Enhancing Quality of Life through Telerehabilitation

Telerehabilitation is an emerging method of delivering rehabilitation services that uses technology to serve clients, clinicians, and systems by minimizing the barriers of distance, time, and cost. The driving force for telerehabilitation has been as an alternative to face-to-face rehabilitation approaches to reduce costs, increase geographic accessibility, or act as a mechanism to extend limited resources. A rationale for telerehabilitation is the potential to enhance outcomes beyond what may result from face-to-face interventions by enabling naturalistic, in vivo interventions. There is considerable support for the value of interventions delivered in the natural environment, ranging from addressing efficacy concerns by addressing problems of generalization, to increasing patient participation, including environmental context in rehabilitation, and increasing patient satisfaction. Further clinical and research exploration should explore telerehabilitation as a tool for the delivery of rehabilitation services in vivo.

Telerehabilitation is an emerging method of delivering rehabilitation services that uses technology to serve clients, clinicians, and systems by minimizing the barriers of distance, time, and cost. More specifically, “telerehabilitation can be defined as the application of telecommunication, remote sensing and operation technologies, and computing technologies to assist with the provision of medical rehabilitation services at a distance.” Much attention has been paid to the efficacy of telerehabilitation in efforts to decrease time and cost in the delivery of rehabilitation services. Some studies have also compared telerehabilitation services to face-to-face interventions to discover whether these approaches are “as good as” traditional rehabilitation approaches. However, telerehabilitation may in fact provide new opportunities that are more effective by increasing accessibility and creating the least restrictive environment.

Telerehabilitation was first documented in 1959, when interactive video was first used at Nebraska Psychiatric Institute in the delivery of mental health services. Over the past 50 years, technologists and clinicians have investigated the use of bridging the gap between individuals with specialized medical needs living in remote areas and the source of specialty care. Closely related to the emergence and use of telerehabilitation are solutions to problems associated with technological, functional, economic, political, and geographic convergence. Technologies that enable telerehabilitation services, such as increased computer power and availability of high-speed data transmission lines, have become more prominent in recent years.

Winters provides a comprehensive review of the conceptual models of telerehabilitation. He explains that telerehabilitation falls under a broader category of services that use telecommunication to provide health information and care across distance, termed telehealth. Telehealth is broken into 3 subcategories: telemedicine, telehealthcare, and e-health/education. Telerehabilitation is classified into the category of telehealthcare along with telehomecare, telenursing, and telecoaching. Not clearly defined, these terms are often used interchangeably throughout the research literature. There is an existing need for consensus of the terminology used in this field to allow for a clear description of services. It has been proposed that telerehabilitation warrants a separate and parallel identity alongside telehealthcare and telemedicine.

An alternative model of telerehabilitation to promote quality of life

Much of the research literature on telerehabilitation has focused on the outcome measure of decreasing costs, saving travel time, and improving access to specialty services and expert practitioners. The rationale proposed to support the exploration and implementation of telerehabilitation has been essentially based on the use of various technologies to address geographic and economic barriers, and potentially enhance cost effectiveness. An alternative perspective is that the potential benefit of telerehabilitation technologies is that effective rehabilitation services can be implemented in the individual’s environment (home, community, workplace, and so forth).

Examples are found in the behavior therapy literature, in which there is substantial evidence that interventions delivered in vivo, or in the patient’s natural environment, have been more effective than the same therapy delivered in the clinic. This benefit has been demonstrated with treatment of agoraphobia, panic, pain, fear of reinjury in patients with back pain, and social phobia.

There is also significant impetus to support the value of medical rehabilitation services delivered in the home. Although much of this literature seems to be motivated by providing a rationale for expeditious discharge from the inpatient setting for cost-saving purposes, the research supports that the delivery of some home-based rehabilitation services is at least as effective as the delivery of those services in hospitals, and in some cases adds contextual factors that enhance rehabilitation and outcomes. These findings support the development and implementation of telerehabilitation approaches to facilitate naturalistic rehabilitation treatment in the home.

