REVIEW URRENT C OPINION
Telerehabilitation and emerging virtual reality approaches to stroke rehabilitation David Putrino
Purpose of review Stroke is the leading cause of permanent motor disability in the United States, and the rapidly aging population makes finding large-scale treatment solutions to this problem a national priority. Telerehabilitation is an emerging approach that is being used for the effective treatment of multiple diseases, and is beginning to show promise for stroke. The purpose of this review is to identify and highlight the areas of telerehabilitation that require the most research attention. Recent findings Although there are many different forms of telerehabilitation approaches being attempted for stroke, the only approach that is currently showing moderate–strong evidence for efficacy is videogame-driven telerehabilitation (VGDT). However, targeted research is still required to determine the feasibility of VGDT: metrics regarding system usability, cost-effectiveness, and data privacy concerns still require major attention. Summary VGDT is an emerging approach that shows enormous promise for stroke rehabilitation. Future studies should focus less on developing custom task controllers and therapy games and more on developing innovative, online data acquisition and analytics pipelines, as well as understanding the patient population so that the rehabilitation experience can be better customized. Keywords physical therapy, stroke, telemedicine, telerehabilitation, virtual reality
INTRODUCTION Stroke is the leading cause of permanent motor disability in the United States, and although its incidence per capita over the age of 65 is not changing [1], the population of Americans over 65 is expected to almost double to 90 million (http:// www.aoa.gov) by 2050. Given that an individual over the age of 65 has a 9% chance of being affected by stroke [1], the accelerated rate of aging in the United States is projected to cause an unprecedented spike in the number of stroke occurrences. Paired with a mean lifetime cost of $145 000 per stroke [2], these projections suggest that the direct medical costs of treating all the new cases of stroke over the age of 65 will increase by approximately $105 billion by the year 2030 [1]. In the context of an already stressed public health system, the implications of these statistics are grave. Management and rehabilitation of stroke desperately requires innovation. The problem is challenging; potential solutions require delivery of effective, low-cost, and accessible services to a large number of people.
Telehealth is an evolving field that is currently drawing global attention; this is because of its potential for low-cost implementation and proven efficacy in improving clinical outcomes in specific patient populations [3]. Although telehealth is not a novel concept, advances in low-cost, accessible sensor and motion capture technology have made it possible to collect and synthesize patient data with unprecedented accuracy and ease. Telerehabilitation is an emerging branch of telehealth that has recently shown promise in the rehabilitation of many different conditions including chronic obstructive pulmonary disease (reviewed by [4]), Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, Department of Physical Medicine and Rehabilitation, Weill Medical College of Cornell University, New York, New York, USA Correspondence to David Putrino, Burke-Cornell Medical Research Institute, 785, Mamaroneck Ave, White Plains, New York, NY 10605, USA. Tel: +1 914 368 3183; e-mail: [email protected] Curr Opin Neurol 2014, 27:631–636 DOI:10.1097/WCO.0000000000000152
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KEY POINTS Video-game based telerehabilitation protocols for stroke show significantly improved outcomes compared with conventional therapies. The literature investigating optimized, user-friendly telerehabilitation interfaces for patients and clinicians is sparse, and must be developed. To date, a rigorous investigation of the costeffectiveness of telerehabilitation compared with conventional therapy has not been performed. Telerehabilitation has the potential to revolutionize the delivery of care to stroke patients, but many factors need to be investigated prior to mainstream deployment.
total knee replacements (reviewed by [5]), coronary heart disease (reviewed by [6]), diabetes (reviewed by [7]), and many other conditions. Broadly speaking, the goal of telerehabilitation is to use communications technology to create effective and safe rehabilitation environments that do not require the constant oversight of a treating therapist.
TELEREHABILITATION AND STROKE: APPROACHES AND IMPACT Impaired voluntary movement, one of the hallmarks of stroke, is the main cause of severe functional limitations. Although there is good scientific evidence to advocate for the use of high-intensity exercise to improve function following stroke, most people do not receive the recommended care [8,9]. Unfortunately, delivery of adequate therapy is limited by cost, convenience of transport to the treatment facility, and difficulty motivating patients to perform highly repetitive motor training [10]. In regards to stroke rehabilitation alone, the term ‘telerehabilitation’ has been used to describe many different therapies. Such motor rehabilitation conventions have included reinforced phone or video conferencing as well as robot-assisted rehabilitation and augmented and virtual reality therapy protocols [11 ]. Given the highly variable nature of implementation of many different therapies under the ‘telerehabilitation’ umbrella, it is challenging to make specific statements about the general efficacy of telerehabilitation for stroke. A recent Cochrane review of 10 studies of telerehabilitation following stroke, involving a total of 933 participants, could show no significant evidence to support the implementation of a telerehabilitation protocol for stroke [11 ]. A limiting factor with this review, however, &&
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was the working definition of telerehabilitation: ‘the provision of rehabilitation services to patients at a remote location using information and communication technologies’. The styles of interventions that were studied were diverse, exploring some studies that utilized a simple phone-based follow-up schedule with patients, to studies involving computerized therapy sessions, accompanied by outpatient therapy visits and teleconferencing. Attempting to evaluate such a large variety of interventions is problematic, and it is unsurprising that the authors were unable to show clear efficacy in a single meta-analysis. Despite its negative conclusion, however, this review is essential to the field of stroke telerehabilitation, as it highlights the need for more targeted, large-scale research with a unified commitment to a specific format of telerehabilitation delivery. A more recent review, focusing exclusively on videogame-driven telerehabilitation (VGDT) protocols, showed that the outcome of stroke rehabilitation using game-based therapy significantly outperformed conventional therapy [12 ]. This review shall focus almost exclusively on investigating progress in VGDTs designed for stroke rehabilitation using commercially available motion capture hardware. &&
APPROPRIATE HARDWARE FOR VIDEOGAME-DRIVEN TELEREHABILITATION In the past decade, the ability for amateur and professional computer scientists to become proficient in different programming languages and generate custom task controllers for hardware devices has grown rapidly. In response to this, most new hardware devices come with specific ‘software developer kits (SDKs)’ or ‘application programming interface’ to allow users to fully customize hardware interaction experience to their own needs. The response to the spike in device availability has been a rapid development of innovative research tools for patient monitoring and biometric data acquisition for particular disease processes or patient populations. In fact, some recent reviews have explored the enormous range of biosensors that are currently being integrated into rehabilitation systems [13,14], and this digital health trend is continuing to grow. Although it is tempting to engage in the trend of developing custom technological solutions for particular patient populations, one must also consider that for a stroke rehabilitation solution to be truly effective globally, it must also be highly scalable. Early attempts at adopting telerehabilitation systems for stroke are to be commended for their Volume 27 Number 6 December 2014
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Telerehabilitation and emerging virtual reality approaches to stroke rehabilitation Putrino
role in creating proof of concept, but often did not represent a practical solution for large-scale deployment [15], or decrease the amount of therapist input required to service the intended population [16]. Systems that are intended as stroke telerehabilitation tools must be available, affordable, and require very little assembly on the end of the patient or the treating therapist. Many clinicians are not well versed in computer science or biomedical engineering and should not be expected to learn to use complex systems to assist in the delivery of patient care. Recently, many mainstream gaming consoles have been released with sophisticated motion capture capabilities, highly engaging user interfaces and surprisingly open SDKs. Given that gaming consoles are specifically designed to be low cost, easily available almost anywhere in the world, and enjoyable and simple to interact with, it would appear that they represent the ideal interface for developing the most scalable VGDT systems. Many researchers are beginning to take advantage of affordable and accessible electronic or gaming devices to create highly state-of-the-art telerehabilitation software solutions [17].
