Exergaming Telerehabilitation for Veterans with Multiple

SclerosisKimberly Benson, PT, DPT, NCS, Physical Therapist, Washington DC Veterans Affairs Medical Center

Shane Chanpimol, PT, DPT Physical Therapist and Researcher, MS Center of Excellence,

Washington DC VA Medical Center, Washington, DC

Susan Conroy, Dsc.PT, Health Scientist, Department of Research and Development

VA Maryland Health Care System

DisclosuresThis work was supported by the U.S. Department of Veterans Affairs (VA) Office of Rural Health (ORH) through each facility’s participation in the MS Telerehabilitation Promising Practice Program

This continuing education activity is managed and accredited by Affinity CE in cooperation with PVA. Affinity CE,PVA, as well as all accrediting organizations, do not support or endorse any product or service mentioned in this activity. Disclosure will be made when a product is discussed for an unapproved use.

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Overview of Telerehabilitation

Telehealth in the VA The U.S. Department of Veterans Affairs (VA) is the world

leader in the development and use of telehealth. Telehealth services are mission-critical to the future direction of VHA’s care for Veterans.

It is the use of health informatics, disease management tools, and technology to provide access to clinical care when distance separates patients and providers.

Telehealth

VA Telehealth Services Fact Sheet, U.S. Department of Veterans Affairs Veterans Health Administration Office of Connected Care 2018 https://www.va.gov/anywheretoanywhere/docs/Telehealth_Services_factsheet.PDF

TeleRehabilitation

TeleMental health TeleNeurology

TeleSurgery

TeleNutrition TeleICU

Telerehabilitation

Telerehabilitation: the delivery of rehabilitation services remotely via information and communication technologies May include consultations, homecare, monitoring, direct therapy

to home, community, health facilities and/or work settings.

Synchronous: phone, webcam, video conference Clinical video telemedicine (CVT): internet-based video-

conferencing for patient-provider communication in real-time. VA Video Connect (mobile app): connect patient-provider using

any mobile device.

Asynchronous: messaging, activity/exercise monitoring, etc. Store-and-forward telemedicine (SFT): the use of technologies

to acquire and store information to be forwarded for laterevaluation by a specialist.

Modes of Care

VA Telehealth Services Fact Sheet, U.S. Department of Veterans Affairs. Veterans Health Administration Office of Connected Care 2018 https://www.va.gov/anywheretoanywhere/docs/Telehealth_Services_factsheet.PDF

Telerehabilitation InterventionsAssessmentStructured evaluation of function delivered remotely.

Video: Consultation, Education, Home Evaluation

Monitoring: Activity or exercise monitoring

TherapyRehabilitation activities delivered remotely.

Web or App-Based: HEP, Behavior modifications

Exergaming: Technology-assisted exercise format

Marziniak M et al. JMIR Rehabil Assist Technol. 2018 Apr 24;5(1):e5

Geographic Location of Veterans with MS

Map of MS Specialty Care

MS Centers of Excellence East-Baltimore; West-Seattle

A substantial portion of Veterans with MS reside in rural areas with greater than two-hours travel time to the nearest MS specialty clinic

These patients are high consumers of health care resources To manage their MS

To manage comorbidities

Transportation costs are high given the complex needs of Veterans with MS

Barriers and Facilitators to Telerehabilitation

Barriers and ChallengesOverall

Cost of equipment Safety and liability issues Limited geographic reach of

high speed internet Variable state

reimbursement and polices Provider licensing to deliver

telehealth services across state lines

Individuals with MS Access to specialty care

(exacerbated by distance) Cognitive and physical

mobility restrictions increase burden of access

Therapies often impairment-specific rather than holistic

Minimal to no follow-up after DC

Financial burden of recurring episodes

Turner AP, et al. PMR. 2013 Dec;5(12):1044–50.; Minden SL, et al. Mult Scler Houndmills Basingstoke Engl. 2007 May;13(4):547–58; Buchanan RJ, et al. J Health Hum Serv Adm. 2006;29(3):360–75; Finlayson M, et al. Phys Ther. 2010 Nov;90(11):1607–18

Advantages and Opportunities

Consumer adoption of electronic services across all ages

Anywhere to Anywhere VA health care: Allows VA providers to treat Veterans anywhere in the country Matches demand for services with supply of providers located elsewhere

Removes geography as a barrier and regulations limiting care across state lines

VA Video Connect: Home can be the preferred place of care

Patients able to practice exercises and skills with supervision in their own home

Low resource cost for follow-up after DC

Brennan et al Stud Health Technol Inform 2009.; Khan F, et al. Eur J Phys Rehabil Med. 2015 Jun;51(3):311–25https://news.careinnovations.com/blog/va-connected-care-chief-telehealth-is-going-to-become-health-care

Laws

Telehealth laws are primarily state specific

Sources Nationally recognized professional associations

State Boards

Center for Connected Health Policy’s (CCHP)

PT compact

Telehealth Resource Centers

CMS

Bierman 2018

PT Compact changing access

Adoption of the Physical Therapy Licensure Compact (PTLC) was noted under licensing requirements as it allows providers licensed within a compact state to practice in any other compact state through the use of telehealth (The Federation of State Boards of Physical Therapy [FSBPT], 2018

Telerehabilitation Research Advantages:

Internet, tele-conferencing, virtual reality

Supports a wide range of rehabilitation strategies, physical activity, education, fatigue management

Disadvantages Limitations of 2D visualization, No “hands on”

Guidelines: Limited by low # of high quality studies and diverse methods

Goal: Evidence-based recommendations, research demonstrating equivalence to in-person assessment and therapy. Development of new data systems for therapist use in practice.

Khan et al. Cochrane database Syst Rev 2015; Amatya et al Mult Scler Relat Disord 2015; Yeroushalmi S, J Telemed Telecare 2019.Rintala et al Disability and Rehab 2016.

Self-directed exercise in MS: Evaluation of Home Automated Telemanagement System

MS HAT system was an internet-based module specifically designed for PwMS to support individualized patient-centered care, self-management, and patient-provider communication.

Web-based MS Exercise Program (MS HAT) vs. Home Exercise Program Asynchronous messaging, videos, education vs. written exercise program

Outcomes (Baseline, 3 months, 6 months) Timed 25’ walk (T25FW), 6 minute walk test (6MWT), