Richard M. Schein, MS¹ & Mark Schmeler, PhD, OTR/L, ATP¹
Department of Rehab. Sciences & Technology, University of Pittsburgh, Pittsburgh, PA 15261

ABSTRACT

Wheelchair provision and service delivery for individuals with mobility impairments is a complex and challenging clinical intervention. Availability of practitioners with specific expertise in wheeled mobility and seating is limited, especially in rural areas. People are isolated from rehabilitation services due to geography or physical limitations; large distances mean excessive travel times increasing costs. Telerehabilitation (TR) is a tool that can alleviate the severity of some of the problems. This study will determine the effectiveness and accuracy of using a TR consultation model for procuring appropriate wheeled mobility and seating devices for individuals with mobility impairments. Anticipated outcomes for this study are improved function measured by the Functioning Everyday with a Wheelchair (FEW).

KEYWORDS

telerehabilitation; communications technology; assistive technology; service delivery

BACKGROUND

The wheelchair is viewed as one of the most important Assistive Technology (AT) devices in the field of rehabilitation (1). In the United States, an estimated 2.2 million people currently use wheelchairs for their daily mobility (2). However, demography studies of disability show that there are 12.5 million rural Americans who have disabilities in non-metropolitan areas who are in need of rehabilitation services (3). The assessment of the user’s needs and matching the user with an appropriate wheeled mobility and seating intervention as well as fitting and training is essential for successful outcomes (4).

In the past thirty years, technologists and clinicians have investigated the use of advanced telecommunications and information technologies as a way of bridging the gap between individuals with specialized medical needs living in remote areas and the source of specialty care (5). Telerehabilitation (TR), a subcomponent of the broader area of telemedicine, is the application of telecommunication technology that provides distant support, assessment and intervention to individuals with disabilities (6). There are more people in need of the services of assistive technology specialists than there are regional clinics to serve them. The durable medical equipment industry has seen new coverage guidelines implemented by Centers for Medicare and Medicaid Services recently for wheelchairs (i.e. mobility assistive equipment) of who can perform these assessments.

The question becomes is it possible to find a way to deliver the same technology and assessment to a remote site? One way to consider TR is point of delivery, where TR attempts to bring the expert clinician from a large urban clinical setting to places where such care is not yet available via a secure videoconference transmitting data, video, and audio simultaneously. This has led to the development of remote clinical locations modeled after the Center for Assistive Technology at the University of Pittsburgh Medical Center (CAT-UPMC). Cooper, et al (4), has discussed the potential of rapid improvement in telecommunications technology to improve access to AT services for people with disabilities in rural areas. Consequently, TR offers many new opportunities to provide rehabilitation services in alternative ways and in different settings.

METHOD

A repeated measure study design will be used to appraise the effectiveness of wheeled mobility and seating interventions provided in a remote location by a Generalist Occupational and/or Physical Therapy Practitioner with consultation from an Expert Practitioner via interactive secure videoconferencing. Effectiveness will be measured by magnitude of change in function as scored by both the Functioning Everyday with a Wheelchair (FEW) pre and post provision of their device. The FEW is a 10 item self-report outcome measurement tool that was systematically developed based on consumer input and validation that included structured interviews with wheelchair users. It uses a 6 point scale to answer questions, with 6 indicating they strongly agree and 0 indicating they strongly disagree. The FEW has also undergone concurrent validation whereby items were further developed by comparing goals and items documented in other measurement tools. The FEW has demonstrated good test-retest reliability and takes about 20 minutes to complete (7). The equipment includes the use of a personal computer, Logitech webcam with a built in microphone for both video and audio, and videoconferencing software.

Figure 1: Clinical/Service Delivery Protocol (Click for larger view)

Each participant will be evaluated through a comprehensive initial assessment with regard to their needs, preferences, and goals with the Generalist Practitioner who will receive consultation from the Expert Practitioner observing via telerehabilitation. During the visit, a baseline administration of the FEW will be given in their current wheeled mobility and seating device. The complete service delivery protocol is shown in Figure 1.