GAMING CONSOLES AND TELEREHABILITATION
designed to be fun and engaging in order to encourage patients to perform many repetitions of a motor task, they are often dull, and do not encourage the desired response. Although these issues are understandable limitations for a new therapy, clinical researchers should be aware that there is already good evidence to support the use of commercially available video games to drive the telerehabilitation interface, negating the need for clinicians to design their own games, and allowing large numbers of individuals to be recruited more rapidly [37,12 ]. &&
ENJOYMENT, USABILITY, AND ACCEPTANCE One of the most important elements of any rehabilitation protocol is patient engagement [10]. However, when dealing with telerehabilitation protocols, this is not an element that is exclusively for the patient – if clinicians are to be expected to adopt VGDT systems, we must ensure that the user interface design on the side of the therapist is equally simple to navigate and informative. Unfortunately, despite the urging of previous studies to design telerehabilitation protocols that ensure patient usability and clinical utility, very few researchers have conducted these studies [38 ]. For most of the literature that has been discussed in this review, this has been a clear omission in study design. A few studies have explored the question of usability of VGDTs in stroke patients and found their system usability to be satisfactory to both patients and clinicians, indicating that the design of a highly usable VGDT is a feasible possibility [27,39 ,40,41]. &&
Recently, a number of studies have used VGDTs for the motor rehabilitation of stroke symptoms. Gaming consoles such as the Microsoft Kinect, Leap Motion or even a simple 3D joystick have been used to generate gesture recognition and inverse kinematics data effectively within a gaming framework [18,19]. Furthermore, the Microsoft Kinect in particular has been shown to generate kinematic data that is accurate enough to provide informative, real-time feedback to patients and therapists about joint kinematics [20,21]. However, very few other commercial gaming systems have been validated as rigorously as the Kinect, and this should be a clear goal for individuals working in this field of research. These gaming consoles have also been used as effective tools for simple, home-based stroke rehabilitation for the upper limb [22 ,23–29], standing balance [30–32], and training to overcome aphasias [33–35]. Most of these studies show either comparable or superior efficacy when compared with conventional therapies, and a potential mechanism for this is that the engaging nature of VGDT increases patient use of the affected limb [36]. However, as with many emerging therapies, the most common limitations with existing VGDT studies are that they are pilot studies with extremely low participant numbers, and the games themselves are somewhat rudimentary – meaning that although they were &
&
DATA ANALYSIS AND PRIVACY A main advantage of VGDTs over conventional therapy approaches is the potential for data collection during periods of home exercise and remote patient monitoring. In the last 5 years, the access to truly powerful, yet accessible and affordable motion capture and sensing technology has resulted in an unprecedented ability to engage in detailed remote patient monitoring. If used appropriately, these data will be instrumental in designing and optimizing the next generation of VGDTs – helping us to understand factors such as optimal exercise duration and intensity for different stroke-related impairments, more targeted and quantitative assessment protocols for specific functional goals, and better overall understanding of long-term outcome of different types of stroke. Given the ability for such valuable data collection, it is imperative that it is stored and curated in an effective and appropriate manner.
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Computational strategies for the seamless analysis of the data being collected have begun to be developed so that behavioral classification, disease and impairment staging, and condition progress can be logged efficiently and quantitatively in stroke patients [42,43]. Furthermore, the streaming of data onto secure database systems such as REDCap (http:// www.project-redcap.org/) is becoming increasingly necessary to ensure logical storage and organization of large sets of biometric data. When designing any form of telemedicine system, the confidentiality and security must always be the paramount concern. Designing VGDTs for research purposes is no exception: patient data should be de-identified as early as possible in the data acquisition pipeline and never stored on a patient’s local telerehabilitation device; instead, data should be streamed to secure storage across an encrypted network [44 ]. Another data collection challenge to explore is the question of which data should be collected during VGDT design. Patient data should only be collected when necessary and not simply collected because it is convenient or possible to do so with ease. Care should be taken to inform patients of exactly which metrics are going to be taken during the rehabilitation process, why these metrics are important to continued recovery, and what will become of the data. Despite the importance of ensuring that patients are comfortable and fully aware of the data that they are sharing with clinicians, no studies have investigated acceptable forms of remote patient monitoring specific to particular patient populations. Conversely, given the sudden advent of digital health initiatives from large companies such as Samsung (http://www.samsung.com/global/ business/healthcare/), Panasonic (http://home.on 4today.com/), and Apple (https://www.apple.com/ ios/ios8/health/), there is an interesting movement growing toward creating online therapy and support environments for multiple conditions – the ability for stroke patients who are engaged in similar VGDTs to compete and collaborate with one another toward improving their health. This form of ‘social media’ approach to healthcare is a positive step, because it allows even the most socially or physically isolated patients to feel as though they are part of a team, carrying with it all of the benefits of group therapy – improving engagement, and returning a sense of purpose to these patients [45,46]. Although we are waiting for regulatory organizations to catch up with technology on this front, existing online gaming platforms have already shown convincingly that a sufficient level of engagement and competition can be achieved by providing patients with entirely arbitrary metrics of performance that encourage more &
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time spent performing therapy exercises, while not publicly posting medical data.
