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Telerehabilitation (or e-rehabilitation is the delivery of
rehabilitation Rehabilitation or Rehab may refer to: Health * Rehabilitation (neuropsychology), therapy to regain or improve neurocognitive function that has been lost or diminished * Rehabilitation (wildlife), treatment of injured wildlife so they can be retur ...
services over
telecommunication network A telecommunications network is a group of nodes interconnected by telecommunications links that are used to exchange messages between the nodes. The links may use a variety of technologies based on the methodologies of circuit switching, messag ...
s and the internet. Telerehabilitation allows patients to interact with providers remotely and can be used both to assess patients and to deliver therapy. Fields of medicine that utilize telerehabilitation include:
physical therapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
, occupational therapy, speech-language pathology,
audiology Audiology (from Latin , "to hear"; and from Greek , ''-logia'') is a branch of science that studies hearing, balance, and related disorders. Audiologists treat those with hearing loss and proactively prevent related damage. By employing various ...
, and psychology. Therapy sessions can be individual or community-based. Types of therapy available include motor training exercises, speech therapy, virtual reality, robotic therapy, goal setting, and group exercise. Commonly used modalities include webcams,
videoconferencing Videotelephony, also known as videoconferencing and video teleconferencing, is the two-way or multipoint reception and transmission of audio signal, audio and video signals by people in different locations for Real-time, real time communication. ...
, phone lines,
videophone Videotelephony, also known as videoconferencing and video teleconferencing, is the two-way or multipoint reception and transmission of audio and video signals by people in different locations for real time communication.McGraw-Hill Concise Ency ...
s and webpages containing rich Internet applications. The visual nature of telerehabilitation technology limits the types of rehabilitation services that can be provided. Telerehabilitation is therefore often combined with other modalities such as in-person therapy. Important areas of telerehabilitation research include the investigation of new and emerging rehabilitation modalities as well as comparisons between telerehabilitation and in-person therapy in terms of patient functional outcomes, cost, patient satisfaction, and compliance. As of 2006, only a few health insurers in the United States will
reimburse Reimbursement is the act of compensating someone for an out-of-pocket expense by giving them an amount of money equal to what was spent. Companies, governments and nonprofit organizations may compensate their employees or officers for necessary a ...
for telerehabilitation services. If the research shows that tele-assessments and tele-therapy are equivalent to clinical encounters, it is more likely that insurers and Medicare will cover telerehabilitation services.


