Acknowledgements

The distance communication project is a joint effort involving a variety of institutions. Clinically, the efforts and enthusiasm of Yvonne Jeffreys, Nathalie Anglehart, David Nielen (The Rehabilitation Centre - Ottawa) - Sheila McBride, Linda Buttle, and Sheila Cameron (Arnprior and District Memorial Hospital) - Leslie Bangs, Andree Campbell, Rachel Bertrand (Hawkesbury General Hospital) were essential to the success of this endeavour. Gayle Greene and the Terry Fox Mobile Clinic team are acknowledged for sharing their community-based experience and providing physical space for the host system. Guy Morazain, Colin MacKenzie (ROHCG) and the IBM Ottawa staff are also acknowledged for their technical assistance. Jean Cruikshank and Sylvia Ralphs-Thibodeau are thanked for their assistance with the dissemination of information concerning this project. This project was funded by the National Strategy for the Integration of Persons with Disabilities (Industry Canada), the Labatt's Relay Research Fund, and IBM Canada.

Overview

The combination of computer technology and telecommunications is an exciting prospect for the rehabilitation field. Recent advancements in video conferencing systems and Internet access provide a basis for remote assessment and consultation at a reasonable cost. By using computer/telecommunication links to send data, graphics, video, and sound between two or more sites, remote areas will be able to access clinical assessment and follow-up services without travelling to a central rehabilitation facility. This study involved developing a model for the application of computer distance communication to orthotic assessment, setting-up two pilot sites and one central rehabilitation site with the computerized communication equipment, and testing the system with a series of people who would benefit from lower extremity orthoses.

To test the appropriateness of the remote assessment method, one orthotist performed an on-site assessment of a person who required an ankle foot orthosis (AFO). This information was compared with an on-line assessment from a therapist at the remote site and an orthotist at The Rehabilitation Centre (Ottawa). Three on-site assessment sessions were completed, two at Arnprior and District Memorial Hospital and one at Hawkesbury General Hospital.

Generally, the on-site and on-line results were very similar; however, selected measures showed small to medium differences. These discrepancies were attributed to individual differences between clinicians, differences in measurement technique between orthotists and other therapists, technical and learning obstacles at the start of the project, and individual variations between subjects during the day (i.e., the amount of spasticity may change between an early assessment and one later in the day).

On-line assessment efficiency improved with each on-line session. Between the first and the third on-site visits, the average amount of time to complete an assessment decreased from 84 minutes to 43 minutes. This increased assessment efficiency corresponded with improvements in ease of use, confidence in the system, and overall satisfaction.

An on-line debriefing session was held after the third testing session. During the meeting, Ottawa, Hawkesbury, and Arnprior shared communication resources over an Internet link. Information from this session confirmed that clinicians support continued use of the distance communication system for rehabilitation consultation and education. Technically, the system was considered good; however, certain changes were recommended. These changes included installing a better speaker-phone system, streamlining the video capture process, and providing more reliable telecommunication connections. Clinically, the system/protocol could be improved by having some face-to-face meetings to better define therapist roles and techniques. A regular and more structured practice schedule was recommended for continued use of the system.

Based on the test results and the clinician feedback, computerized distance communication can be considered an appropriate technology for consultations in orthotic and many areas of physical rehabilitation. The low-cost solution presented in this report should make remote rehabilitation assessment accessible by most clinics in Canada since existing communication lines can be used, low-end computers are required, and the system is easy to use.

Introduction

This report describes a joint project in which a clinical service communication system for people using lower limb orthotics was developed and evaluated. Specifically, the objectives for this project were to:

1. Identify requirements for providing orthotic services using computer distance communication technology,
2. Set up two remote pilot sites (Arnprior and District Memorial Hospital and Hawkesbury General Hospital) so remote clinicians can communicate with clinicians at The Rehabilitation Centre (Ottawa),
3. Develop tools to help with distance communication issues specific to clinical assessment and treatment,
4. Assess the results of implementing this system.

The following sections will describe technical requirements and obstacles for setting up a distance communication system, clinical criteria for orthotic assessment, system validation, and clinician feedback. Background information on related research, research partners, conferencing hardware/software, and assessment data are located in the appendices.

Methods

This section will outline the procedures used to develop and validate a distance communication approach for remote orthotic assessment. Since this project is community oriented, a brief description of the Terry Fox Mobile Clinic is also included. All interactions between the remote communities and The Rehabilitation Centre occurred through the Mobile Clinic.