COST-EFFECTIVENESS OF TELEREHABILITATION SERVICES The final issue to discuss in this review is one that was not addressed satisfactorily in any of the studies that were presented. One of the major goals of a well implemented VGDT system is to create a cost-effective way of treating multiple patients remotely, saving them from the expense and inconvenience of clinic visits. However, we are yet to see an article that provides a detailed cost-analysis of a telerehabilitation protocol vs. conventional therapy that shows a clear benefit [47 ]. Although this is due, in part, to the fact that there is still great uncertainty as to the most appropriate way to regulate, bill and reimburse telerehabilitation services [45]. As a result, this continues to be a serious void in the literature, and even a study that attempts to project these costs would be a valuable addition to the field. &&
CONCLUSION Although the challenges to be faced globally by public health systems will be great over the next few decades, telemedicine appears to have very real potential to transform the way in which stroke rehabilitation is carried out. Given the accessibility, affordability, and quality of commercially available gaming systems, clinical research should focus on repurposing existing gaming frameworks as treatment protocols. Rather than spending time ‘reinventing the wheel’ on custom solutions with little potential for scalability, gaming systems should be deployed to a large number of patients. Optimization of VGDT will come from a deeper understanding of effective user interfaces for the therapist and patient, more sophisticated data acquisition and analytics pipelines, and careful attention to maintaining the highest standards of privacy when dealing with online acquisition of personal information. Although there is much to accomplish, there is strong evidence to suggest that VGDT will lead the way in the management of stroke recovery for the 21st century. Acknowledgements D.P. would like to acknowledge the Burke Foundation for its financial support. Conflicts of interest D.P. is a founding member and equity holder in GesTherapy, Inc – a telerehabilitation software company. Volume 27 Number 6 December 2014
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REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Ovbiagele B, Goldstein LB, Higashida RT, et al. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke 2013; 44:2361–2375. 2. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke 2010; 41:2402–2448. 3. DelliFraine JL, Dansky KH. Home-based telehealth: a review and metaanalysis. J Telemed Telecare 2008; 14:62–66. 4. Polisena J, Tran K, Cimon K, et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Telemed Telecare 2010; 16:120–127. 5. Tousignant M, Moffet H, Boissy P, et al. A randomized controlled trial of home telerehabilitation for postknee arthroplasty. J Telemed Telecare 2011; 17:195–198. 6. Neubeck L, Redfern J, Fernandez R, et al. Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Prev Cariol 2009; 16:281–289. 7. Polisena J, Tran K, Cimon K, et al. Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes Obes Metab 2009; 11:913–930. 8. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet 2009; 8:741–754. 9. Schaechter JD. Motor rehabilitation and brain plasticity after hemiparetic stroke. Prog Neurobiol 2004; 73:61–72. 10. Bayley MT, Hurdowar A, Richards CL, et al. Barriers to implementation of stroke rehabilitation evidence: findings from a multisite pilot project. Disabil Rehabil 2012; 34:1633–1638. 11. Laver KE, Schoene D, Crotty M, et al. Telerehabilitation services for stroke && (review). Cochrane Database Syst Rev 2013; 12:CD010255. This article provides a comprehensive review and discussion of the evidencebased practice for telerehabilitation following stroke. This review highlights the fact that the telerehabilitation field is lacking large-scale, well-designed studies investigating the efficacy of telerehabilitation during stroke. 12. Lohse KR, Hilderman CG, Cheung KL, et al. Virtual reality therapy for adults && post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy. PLoS One 2014; 9:e93318. This article provides an essential and potentially paradigm-shifting point of view about VGDT. This review provides evidence that commercially available video games may be equally effective as custom-built video games in producing therapeutic gains. If these findings can be replicated in larger cohort studies, this will significantly increase the immediate scalability of VGDT approaches. 13. Ahamed NU, Sundaraj K, Ahmad B, et al. Rehabilitation systems for physically disabled patients: a brief review of sensor-based computerised signal-monitoring systems. Biomed Res 2013; 24:370–376. 14. Patel S, Park H, Bonato P, et al. A review of wearable sensors and systems with application in rehabilitation. J Neuroeng Rehabil 2012; 9:1–17. 15. Sanchez R, Reinkensmeyer D, Shah P, et al. Monitoring functional arm movement for home-based therapy after stroke. Conf Proc IEEE Eng Med Biol Soc 2004; 7:4787–4790. 16. Clark PG, Dawson SJ, Scheidman-Miller C, Post ML. TeleRehab: stroke teletherapy and management using two-way interactive video. Neurol Rep 2002; 26:87–93. 17. Khademi M, Mousavi Hondori H, Dodakian L, et al. An assistive tabletop keyboard for stroke rehabilitation. ITS 2013; 337–340. 18. Brooks AL. Camera-based software in rehabilitation/therapy intervention. JACCES 2014; 4:130–143. 19. Ojeda J, Ramirrez EJ, Moreno F, Rodriguez O. Gesture-gross recognition of upper limbs to physical rehabilitation. In: Proceedings of the 12th International Congress of Numerical Methods in Engineering and Applied Sciences (CIMENICS); 24–26 March 2014; Isla de Margarita. 20. Schmitz A, Ye M, Shapiro R, et al. Accuracy and repeatability of joint angles measured using a single camera markerless motion capture system. J Biomech 2014; 47:587–591. 21. Metcalf CD, Robinson R, Malpass AJ, et al. Markerless motion capture and measurement of hand kinematics: validation and application to home-based upper limb rehabilitation. IEEE Trans Biomed Eng 2013; 60:2184–2192. 22. Deutsch JE, Maidan I, Dickstein R. Patient-centered integrated motor imagery & delivered in the home with telerehabilitation to improve walking after stroke. Phys Ther 2012; 92:1065–1077. This is an important study that shows efficacy of motor imagery in treating strokerelated ambulation impairments. It is worth highlighting as it shows a simple and highly accessible telerehabilitation solution can yield impressive therapeutic results. 23. Kizony R, Weiss PL, Feldman Y, et al. Evaluation of a tele-health system for upper extremity stroke rehabilitation. In: Proceedings of the 2013 International Conference on Virtual Rehabilitation (ICVR); 26–29 August 2013; Philadelphia. IEEE; 2013. pp. 80–86.