History

In 1999, D.M. Angaran published "Telemedicine and Telepharmacy: Current Status and Future Implications" in the
American Journal of Health-System Pharmacy The ''American Journal of Health-System Pharmacy'' is a biweekly peer-reviewed medical journal covering all aspects of drug therapy and pharmacy practice specific to hospitals. It was established in 1943 and is published by the American Society ...
. He provided a comprehensive history of telecommunications, the internet and telemedicine since the 1950s. The Department of Defense (DoD) and the National Aeronautics and Space Administration (NASA) spearheaded the technology in the United States during the Vietnam War and the
space program A space program is an organized effort by a government or a company with a goal related to outer space. Lists of space programs include: * List of government space agencies * List of private spaceflight companies * List of human spaceflight prog ...
; both agencies continue to fund advances in telemedicine. Three early adopters of telemedicine were state penitentiary systems, rural health care systems, and the radiology profession. Telemedicine makes business sense for the states because they do not have to pay for security escorts to have a prisoner receive care outside the prison. Rural telemedicine in the United States is heavily subsidized through federal agency
grants Grant or Grants may refer to: Places *Grant County (disambiguation) Australia * Grant, Queensland, a locality in the Barcaldine Region, Queensland, Australia United Kingdom *Castle Grant United States * Grant, Alabama * Grant, Inyo County, ...
for telecommunications operations. Most of this funding comes through the Health Services Research Administration and the Department of Commerce. Some state universities have obtained state funding to operate tele-clinics in rural areas. As of 2006, few (if any) of these programs are known to financially break-even, mostly because the Medicare program for people over age 65 (the largest payer) is very restrictive about paying for telehealth. In contrast, the
Veterans Administration The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing life-long healthcare services to eligible military veterans at the 170 VA medical centers an ...
is relatively active in using telemedicine for people with disabilities. There are several programs that provide annual physical exams or monitoring and consultation for veterans with spinal cord injuries. Similarly, some state Medicaid programs (for poor people and people with disabilities) have pilot programs using telecommunications to connect rural practitioners with subspecialty therapists. A few school districts in Oklahoma and Hawaii offer school-based rehabilitation therapy using therapy assistants who are directed by a remote therapist. The National Rehabilitation Hospital in Washington DC and
Sister Kenny Rehabilitation Institute The Courage Kenny Rehabilitation Institute is a rehabilitation medicine institute in Minneapolis, United States. History This Allina Health facility was created in 2013 by the merger of Courage Center and Sister Kenny Rehabilitation Institute. ...
in Minneapolis provided assessment and evaluations to patients living in Guam and
American Samoa American Samoa ( sm, Amerika Sāmoa, ; also ' or ') is an unincorporated territory of the United States located in the South Pacific Ocean, southeast of the island country of Samoa. Its location is centered on . It is east of the International ...
. Cases included post- stroke, post-
polio Poliomyelitis, commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 70% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe sy ...
,
autism The autism spectrum, often referred to as just autism or in the context of a professional diagnosis autism spectrum disorder (ASD) or autism spectrum condition (ASC), is a neurodevelopmental condition (or conditions) characterized by difficulti ...
, and wheel-chair fitting. An argument can be made that "telerehabilitation" began in 1998 when NIDRR funded the first RERC on tele-rehabilitation. It was awarded to a consortium of biomedical engineering departments at the National Rehabilitation Hospital and The Catholic University of America, both located in Washington, DC; the Sister Kenny Rehabilitation Institute in Minnesota; and the
East Carolina University East Carolina University (ECU) is a public university, public research university in Greenville, North Carolina. It is the fourth largest university in North Carolina. Founded on March 8, 1907, as a Normal school, teacher training school, East ...
in North Carolina. Some of this early research work, and its motivation, is reviewed in Winters (2002). The State of Science Conference held in 2002 convened most of military and civilian clinicians, engineers, and government officials interested in using telecommunications as a modality for rehabilitation assessment and therapy; a summary is provided in Rosen, Winters & Lauderdale (2002). The conference was attended by the incoming president of the American Telemedicine Association (ATA). This led to an invitation by ATA to the conference attendees to form a special interest group on telerehabilitation. NIDRR funded the second 5-year RERC on telerehabilitation in 2004, awarding it to the University of Pittsburgh. This RERC was renewed in 2010. In 2001, O. Bracy, a neuropsychologist, introduced the first web based, rich internet application, for the telerehabilitation presentation of cognitive rehabilitation therapy. This system first provides the subscriber clinician with an economical means of treating their own patients over the internet. Secondly, the system then provides, directly to the patient, the therapy prescription set up and controlled by the member clinician. All applications and response data are transported via the internet in real time. The patient can login to do their therapy from home, the library or anywhere they have access to an internet computer. In 2006, this system formed the basis of a new system designed as a cognitive skills enhancement program for school children. Individual children or whole classrooms can participate in this program over the internet. In 2006, M.J. McCue and S.E. Palsbo published an article in the Journal of Telemedicine and Telecare that explored how telemedicine can become a profitable business for hospitals. They argue that telerehabilitation should be expanded so that people with disabilities and people in pain (perhaps after hip-replacement surgery or people with
arthritis Arthritis is a term often used to mean any disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, swelling, and decreased range of motion of the affected joints. In some ...
) can get the rehabilitative therapy they need. It is unethical to limit payments for telerehabilitation services only to patients in rural areas. Research in telerehabilitation is in its infancy, with only a handful of equivalence trials. As of 2006, most peer-reviewed research in telemedicine are case reports of pilot programs or new equipment. Rehabilitation researchers need to conduct many more controlled experiments and present the evidence to clinicians (and payers) that telerehabilitation is clinically effective. The discipline of speech-language pathology is far head of occupational therapy and physical therapy in demonstrating equivalence over various types of telecommunications equipment.