Terry Fox Mobile Clinic

The Terry Fox Mobile Clinic is an interdisciplinary rehabilitation team affiliated with The Rehabilitation Centre in Ottawa, Ontario, Canada (Greene, 1993; Lavallee and Crupi, 1992). It travels to fifteen rural communities in eastern and northeastern Ontario. The broad goal of the Mobile Clinic is to enhance the quality of care that is available in rural communities so that people with rehabilitation needs can be served adequately in their home towns. Structurally, the team includes a physiatrist, a nurse, a physiotherapist, a speech-language pathologist, an occupational therapist, a social worker, a psychologist, a secretary, a driver, and, when necessary, specialists in prosthetics, orthotics, and custom seating.

Functionally the team has several roles, including consultation (e.g., providing interdisciplinary assessments and treatment recommendations to patients, families, and local health professionals), direct service (e.g., providing assistive devices and wheelchair support services that would otherwise be unavailable in rural communities), and education (e.g., workshops and seminars to local health-care providers). For this study, the Mobile Clinic acted as the administrative mechanism through which community sites and The Rehabilitation Centre interacted.

Inventory of Current Clinical Methods

To determine the methods and procedures for orthotic assessment and follow-up, an inventory of current orthotic practices on the Mobile Clinic was amassed. This information was collected through interviews with Mobile clinic orthotists and other members of the Mobile Clinic team. The assessment and follow-up information was used to develop a standard assessment form and database for use in this study.

Once the assessment method was defined, two orthotists were trained to use this protocol. A group of five lower extremity orthotic clients were recruited through the Prosthetics and Orthotics service to ensure that both orthotists were employing the same technique. Both orthotists independently assessed each client and recorded the results on the assessment form. If the measurements were different, the orthotists would review the standard assessment protocol and assess a second group of clients.

Clinical Intervention Plan

After a thorough description of orthotic clinical methods were documented, assessment and follow-up plans were prepared to include the computer conferencing link. The standard assessment and follow-up forms were revised based on the computer intervention plan. This study focussed on the assessment section.

The first on-site visit was used as a test session. These tests ensured that the computer assessment methods were appropriate for people who require lower extremity orthoses. These pre-tests also permitted debugging of the computer link and gave all participants some experience using the system with clients before data collection began.

System Training

When the computer hardware and software was functioning, clinical and technical staff at the Rehabilitation Centre and the remote sites received training on the computer communication system. The first training session was done on-site (i.e., The Rehabilitation Centre, Hawkesbury General Hospital, and Arnprior and District Memorial Hospital). Subsequent training was performed using the conferencing link and on-line tutorials. Additional face-to-face instruction was performed whenever the principle investigator happened to be on-site.

Client and Clinician Questionnaires

Clinician questionnaires were used to assess clinical success, satisfaction with the system, and evaluate the clinical intervention plan. The questionnaires included client demographic information, temporal information, and a session log for comments. The questionnaires are shown in Appendix F. One clinician questionnaire was completed for each clinical intervention.

Subjects

A total of 21 people who needed or could benefit form lower extremity orthotics participated in this study. Five people were recruited from the Prosthetics and Orthotics Service at the Rehabilitation Centre for clinical assessment method testing. The other 16 people were recruited from two Mobile Clinic remote sites: Hawkesbury General Hospital and Arnprior and District Memorial Hospital. The experimental protocol was explained to each subject before he/she completed a consent form.

Assessment

The subjects were assessed using the computer communication link on the same day as the on-site physical assessment. One orthotist performed the on-site assessment and a second orthotist, in association with on-site therapists, performed an assessment using the computer communication link. Both orthotists used the standard assessment protocol and record the results on the assessment form.

Debriefing

Upon completion of the client data collection phase, a debriefing session was held on-line, with each community and The Rehabilitation Centre. All involved clinical staff discussed the benefits, contraindications, and future developments related to the distance communication system.

Data Analysis

All data were analyzed using descriptive statistics. A Spearman correlation coefficient was used to assess the linearity between assessment ratings from the two assessments. If there is no significant difference between the manual and computer assessment or follow-up results, or if the computer system results are better than the manual results, the computerized communication system will be considered an appropriate method for conducting lower extremity orthotic assessments and follow-ups.