24. Kiper PB, Agostini M, Luque-Moreno C, et al. Reinforced feedback in virtual environment for rehabilitation of upper extremity dysfunction after stroke: preliminary data from a randomized controlled trial. Biomed Res Int 2014; 2014:752128. 25. Langan J, DeLave K, Phillips L, et al. Home-based telerehabilitation shows improved upper limb function in adults with chronic stroke: a pilot study. J Rehabil Med 2013; 45:217–220. 26. Perry JC, Rodriguez-de-Pablo C, Balasubramanian S, et al. Assessment and training in home-based telerehabilitation of arm mobility impairment. JACCES 2013; 3:45–75. 27. Prange GB, Nijenhuis SM, Sale P, et al. Preliminary findings of feasibility and compliance of technology-supported distal arm training at home after stroke. BIOSYSROB 2014; 7:665–673. 28. Slijper A, Svensson KE, Backlund P, et al. Computer game-based upper extremity training in the home environment in stroke persons: a single subject design. J Neuroeng Rehabil 2014; 11:35–53. 29. Kottink AI, Prange GB, Krabben T, et al. Gaming and conventional exercises for improvement of arm function after stroke: a randomized controlled pilot study. Games Health J 2014; 3:184–191. 30. Cho KH, Lee KJ, Song CH. Virtual-Reality balance training with a video-game system improves dynamic balance in chronic stroke patients. Tohoku J Exp Med 2012; 228:69–74. 31. Gil-Go´mez J-A, Llore´ns R, Alcan˜iz M, Colomer C. Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury. J Neuroeng Rehabil 2011; 8:30–40. 32. Morone G, Tramontano M, Iosa M, et al. The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial. Biomed Res Int 2014; 2014:580861. 33. Hall N, Boisvert M, Steele R. Telepractice in the assessment and treatment of individual with aphasia: a systematic review. Int J Telerehabil 2013; 5:27– 38. 34. Cherney LR, van Vuuren S. Telerehabilitation virtual therapists, and acquired neurologic speech and language disorders. Semin Speech Lang 2012; 33:243–257. 35. Agostini M, Garzon M, Benavides-Varela S, et al. Telerehabilitation in poststroke anomia. Biomed Res Int 2014; 2014:706909. 36. Rand D, Givon N, Weingarden H, et al. Eliciting upper extremity purposeful movements using video games: a comparison with traditional therapy for stroke rehabilitation. Neurorehabil Neural Repair 2014; 28:733–739. 37. Laver K, George S, Thomas S, et al. Virtual reality for stroke rehabilitation. Stroke 2012; 43:e20–e21. 38. Mountain G, Wilson S, Eccleston C, et al. Developing and testing a tele&& rehabilitation system for people following stroke: issues of usability. J Eng Des 2010; 21:223–236. This is one of the few studies that have exclusively focused on usability of telerehabilitation protocols for stroke patients, especially in the home environment. It investigates not only usability, but also the effects of system changes on usability in the same patient cohort. This is a highly instructive study focusing on an often overlooked, but essential feature of telehealth. 39. Corriveau H, Tousignant M, Gosselin S, Boissy P. Patients satisfaction with an & n-home telerehabilitation exercise program and physiotherapists’ satisfaction toward technology for an acute stroke population: a pilot study. In: Encarnac¸a˜o P, Azevedo L, Gelderblom GJ, et al., editors. Assistive Technology: From Research to Practice. The Netherlands: IOS Press; 2013. pp. 753– 757. Although suffering from a low participant size, this pilot study is one of the very few that investigates patient and therapist satisfaction with telerehabilitation protocols. Although a larger sample size is required to confirm the results of this study, it should be highlighted due to its attention to an underreported element of telerehabilitation. 40. Shah N, Amirabdollahian F, Basteris A. Designing motivational games for stroke rehabilitation. In: Proceedings of the 7th International Conference on Human Systems Interactions (HSI); 16–18 June 2014; Costa da Caparica. IEEE; 2014. pp. 166–171. 41. Burke JW, McNeill MDJ, Charles DK, et al. Optimising engagement for stroke rehabilitation using serious games. Vis Comput 2009; 25:1085– 1099. 42. Fahim M, Idris M, Ali R, et al. ATHENA: a personalized platform to promote an active lifestyle and wellbeing based on physical, mental and social health primitives. Sensors 2014; 14:9313–9329. 43. Venkataraman V, Turaga P, Lehrer N, et al. Decision support for stroke rehabilitation therapy via describable attribute-based decision trees. 36th Annual Conference of the IEEE Engineering in Medicine and Biology Society; 27–30 August 2014; Chicago. 44. Boulos MN, Brewer AC, Karimkhani C, et al. Mobile medical and health apps: & state of the art, concerns, regulatory control and certification. Online J Public Health Inform 2014; 5:e229. Telerehabilitation is currently in a formative state, wherein regulatory bodies are struggling to keep up with technological progress. As such, it is essential that we consider adequate security for protected health information when implementing telerehabilitation systems. This article is an excellent resource for the ways that telehealth systems are currently being securely and legally implemented.
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Trauma and rehabilitation 45. Norval C, Arnott JL, Hanson VL. What’s on your mind? Investigating recommendations for inclusive social networking and older adults. In: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; 26 April–1 May 2014; Toronto. New York: Association for Computing Machinery; 2014. pp. 3923–3932. 46. Norval C, Arnott JL, Hine N, Hanson VL. Purposeful social media as support platform: communication frameworks for older adults requiring care. In: Proceedings of the 5th International Conference on Pervasive Computing Technologies for Healthcare (PervasiveHealth); 23–26 May 2011; Dublin. IEEE; 2011. pp. 492–494.