In a study by Von Koch and colleagues, a comparison between therapy following stroke delivered in the home versus in the clinic revealed that patients treated in the home took greater initiative and were more likely to express goals than patients treated in the hospital. In a similar randomized clinical control study of poststroke patients, Holmqvist and colleagues determined a systematic positive effect for those treated in the home in levels of social activity, activities of daily living, motor capacity, manual dexterity, and walking. Significant differences were also noted in rate of readmission and in patient satisfaction in favor of the home treatment group. Legg and Langhorne completed a systematic review of randomized clinical trials of rehabilitation therapy provided at home, and found that therapy at home resulted in improved ability to undertake personal activities of daily living and reduce risk of deterioration in ability. In-home treatment was found to reduce the incidence of delirium, reduce the duration of rehabilitation, and reduce rehabilitation costs in a frail elderly population. Telerehabilitation approaches have been recommended to facilitate in-home intervention approaches with persons with traumatic brain injury and the elderly.

Attention to contextual factors in rehabilitation is reinforced by the World Health Organization framework that emphasizes an individual’s functioning within the context of their environment. Recognizing that the social and physical environment can be facilitative (or inhibitory), rehabilitation that can occur within the patient’s own home and community has greater relevance to the patient. Ylvisaker states that for individuals with brain injury, cognitive rehabilitation that occurs in the natural setting and within the context of everyday interaction and demand domains is more relevant to the individual. Willer and Corrigan cite that the issue of generalization can be a major obstacle to achieving a successful rehabilitation outcome. What is learned or accomplished in one setting (eg, a clinic) does not necessarily generalize to other settings. Willer and Corrigan assert that the problem of failure of generalizability can be successfully addressed by conducting rehabilitation in the environment in which the skills must be applied.

The literature on supported employment, a demonstrated effective vocational rehabilitation strategy for enabling persons with severe disabilities to achieve competitive employment outcomes, stresses 2 naturalistic features. The model is built on the “place and train” premise, which states that individuals with disabilities should be placed in the real workplace as soon as possible, and that “pretraining” in clinical or simulated environments is less effective. The second feature is that supports and interventions (including cognitive rehabilitation, assistive technology, and adjustment counseling) can be delivered in the natural environment, through a job coach. Job coaching can be delivered by a live job coach, on-site, or through the use of telerehabilitation technologies to monitor and intervene remotely.

In summary, there is considerable evidence to support the value of conducting some aspects of rehabilitation within the natural environment. The literature suggests that such naturalistic treatment increases functional outcomes, addresses problems with generalizability, and enhances patient satisfaction and self-direction. These factors have also been related to quality of life issues. Therefore, telerehabilitation can play a key role in the accessibility and implementation of naturalistic and in vivo treatment.

As of April 2009, 63% of adult Americans reported broadband usage within their homes, up from 55% in May 2008. Given that the availability of Internet access is increasing extensively, and that wireless access is projected to become much more universally available, the potential to integrate treatment and monitoring into the environments where people live and work through in vivo telerehabilitation applications can become a viable option.

Telerehabilitation technologies

Traditional models of telemedicine began with videoconference interactions between a service provider, such as a physician or nurse, directly to a patient at the remote site. In recent years the model has been broadened, and the technologies supporting the remote service provision have diversified dramatically. This section briefly addresses models and then provides an overview of telerehabilitation technologies.

Models for providing telerehabilitation may provide services either synchronously (in real time) or asynchronously, in which data are collected and then later forwarded via email, bluetooth technology, or other electronic format for review by a clinician. Asynchronous applications are therefore often referred to as a “store and forward” approach. The exchange may occur directly between provider and patient, but more frequently includes a paraprofessional or facilitating staff person at the remote site who may be tasked simply with technology management, or may play a significant role in engaging the patient in interview or physical tasks. Telerehabilitation may alternatively follow a consultative model, in which the telerehabilitation provider participates in an assessment with the patient and his or her primary clinician at the remote site. Technology may also be developed in Web-based, robotic, or virtual reality-based formats and used autonomously by patients remotely, with the clinician observing patient responses and modifying the tasks accordingly. Here a variety of commonly used technologies for telerehabilitation are briefly reviewed, including telephones and videophones, video-conferencing, sensors, personal digital assistants (PDAs) and smart phones, virtual reality, and robotics.