Technologies

# Plain old telephone service (POTS) with
videophone Videotelephony, also known as videoconferencing and video teleconferencing, is the two-way or multipoint reception and transmission of audio and video signals by people in different locations for real time communication.McGraw-Hill Concise Ency ...
s/phones in telerehabilitation #: There are several types of connections used with real time exchanges. Plain old telephone service (POTS) uses standard analog
telephone line A telephone line or telephone circuit (or just line or circuit industrywide) is a single-user circuit on a telephone communication system. It is designed to reproduce speech of a quality that is understandable. It is the physical wire or ot ...
s. Videophones are used with POTS lines and include a camera, display screen, and telephone. Videophones use telephone lines that are available in most homes, so are easy to set up; however small display screens make them problematic for individuals with vision problems. This can be solved by using a large screen or television as a screen. # Videotelephony/Videotelephony in telerehabilitation #:The use of improved quality video-assisted telecommunication devices, such as
videoconferencing Videotelephony, also known as videoconferencing and video teleconferencing, is the two-way or multipoint reception and transmission of audio signal, audio and video signals by people in different locations for Real-time, real time communication. ...
, webcams and
telepresence Telepresence refers to a set of technologies which allow a person to feel as if they were present, to give the appearance or effect of being present via telerobotics, at a place other than their true location. Telepresence requires that the user ...
to assist in treatments. # Virtual reality/ Virtual reality in telerehabilitation #: Virtual reality in telerehabilitation is one of the newest tools available in that area. This computer technology allows the development of
three-dimensional Three-dimensional space (also: 3D space, 3-space or, rarely, tri-dimensional space) is a geometric setting in which three values (called '' parameters'') are required to determine the position of an element (i.e., point). This is the inform ...
virtual environments. # Motion technology/Motion technology in telerehabilitation # Web-based approaches/Web-based approaches in telerehabilitation #: Applications that run over the internet, just as if they were installed in your computer (called Rich Internet Applications), represent a new direction in software development. A person subscribes to the website rather than purchase the software. Any updates or changes to the software system are instantly available to all subscribers. The applications can be accessed from any location where one has access to an internet connected computer. Likewise, a patient's data is accessible from where ever the therapist is located. Neither the application nor the patient's data is tied to one computer. # Sensors and body monitoring/Sensors and body monitoring in telerehabilitation #
Haptic technology Haptic technology (also kinaesthetic communication or 3D touch) is technology that can create an experience of touch by applying forces, vibrations, or motions to the user. These technologies can be used to create virtual objects in a computer ...
/Haptic technology in telerehabilitation #
Artificial intelligence Artificial intelligence (AI) is intelligence—perceiving, synthesizing, and inferring information—demonstrated by machines, as opposed to intelligence displayed by animals and humans. Example tasks in which this is done include speech re ...
/Artificial intelligence in telerehabilitation #
Wireless technology Wireless communication (or just wireless, when the context allows) is the transfer of information between two or more points without the use of an electrical conductor, optical fiber or other continuous guided medium for the transfer. The most ...
/Wireless technology in telerehabilitation # PDAs/PDA in telerehabilitation #
Mobile telephony Mobile telephony is the provision of telephone services to phones which may move around freely rather than stay fixed in one location. Telephony is supposed to specifically point to a voice-only service or connection, though sometimes the ...
/Mobile telephony in telerehabilitation # Electronic medical records/Electronic medical record telerehabilitation # Mobile apps/Mobile apps telerehabilitation