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47. McLean S, Sheikh A, Cresswell K, et al. The impact of telehealthcare on the quality and safety of care: a systemic overview. PLoS One 2013; 8:e71238. This is a pragmatic, excellent overview of some of the practical concerns and considerations of implementing telehealth system. It also discusses some of the rare studies that have investigated cost-effectiveness of telerehabilitation approaches that have been implemented in the past. This review is an excellent resource for investigating the safety and cost-effectiveness of telerehabilitation.
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Telerehabilitation and emerging virtual reality approaches to stroke rehabilitation David Putrino
Purpose of review Stroke is the leading cause of permanent motor disability in the United States, and the rapidly aging population makes finding large-scale treatment solutions to this problem a national priority. Telerehabilitation is an emerging approach that is being used for the effective treatment of multiple diseases, and is beginning to show promise for stroke. The purpose of this review is to identify and highlight the areas of telerehabilitation that require the most research attention. Recent findings Although there are many different forms of telerehabilitation approaches being attempted for stroke, the only approach that is currently showing moderate–strong evidence for efficacy is videogame-driven telerehabilitation (VGDT). However, targeted research is still required to determine the feasibility of VGDT: metrics regarding system usability, cost-effectiveness, and data privacy concerns still require major attention. Summary VGDT is an emerging approach that shows enormous promise for stroke rehabilitation. Future studies should focus less on developing custom task controllers and therapy games and more on developing innovative, online data acquisition and analytics pipelines, as well as understanding the patient population so that the rehabilitation experience can be better customized. Keywords physical therapy, stroke, telemedicine, telerehabilitation, virtual reality
INTRODUCTION Stroke is the leading cause of permanent motor disability in the United States, and although its incidence per capita over the age of 65 is not changing [1], the population of Americans over 65 is expected to almost double to 90 million (http:// www.aoa.gov) by 2050. Given that an individual over the age of 65 has a 9% chance of being affected by stroke [1], the accelerated rate of aging in the United States is projected to cause an unprecedented spike in the number of stroke occurrences. Paired with a mean lifetime cost of $145 000 per stroke [2], these projections suggest that the direct medical costs of treating all the new cases of stroke over the age of 65 will increase by approximately $105 billion by the year 2030 [1]. In the context of an already stressed public health system, the implications of these statistics are grave. Management and rehabilitation of stroke desperately requires innovation. The problem is challenging; potential solutions require delivery of effective, low-cost, and accessible services to a large number of people.
Telehealth is an evolving field that is currently drawing global attention; this is because of its potential for low-cost implementation and proven efficacy in improving clinical outcomes in specific patient populations [3]. Although telehealth is not a novel concept, advances in low-cost, accessible sensor and motion capture technology have made it possible to collect and synthesize patient data with unprecedented accuracy and ease. Telerehabilitation is an emerging branch of telehealth that has recently shown promise in the rehabilitation of many different conditions including chronic obstructive pulmonary disease (reviewed by [4]), Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, Department of Physical Medicine and Rehabilitation, Weill Medical College of Cornell University, New York, New York, USA Correspondence to David Putrino, Burke-Cornell Medical Research Institute, 785, Mamaroneck Ave, White Plains, New York, NY 10605, USA. Tel: +1 914 368 3183; e-mail: [email protected] Curr Opin Neurol 2014, 27:631–636 DOI:10.1097/WCO.0000000000000152
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Trauma and rehabilitation
KEY POINTS Video-game based telerehabilitation protocols for stroke show significantly improved outcomes compared with conventional therapies. The literature investigating optimized, user-friendly telerehabilitation interfaces for patients and clinicians is sparse, and must be developed. To date, a rigorous investigation of the costeffectiveness of telerehabilitation compared with conventional therapy has not been performed. Telerehabilitation has the potential to revolutionize the delivery of care to stroke patients, but many factors need to be investigated prior to mainstream deployment.
total knee replacements (reviewed by [5]), coronary heart disease (reviewed by [6]), diabetes (reviewed by [7]), and many other conditions. Broadly speaking, the goal of telerehabilitation is to use communications technology to create effective and safe rehabilitation environments that do not require the constant oversight of a treating therapist.
TELEREHABILITATION AND STROKE: APPROACHES AND IMPACT Impaired voluntary movement, one of the hallmarks of stroke, is the main cause of severe functional limitations. Although there is good scientific evidence to advocate for the use of high-intensity exercise to improve function following stroke, most people do not receive the recommended care [8,9]. Unfortunately, delivery of adequate therapy is limited by cost, convenience of transport to the treatment facility, and difficulty motivating patients to perform highly repetitive motor training [10]. In regards to stroke rehabilitation alone, the term ‘telerehabilitation’ has been used to describe many different therapies. Such motor rehabilitation conventions have included reinforced phone or video conferencing as well as robot-assisted rehabilitation and augmented and virtual reality therapy protocols [11 ]. Given the highly variable nature of implementation of many different therapies under the ‘telerehabilitation’ umbrella, it is challenging to make specific statements about the general efficacy of telerehabilitation for stroke. A recent Cochrane review of 10 studies of telerehabilitation following stroke, involving a total of 933 participants, could show no significant evidence to support the implementation of a telerehabilitation protocol for stroke [11 ]. A limiting factor with this review, however, &&
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was the working definition of telerehabilitation: ‘the provision of rehabilitation services to patients at a remote location using information and communication technologies’. The styles of interventions that were studied were diverse, exploring some studies that utilized a simple phone-based follow-up schedule with patients, to studies involving computerized therapy sessions, accompanied by outpatient therapy visits and teleconferencing. Attempting to evaluate such a large variety of interventions is problematic, and it is unsurprising that the authors were unable to show clear efficacy in a single meta-analysis. Despite its negative conclusion, however, this review is essential to the field of stroke telerehabilitation, as it highlights the need for more targeted, large-scale research with a unified commitment to a specific format of telerehabilitation delivery. A more recent review, focusing exclusively on videogame-driven telerehabilitation (VGDT) protocols, showed that the outcome of stroke rehabilitation using game-based therapy significantly outperformed conventional therapy [12 ]. This review shall focus almost exclusively on investigating progress in VGDTs designed for stroke rehabilitation using commercially available motion capture hardware. &&
APPROPRIATE HARDWARE FOR VIDEOGAME-DRIVEN TELEREHABILITATION In the past decade, the ability for amateur and professional computer scientists to become proficient in different programming languages and generate custom task controllers for hardware devices has grown rapidly. In response to this, most new hardware devices come with specific ‘software developer kits (SDKs)’ or ‘application programming interface’ to allow users to fully customize hardware interaction experience to their own needs. The response to the spike in device availability has been a rapid development of innovative research tools for patient monitoring and biometric data acquisition for particular disease processes or patient populations. In fact, some recent reviews have explored the enormous range of biosensors that are currently being integrated into rehabilitation systems [13,14], and this digital health trend is continuing to grow. Although it is tempting to engage in the trend of developing custom technological solutions for particular patient populations, one must also consider that for a stroke rehabilitation solution to be truly effective globally, it must also be highly scalable. Early attempts at adopting telerehabilitation systems for stroke are to be commended for their Volume 27 Number 6 December 2014
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role in creating proof of concept, but often did not represent a practical solution for large-scale deployment [15], or decrease the amount of therapist input required to service the intended population [16]. Systems that are intended as stroke telerehabilitation tools must be available, affordable, and require very little assembly on the end of the patient or the treating therapist. Many clinicians are not well versed in computer science or biomedical engineering and should not be expected to learn to use complex systems to assist in the delivery of patient care. Recently, many mainstream gaming consoles have been released with sophisticated motion capture capabilities, highly engaging user interfaces and surprisingly open SDKs. Given that gaming consoles are specifically designed to be low cost, easily available almost anywhere in the world, and enjoyable and simple to interact with, it would appear that they represent the ideal interface for developing the most scalable VGDT systems. Many researchers are beginning to take advantage of affordable and accessible electronic or gaming devices to create highly state-of-the-art telerehabilitation software solutions [17].