Plain old telephone service (POTS) technologies use a real-time, standard analog voice-grade telephone service that remains the basic form of residential and small business service connection to the telephone network in most parts of the world. POTS is available in 97% of United States households. Despite the growing availability of high-speed Internet availability in individuals’ homes throughout the United States, the use of the POTS is still the most widely used mechanism for providing home tele-services. This situation may be in part due to the fact that prevalence and acceptance of technologies depend largely on ease of use and keeping implementation costs low. One step further is the videophone that is basically a telephone with a video screen, and is capable of full bidirectional video and audio transmissions for communication between people in real time. Videophones can especially be useful to persons who are deaf or who have hearing impairments, and can use them with sign language or for lip reading. Video-conferencing differs from the videophone in that it is designed to serve multiple participants through a conference rather than individuals. Video-conferencing is a set of interactive telecommunication technologies that allow 2 or more locations to interact via 2-way video and audio transmissions simultaneously. These interactive systems consist of some version of a video monitor, video camera, speakers, microphone, and a CODEC. The CODEC (stands for COder-DECoder) uses hardware or software to simultaneously code and decode (compress and decompress) digital video and audio information, and sends it to another CODEC where the same process is also occurring.

Real-time access may also be provided through wireless technologies that transfer information over a distance without the use of electrical conductors or “wires.” The distances involved may be short (a few meters as in television remote control) or long (thousands of miles for radio communications). When the context is clear, this term is often shortened to “wireless.” Technology that is able to be provided wirelessly allows increased freedom to be used within various environments and unrestricted movement.

PDAs and cell phones are some of the most common and widely used wireless devices. PDAs are handheld computers, also known as palmtop computers or handheld mobile computing. Newer PDAs also have both color screens and audio capabilities, enabling them to be used as mobile phones (smart phones), web browsers, or portable media players. Many of today’s PDAs or smart phones can access the Internet, intranets, or extranets wirelessly. Wireless, interactive, Web-based interventions are particularly suited to providing rehabilitation intervention and monitoring in the home and community environments. Gentry has completed studies in the use of PDAs as cognitive supports for persons with traumatic brain injury and multiple sclerosis. Positive outcomes were found with the use of PDAs as an intervention to improve performance of everyday life tasks for both of these populations. Technology is quickly converging with the development of smart phones, which combine PDAs with Internet access and cellphone technology as the convention of today.

Likewise, newer technologies include software applications that allow the user to make a voice or video call over the Internet, such as in the popular application called Skype. However, clinicians must consider the need for security and ensure that all precautions are taken to maintain patient confidentiality in accordance with Health Insurance Portability and Accountability Act regulations. Other technologies, including remote desktop control by the therapist (or desktop “push”), are examples of how rehabilitation services, such as job coaching and career development counseling, can be applied remotely.

Many motion sensors and technology involving body monitoring are now available wirelessly. A motion sensor is a device that contains a physical mechanism or electronic sensor that quantifies motion, which can be integrated with or connected to other devices that alert the user of the presence of a moving object (or person). Some examples of these devices include accelerometers for determining position in space and rate of movement, physiologic monitoring sensors that can track or check blood pressure or body temperature, electrocardiogram for heart rate, contactless sensors fatigue electromyogram for monitoring muscle activity, or electroencephalogram for monitoring brain electrical activity.

A newer technology that is being used with increasing frequency is Virtual Reality (VR). VR technology allows a user to interact with a 3-dimensional computer-simulated environment, whether that environment is a simulation of the real world or an imaginary world. VR systems provide sensory feedback to the user and whereas most systems use visual feedback, some simulations include additional sensory information, such as sound through speakers or headphones. Although VR is not geared toward the natural environment, it approximates or recreates it. For example, the popular game called The Sims encourages players to make choices while fully engaged in an interactive environment. This characteristic has helped the game successfully attract casual gamers. The Sims does not have the person engage in their natural environment to practice social skills, but creates a quasi-realistic setting to safely practice skills, with consequences but without long-term detrimental effects.

Other advanced systems called haptic systems now include tactile information, known as force feedback in applications. Haptic technology interfaces with the user through the sense of touch by applying forces, vibrations, or motions to the user. The user can “feel” objects in the virtual environment, and with practice can become skilled at subconsciously using an object as if it were an extension of their own body (ie, a pen for writing). Rehabilitation robotics is a growing area in which haptic technology is being used to aid and augment the traditional therapy intended for patients with motor disabilities to improve motor performance, shorten the rehabilitation time, and provide objective parameters for patient evaluation.