Clinical applications


Speech-language pathology

The clinical services provided by speech-language pathology readily lend themselves to telerehabilitation applications due to the emphasis on auditory and visual communicative interaction between the client and the clinician. As a result, the number of telerehabilitation applications in speech-language pathology tend to outnumber those in other allied health professions. To date, applications have been developed to assess and/or treat acquired adult speech and language disorders,
stuttering Stuttering, also known as stammering, is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words, or phrases as well as involuntary silent pauses or blocks in which the ...
,
voice disorders Voice disordersTitze, I.R. (1994). Principles of Voice Production, Prentice Hall, . are medical conditions involving abnormal pitch, loudness or quality of the sound produced by the larynx and thereby affecting speech production. These include: * ...
, speech disorders in children, and swallowing dysfunction. The technology involved in these applications has ranged from the simple telephone (Plain Old Telephone System – POTS) to the use of dedicated Internet-based videoconferencing systems. Early applications to assess and treat acquired adult speech and language disorders involved the use of the telephone to treat patients with aphasia and motor speech disorders (Vaughan, 1976, Wertz, et al., 1987), a computer controlled video
laserdisc The LaserDisc (LD) is a home video format and the first commercial optical disc storage medium, initially licensed, sold and marketed as DiscoVision, MCA DiscoVision (also known simply as "DiscoVision") in the United States in 1978. Its diam ...
over the telephone and a closed-circuit television system to assess speech and language disorders (Wertz et al., 1987), and a satellite-based videoconferencing system to assess patients in rural areas (Duffy, Werven & Aronson, 1997). More recent applications have involved the use of sophisticated Internet-based videoconferencing systems with dedicated software which enable the assessment of language disorders, the treatment of language disorders, and the assessment and treatment of motor speech disorders (Hill, Theodoros, Russell, Cahill, Ward, Clark, 2006; Theodoros, Constantinescu, Russell, Ward, Wilson & Wootton, in press) following brain impairment and Parkinson's disease. Collectively, these studies have revealed positive treatment outcomes, while assessment and diagnoses have been found to be comparable to face-to-face evaluations. The treatment of stuttering has been adapted to a telerehabilitation environment with notable success. Two Australian studies (Harrison, Wilson & Onslow, 1999; Wilson, Onslow & Lincoln, 2004) involving the distance delivery of the Lidcombe program to children who stutter have utilized the telephone in conjunction with offline video recordings to successfully treat several children. Overall, the parents and children responded positively to the program delivered at a distant. Using a high speed videoconferencing system link, Sicotte, Lehoux, Fortier-Blanc and Leblanc (2003) assessed and treated six children and adolescents with a positive reduction in the frequency of dysfluency that was maintained six months later. In addition, a videoconferencing platform has been used successfully to provide follow-up treatment to an adult who had previously received intensive therapy (Kully, 200). Reports of telerehabilitation applications in
paediatric Pediatrics ( also spelled ''paediatrics'' or ''pædiatrics'') is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until the ...
speech and language disorders are sparse. A recent Australian pilot study has investigated the feasibility of an Internet-based assessment of speech disorder in six children (Waite, Cahill, Theodoros, Russell, Busuttin, in press). High levels of agreement between the online and face-to-face clinicians for single-word articulation, speech intelligibility, and oro-motor tasks were obtained suggesting that the Internet-based protocol had the potential to be a reliable method for assessing paediatric speech disorders. Voice therapy across a variety of types of voice disorders has been shown to be effectively delivered via a telerehabilitation application. Mashima et al. (2003) using PC based videoconferencing and speech analysis software compared 23 patients treated online with 28 persons treated face-to-face. The authors reported positive post treatment results with no significant difference in measures between the traditional and videoconferencing group, suggesting that the majority of traditional voice therapy techniques can be applied to distance treatment. Although obvious limitations exist, telerehabilitation applications for the assessment of swallowing function have also been used with success. Lalor, Brown and Cranfield (2000) were able to obtain an initial assessment of the nature and extent of swallowing dysfunction in an adult via a videoconferencing link although a more complete evaluation was restricted due to the inability to physically determine the degree of laryngeal movement. A more sophisticated telerehabilitation application for the assessment of swallowing was developed by Perlman and Witthawaskul (2002) who described the use of real-time videofluoroscopic examination via the Internet. This system enabled the capture and display of images in real-time with only a three to five second delay. There has been considerable research into the assessment and treatment of dysphagia via telerehabilitation, including cost analyses, leading to the establishment of sustainable telerehabilitation services. There continues to be a need for ongoing research to develop and validate the use of telerehabilitation applications in speech-language pathology in a greater number and variety of adult and paediatric communication and swallowing disorders.


Occupational Therapy

Occupational Therapy Practitioners (OTP), work with people across the lifespan in order to facilitate independence, establish or rehabilitate roles, habits and routines. Occupational Therapy can be administered through means of telehealth, and since telehealth is often being performed in the clients' own environment, carry-over and efficacy of interventions is often increased. There are many types of occupational therapy intervention that can be provided through telehealth. Many positive outcomes have been reported across multiple intervention areas including: motor learning/relearning, ADL/IADL retraining (following CVA, TBI, Cancer, joint replacement, etc), functional cognitive training, home modification assessments, vision rehabilitation, pediatric therapies and family training. It is safe to consider telehealth as an emerging practice area for OTPs with evidence of efficacy mounting from various areas of practice. Following the COVID-19 Pandemic, Medicare and many private insurance companies swiftly adopted Telehealth as a reimbursable option for provision of occupational therapy services, although Telehealth has been used for many years prior especially in rural areas. As the public health emergency is due to expire, many advocates of telehealth are working towards establishing more permanent measures to protect telehealth as a reimbursed service. Th
American Occupational Therapy Association (AOTA)
an
World Federation of Occupational Therapists (WFOT)
are both in support of Telehealth as a means to provide care. Most importantly, OTPs themselves are in support of making telehealth a permanent option for service delivery. Telehealth is a promising adjunct to in-person treatment for persons receiving occupational therapy services.