GAMING CONSOLES AND TELEREHABILITATION
designed to be fun and engaging in order to encourage patients to perform many repetitions of a motor task, they are often dull, and do not encourage the desired response. Although these issues are understandable limitations for a new therapy, clinical researchers should be aware that there is already good evidence to support the use of commercially available video games to drive the telerehabilitation interface, negating the need for clinicians to design their own games, and allowing large numbers of individuals to be recruited more rapidly [37,12 ]. &&
ENJOYMENT, USABILITY, AND ACCEPTANCE One of the most important elements of any rehabilitation protocol is patient engagement [10]. However, when dealing with telerehabilitation protocols, this is not an element that is exclusively for the patient – if clinicians are to be expected to adopt VGDT systems, we must ensure that the user interface design on the side of the therapist is equally simple to navigate and informative. Unfortunately, despite the urging of previous studies to design telerehabilitation protocols that ensure patient usability and clinical utility, very few researchers have conducted these studies [38 ]. For most of the literature that has been discussed in this review, this has been a clear omission in study design. A few studies have explored the question of usability of VGDTs in stroke patients and found their system usability to be satisfactory to both patients and clinicians, indicating that the design of a highly usable VGDT is a feasible possibility [27,39 ,40,41]. &&
Recently, a number of studies have used VGDTs for the motor rehabilitation of stroke symptoms. Gaming consoles such as the Microsoft Kinect, Leap Motion or even a simple 3D joystick have been used to generate gesture recognition and inverse kinematics data effectively within a gaming framework [18,19]. Furthermore, the Microsoft Kinect in particular has been shown to generate kinematic data that is accurate enough to provide informative, real-time feedback to patients and therapists about joint kinematics [20,21]. However, very few other commercial gaming systems have been validated as rigorously as the Kinect, and this should be a clear goal for individuals working in this field of research. These gaming consoles have also been used as effective tools for simple, home-based stroke rehabilitation for the upper limb [22 ,23–29], standing balance [30–32], and training to overcome aphasias [33–35]. Most of these studies show either comparable or superior efficacy when compared with conventional therapies, and a potential mechanism for this is that the engaging nature of VGDT increases patient use of the affected limb [36]. However, as with many emerging therapies, the most common limitations with existing VGDT studies are that they are pilot studies with extremely low participant numbers, and the games themselves are somewhat rudimentary – meaning that although they were &
&
DATA ANALYSIS AND PRIVACY A main advantage of VGDTs over conventional therapy approaches is the potential for data collection during periods of home exercise and remote patient monitoring. In the last 5 years, the access to truly powerful, yet accessible and affordable motion capture and sensing technology has resulted in an unprecedented ability to engage in detailed remote patient monitoring. If used appropriately, these data will be instrumental in designing and optimizing the next generation of VGDTs – helping us to understand factors such as optimal exercise duration and intensity for different stroke-related impairments, more targeted and quantitative assessment protocols for specific functional goals, and better overall understanding of long-term outcome of different types of stroke. Given the ability for such valuable data collection, it is imperative that it is stored and curated in an effective and appropriate manner.
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Computational strategies for the seamless analysis of the data being collected have begun to be developed so that behavioral classification, disease and impairment staging, and condition progress can be logged efficiently and quantitatively in stroke patients [42,43]. Furthermore, the streaming of data onto secure database systems such as REDCap (http:// www.project-redcap.org/) is becoming increasingly necessary to ensure logical storage and organization of large sets of biometric data. When designing any form of telemedicine system, the confidentiality and security must always be the paramount concern. Designing VGDTs for research purposes is no exception: patient data should be de-identified as early as possible in the data acquisition pipeline and never stored on a patient’s local telerehabilitation device; instead, data should be streamed to secure storage across an encrypted network [44 ]. Another data collection challenge to explore is the question of which data should be collected during VGDT design. Patient data should only be collected when necessary and not simply collected because it is convenient or possible to do so with ease. Care should be taken to inform patients of exactly which metrics are going to be taken during the rehabilitation process, why these metrics are important to continued recovery, and what will become of the data. Despite the importance of ensuring that patients are comfortable and fully aware of the data that they are sharing with clinicians, no studies have investigated acceptable forms of remote patient monitoring specific to particular patient populations. Conversely, given the sudden advent of digital health initiatives from large companies such as Samsung (http://www.samsung.com/global/ business/healthcare/), Panasonic (http://home.on 4today.com/), and Apple (https://www.apple.com/ ios/ios8/health/), there is an interesting movement growing toward creating online therapy and support environments for multiple conditions – the ability for stroke patients who are engaged in similar VGDTs to compete and collaborate with one another toward improving their health. This form of ‘social media’ approach to healthcare is a positive step, because it allows even the most socially or physically isolated patients to feel as though they are part of a team, carrying with it all of the benefits of group therapy – improving engagement, and returning a sense of purpose to these patients [45,46]. Although we are waiting for regulatory organizations to catch up with technology on this front, existing online gaming platforms have already shown convincingly that a sufficient level of engagement and competition can be achieved by providing patients with entirely arbitrary metrics of performance that encourage more &
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time spent performing therapy exercises, while not publicly posting medical data.
