.96
0.96
Gait
0.95
1.00
Fingers
0.92
1.00
Level of Consciousness
0.92
1.00
Leg (maintain position)
0.92
0.92
Arm (raising)
0.84
0.96
Wrist extension
0.81
1.00
Speech
0.80
1.00
Leg (flex)
0.76
1.00
Facial movement.
0.75
1.00
Dorsiflexion of foot
0.72
1.00
Arm (maintain outstretched)
0.72
0.96
Visual field
0.72
0.72
Conclusions
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Evidence for eHealth and Rehabilitation assement and
management are skimpy – at the moment!
Growing interest in post-stroke rehabilitation
SLP is most conducive to e-therapy using televideo &
things that can be digitized (swallowing)
PT will have more limited visual therapy applications (but
growing use with e-robotics)
Rapid growth in telerehabilitation e-therapy over next 5
years
Funding

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Robert Wood Johnson Foundation,
Methodologies Grant, #49143
US Department of Education, National Institute
on Disability and Rehabilitation Research
(NIDRR), Rehabilitation Engineering and
Research Center (RERC) on Telerehabilitation
#H133E990007-00C
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eHealthcare and Rehabilitation: What is the Evidence?