Physical Therapy

Types of Physical rehabilitation therapies delivered through telerehabilitation include strengthening exercises, motor retraining, goal setting, virtual reality, robotic therapy, community-therapy. Motor strengthening exercises are the most commonly implemented modality. In motor training exercises, a provider guides a patient through performing different motions and activities in order to regain strength and function. Motor training through telerehabilitation has consistently been shown to produce equivalent functional outcomes compared with in-person therapy. However, many patients require in-person therapy initially before transitioning to telerehabilitation. Goal setting has been used in remote areas where cost and provider availability prohibit access to physical therapy. Patients work with a therapist to set personal goals and track their progress through sessions. Goal setting telerehabilitation has been shown to produce increased patient satisfaction and improvement in activities of daily living compared with a control group receiving no therapy. Virtual reality therapy involves the use of a sensor to detect movement and a virtual environment displayed on either a screen or headset. Patients perform therapeutic movements that correspond to tasks within the virtual environment. This provides an immersive environment for the patient and allows computerized monitoring of patient progress. Studies that compared virtual reality with motor training exercises have shown equal or better outcomes with virtual reality. Robotic therapy typically involves the use of hand and foot strengthening robots which provide resistance training and assist the patient with performing movements. Robotic devices can also obtain precise data on patient movements and usage statistics and transmit them to providers for evaluation. Robotic therapy has even been combined with virtual reality telerehabilitation to create a virtual environment which responds to robotic movements. Robotic telerehabilitation studies have shown patient improvement from baseline but equivalent functional outcomes compared with motor training exercises. Community therapy is used to deliver education and therapy to patients remotely, either through group exercise sessions or through kiosks. Community therapy tends to have lower patient compliance than individualized therapy, but can deliver similar results if appropriately utilized.


Chronic respiratory disease

Telerehabilitation for chronic respiratory disease The latest evidence suggests that primary pulmonary rehabilitation and maintenance rehabilitation delivered through telerehabilitation for people with chronic respiratory disease reaches outcomes similar to centre-based rehabilitation. While there are no safety issues identified, the findings are based on evidence limited by a small number of studies.


Cardiovascular Disease

Telerehabilitation for cardiovascular disease A systematic review of ten studies to measure the effectiveness of telerehabilitation as a means to reach "cardiac rehabilitation" has shown to be considered as an effective and appropriate measure to increase participation in underdeveloped areas. The issue noted in the review was the technical drawbacks of broadband and limited internet connectivity, which limited the participation of willing participants of the study. Addressing this technological gap could help showcase the potential impact of telerehabilitation on cardiac rehabilitation accessibility and participation as well as person-centered, health, and economic outcomes.


Stroke Survivors


Telerehabilitation for Stroke Survivors

In a 2018 systematic review of 15 studies it was found that there were no significant differences in given tests and measures between telerehabilitation and control groups when it came to post stroke care. This was supported through tests such as Barthel Index , Berg Balance Scale , Fugl-Meyer Upper Extremity , and Stroke Impact Scale.  Furthermore, the study goes on to conclude that “Telerehabilitation can be a suitable alternative to usual rehabilitation care in post stroke care especially in remote or underserved areas. Larger studies are needed to evaluate the health-related quality of life and cost-effectiveness with the ongoing improvements in telerehabilitation networks.”


Standards and training requirements

# Telerehabilitation standards #
Reimbursement Reimbursement is the act of compensating someone for an out-of-pocket expense by giving them an amount of money equal to what was spent. Companies, governments and nonprofit organizations may compensate their employees or officers for necessary ...
policies/ Reimbursement in telerehabilitation # Legislative activities/ Legislative activities in telerehabilitation # Ethics and privacy issues/ Ethics and privacy issues in telerehabilitation # Clinical and technology training issues


Related organizations

* American Telemedicine Association (ATA) *
American Speech-Language-Hearing Association American(s) may refer to: * American, something of, from, or related to the United States of America, commonly known as the "United States" or "America" ** Americans, citizens and nationals of the United States of America ** American ancestry, pe ...
(ASHA) * National Institute on Disability and Rehabilitation Research (NIDRR) *
Rehabilitation Engineering and Assistive Technology Society of North America Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) is an association of people with an interest in technology and disability. Its mission statement A mission statement is a short statement of why an organizati ...
(RESNA) * Special Interest Group on Telerehabilitation (SIGOT)


See also

* Rehabilitation (neuropsychology)


References


External links

* {{Telemedicine navbox Rehabilitation medicine