COST-EFFECTIVENESS OF TELEREHABILITATION SERVICES The final issue to discuss in this review is one that was not addressed satisfactorily in any of the studies that were presented. One of the major goals of a well implemented VGDT system is to create a cost-effective way of treating multiple patients remotely, saving them from the expense and inconvenience of clinic visits. However, we are yet to see an article that provides a detailed cost-analysis of a telerehabilitation protocol vs. conventional therapy that shows a clear benefit [47 ]. Although this is due, in part, to the fact that there is still great uncertainty as to the most appropriate way to regulate, bill and reimburse telerehabilitation services [45]. As a result, this continues to be a serious void in the literature, and even a study that attempts to project these costs would be a valuable addition to the field. &&
CONCLUSION Although the challenges to be faced globally by public health systems will be great over the next few decades, telemedicine appears to have very real potential to transform the way in which stroke rehabilitation is carried out. Given the accessibility, affordability, and quality of commercially available gaming systems, clinical research should focus on repurposing existing gaming frameworks as treatment protocols. Rather than spending time ‘reinventing the wheel’ on custom solutions with little potential for scalability, gaming systems should be deployed to a large number of patients. Optimization of VGDT will come from a deeper understanding of effective user interfaces for the therapist and patient, more sophisticated data acquisition and analytics pipelines, and careful attention to maintaining the highest standards of privacy when dealing with online acquisition of personal information. Although there is much to accomplish, there is strong evidence to suggest that VGDT will lead the way in the management of stroke recovery for the 21st century. Acknowledgements D.P. would like to acknowledge the Burke Foundation for its financial support. Conflicts of interest D.P. is a founding member and equity holder in GesTherapy, Inc – a telerehabilitation software company. Volume 27 Number 6 December 2014
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REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Ovbiagele B, Goldstein LB, Higashida RT, et al. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke 2013; 44:2361–2375. 2. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke 2010; 41:2402–2448. 3. DelliFraine JL, Dansky KH. Home-based telehealth: a review and metaanalysis. J Telemed Telecare 2008; 14:62–66. 4. Polisena J, Tran K, Cimon K, et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Telemed Telecare 2010; 16:120–127. 5. Tousignant M, Moffet H, Boissy P, et al. A randomized controlled trial of home telerehabilitation for postknee arthroplasty. J Telemed Telecare 2011; 17:195–198. 6. Neubeck L, Redfern J, Fernandez R, et al. Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review. Eur J Prev Cariol 2009; 16:281–289. 7. Polisena J, Tran K, Cimon K, et al. Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes Obes Metab 2009; 11:913–930. 8. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet 2009; 8:741–754. 9. Schaechter JD. Motor rehabilitation and brain plasticity after hemiparetic stroke. Prog Neurobiol 2004; 73:61–72. 10. Bayley MT, Hurdowar A, Richards CL, et al. Barriers to implementation of stroke rehabilitation evidence: findings from a multisite pilot project. Disabil Rehabil 2012; 34:1633–1638. 11. Laver KE, Schoene D, Crotty M, et al. Telerehabilitation services for stroke && (review). Cochrane Database Syst Rev 2013; 12:CD010255. This article provides a comprehensive review and discussion of the evidencebased practice for telerehabilitation following stroke. This review highlights the fact that the telerehabilitation field is lacking large-scale, well-designed studies investigating the efficacy of telerehabilitation during stroke. 12. Lohse KR, Hilderman CG, Cheung KL, et al. Virtual reality therapy for adults && post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy. PLoS One 2014; 9:e93318. This article provides an essential and potentially paradigm-shifting point of view about VGDT. This review provides evidence that commercially available video games may be equally effective as custom-built video games in producing therapeutic gains. If these findings can be replicated in larger cohort studies, this will significantly increase the immediate scalability of VGDT approaches. 13. Ahamed NU, Sundaraj K, Ahmad B, et al. Rehabilitation systems for physically disabled patients: a brief review of sensor-based computerised signal-monitoring systems. Biomed Res 2013; 24:370–376. 14. Patel S, Park H, Bonato P, et al. A review of wearable sensors and systems with application in rehabilitation. J Neuroeng Rehabil 2012; 9:1–17. 15. Sanchez R, Reinkensmeyer D, Shah P, et al. Monitoring functional arm movement for home-based therapy after stroke. Conf Proc IEEE Eng Med Biol Soc 2004; 7:4787–4790. 16. Clark PG, Dawson SJ, Scheidman-Miller C, Post ML. TeleRehab: stroke teletherapy and management using two-way interactive video. Neurol Rep 2002; 26:87–93. 17. Khademi M, Mousavi Hondori H, Dodakian L, et al. An assistive tabletop keyboard for stroke rehabilitation. ITS 2013; 337–340. 18. Brooks AL. Camera-based software in rehabilitation/therapy intervention. JACCES 2014; 4:130–143. 19. Ojeda J, Ramirrez EJ, Moreno F, Rodriguez O. Gesture-gross recognition of upper limbs to physical rehabilitation. In: Proceedings of the 12th International Congress of Numerical Methods in Engineering and Applied Sciences (CIMENICS); 24–26 March 2014; Isla de Margarita. 20. Schmitz A, Ye M, Shapiro R, et al. Accuracy and repeatability of joint angles measured using a single camera markerless motion capture system. J Biomech 2014; 47:587–591. 21. Metcalf CD, Robinson R, Malpass AJ, et al. Markerless motion capture and measurement of hand kinematics: validation and application to home-based upper limb rehabilitation. IEEE Trans Biomed Eng 2013; 60:2184–2192. 22. Deutsch JE, Maidan I, Dickstein R. Patient-centered integrated motor imagery & delivered in the home with telerehabilitation to improve walking after stroke. Phys Ther 2012; 92:1065–1077. This is an important study that shows efficacy of motor imagery in treating strokerelated ambulation impairments. 