After the submission of a Letter of Medical Necessity, funding approval is determined, stating why there is need of a new wheeled mobility and seating intervention. An appointment for the participant to be seen in the remote clinic for fitting and delivery via telerehabilitation is then scheduled. The Expert Practitioner will participate via telerehabilitation to provide assistance as needed. A follow-up session is conducted within two weeks following delivery of the participants wheeled mobility and seating intervention. This involves administration of the FEW items administered during the initial assessment. It is hypothesized that the participants overall gain score within the ten items of the FEW(stability, durability, dependability; comfort needs; health needs; operation; reach; transfers; personal care; indoor mobility; outdoor mobility; and transportation) will be greater at post test than at pre test.

RESULTS

Project team leaders have assisted both Charles Cole Memorial Hospital located in Coudersport, PA located about 180 miles from Pittsburgh and Dubois Regional Medical Center located about 130 miles from Pittsburgh set-up wheelchair clinics modeled after CAT-UPMC. Each hospital’s Institutional Review Board (IRB) have reviewed and accepted the protocols that were approved by the University of Pittsburgh’s own IRB. Clinicians at both sites have been trained on documentation and outcome measures and information technologists have downloaded and trialed the secure videoconferencing. Data collection is in progress as the first TR clinic day was on November 22, 2006 and will be held at least twice a month. As of January 18, 2007, 8 people had consented and their initial assessments were completed. There have been no adverse effects as well as confidentiality and privacy have been established as these are two of the main concerns when performing live assessments and exchanging data via the internet.

CONCLUSION

It is speculated that telerehabilitation has the potential to enhance quality and continuity of care by providing consistent access to rehabilitation expertise and support. It also has the potential to create greater client-tailored rehabilitation interventions that better suits a person’s natural environment and lifestyle. Ultimately, the availability of telerehabilitation services could allow people to receive services and interventions either in their homes or communities by local practitioners and providers with remote support and consultation provided by specialists. . However, these speculations need to be systematically substantiated in order for clinical and consumer entities to accept telerehabilitation as a means of service provision.

REFERENCES

1. Kirby, R.L., Swuste, J., Dupuis, D.J., MacLeod, D.A., & Monroe, R. (2002). The Wheelchair Skills Test: a pilot study of a new outcome measure. Archives of Physical Medicine and Rehabil, 83(1), 10-18.
2. Kaye, H. S., Kang, T., & LaPlante, M. P. (2000). Mobility device use in the United States. (Disability Statistics Report No. 14). Washington, DC: U.S. Department of Education, National Institute on Disability and Rehabilitation Research.
3. Office of Management and Budget. (2004) Revised Definitions of Metropolitan Statistical Areas, New Definitions of Metropolitan Statistical Areas and Combined Statistical Areas, and Guidance on Uses of the Statistical Definitions of these Areas. Bulletin No. 03-04. Washington, DC: Executive Office of the President
4. Cooper, R., Fitzgerald, S., Boninger, M., Brienza, D., Shapcott, N., & Cooper, R. A. (2001). Prolog to Telerehabilitation: expanding access to rehabilitation expertise. Paper presented at the Proceedings of the IEEE.
5. Kinsella, A. (1998). Home Telecare in United States. Journal of Telemedicine and Telecare, 4, 195-200.
6. Ricker, J., Rosenthal, M., Garay, E., DeLuca, J., Germain, A., Abraham-Fuchs, K., & Schmidt, K. (2002). Telerehabilitation needs: A survey of persons with acquired brain injury. The Journal of Head Trauma Rehabilitation, 17(3), 242-250
7. Mills, T., Holm, M. B., Schmeler, M., Trefler, E., Fitzgerald, S., & Boninger, M. (2002). Development and consumer validation of the Functional Evaluation in a Wheelchair (FEW) Instrument. Disability and Rehabilitation, 24(1-3), 38-46.

ACKNOWLEDGEMENT

This study is funded by National Institute on Disability and Rehabilitation Research (#070252).

CONTACT

Richard M. Schein,
Department of Rehabilitation Science and Technology,
University of Pittsburgh
2310 Jane Street Suite1300,
Pittsburgh, PA 15204,
rms35@pitt.edu

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