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24. Kiper PB, Agostini M, Luque-Moreno C, et al. Reinforced feedback in virtual environment for rehabilitation of upper extremity dysfunction after stroke: preliminary data from a randomized controlled trial. Biomed Res Int 2014; 2014:752128. 25. Langan J, DeLave K, Phillips L, et al. Home-based telerehabilitation shows improved upper limb function in adults with chronic stroke: a pilot study. J Rehabil Med 2013; 45:217–220. 26. Perry JC, Rodriguez-de-Pablo C, Balasubramanian S, et al. Assessment and training in home-based telerehabilitation of arm mobility impairment. JACCES 2013; 3:45–75. 27. Prange GB, Nijenhuis SM, Sale P, et al. Preliminary findings of feasibility and compliance of technology-supported distal arm training at home after stroke. BIOSYSROB 2014; 7:665–673. 28. Slijper A, Svensson KE, Backlund P, et al. Computer game-based upper extremity training in the home environment in stroke persons: a single subject design. J Neuroeng Rehabil 2014; 11:35–53. 29. Kottink AI, Prange GB, Krabben T, et al. Gaming and conventional exercises for improvement of arm function after stroke: a randomized controlled pilot study. Games Health J 2014; 3:184–191. 30. Cho KH, Lee KJ, Song CH. Virtual-Reality balance training with a video-game system improves dynamic balance in chronic stroke patients. Tohoku J Exp Med 2012; 228:69–74. 31. Gil-Go´mez J-A, Llore´ns R, Alcan˜iz M, Colomer C. Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury. J Neuroeng Rehabil 2011; 8:30–40. 32. Morone G, Tramontano M, Iosa M, et al. The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial. Biomed Res Int 2014; 2014:580861. 33. Hall N, Boisvert M, Steele R. Telepractice in the assessment and treatment of individual with aphasia: a systematic review. Int J Telerehabil 2013; 5:27– 38. 34. Cherney LR, van Vuuren S. Telerehabilitation virtual therapists, and acquired neurologic speech and language disorders. Semin Speech Lang 2012; 33:243–257. 35. Agostini M, Garzon M, Benavides-Varela S, et al. Telerehabilitation in poststroke anomia. Biomed Res Int 2014; 2014:706909. 36. Rand D, Givon N, Weingarden H, et al. Eliciting upper extremity purposeful movements using video games: a comparison with traditional therapy for stroke rehabilitation. Neurorehabil Neural Repair 2014; 28:733–739. 37. Laver K, George S, Thomas S, et al. Virtual reality for stroke rehabilitation. Stroke 2012; 43:e20–e21. 38. Mountain G, Wilson S, Eccleston C, et al. Developing and testing a tele&& rehabilitation system for people following stroke: issues of usability. J Eng Des 2010; 21:223–236. This is one of the few studies that have exclusively focused on usability of telerehabilitation protocols for stroke patients, especially in the home environment. It investigates not only usability, but also the effects of system changes on usability in the same patient cohort. This is a highly instructive study focusing on an often overlooked, but essential feature of telehealth. 39. Corriveau H, Tousignant M, Gosselin S, Boissy P. Patients satisfaction with an & n-home telerehabilitation exercise program and physiotherapists’ satisfaction toward technology for an acute stroke population: a pilot study. In: Encarnac¸a˜o P, Azevedo L, Gelderblom GJ, et al., editors. Assistive Technology: From Research to Practice. The Netherlands: IOS Press; 2013. pp. 753– 757. Although suffering from a low participant size, this pilot study is one of the very few that investigates patient and therapist satisfaction with telerehabilitation protocols. Although a larger sample size is required to confirm the results of this study, it should be highlighted due to its attention to an underreported element of telerehabilitation. 40. Shah N, Amirabdollahian F, Basteris A. Designing motivational games for stroke rehabilitation. In: Proceedings of the 7th International Conference on Human Systems Interactions (HSI); 16–18 June 2014; Costa da Caparica. IEEE; 2014. pp. 166–171. 41. Burke JW, McNeill MDJ, Charles DK, et al. Optimising engagement for stroke rehabilitation using serious games. Vis Comput 2009; 25:1085– 1099. 42. Fahim M, Idris M, Ali R, et al. ATHENA: a personalized platform to promote an active lifestyle and wellbeing based on physical, mental and social health primitives. Sensors 2014; 14:9313–9329. 43. Venkataraman V, Turaga P, Lehrer N, et al. Decision support for stroke rehabilitation therapy via describable attribute-based decision trees. 36th Annual Conference of the IEEE Engineering in Medicine and Biology Society; 27–30 August 2014; Chicago. 44. Boulos MN, Brewer AC, Karimkhani C, et al. Mobile medical and health apps: & state of the art, concerns, regulatory control and certification. Online J Public Health Inform 2014; 5:e229. Telerehabilitation is currently in a formative state, wherein regulatory bodies are struggling to keep up with technological progress. As such, it is essential that we consider adequate security for protected health information when implementing telerehabilitation systems. This article is an excellent resource for the ways that telehealth systems are currently being securely and legally implemented.
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Trauma and rehabilitation 45. Norval C, Arnott JL, Hanson VL. What’s on your mind? Investigating recommendations for inclusive social networking and older adults. In: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; 26 April–1 May 2014; Toronto. New York: Association for Computing Machinery; 2014. pp. 3923–3932. 46. Norval C, Arnott JL, Hine N, Hanson VL. Purposeful social media as support platform: communication frameworks for older adults requiring care. In: Proceedings of the 5th International Conference on Pervasive Computing Technologies for Healthcare (PervasiveHealth); 23–26 May 2011; Dublin. IEEE; 2011. pp. 492–494.
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47. McLean S, Sheikh A, Cresswell K, et al. The impact of telehealthcare on the quality and safety of care: a systemic overview. PLoS One 2013; 8:e71238. This is a pragmatic, excellent overview of some of the practical concerns and considerations of implementing telehealth system. It also discusses some of the rare studies that have investigated cost-effectiveness of telerehabilitation approaches that have been implemented in the past. This review is an excellent resource for investigating the safety and cost-effectiveness of telerehabilitation.
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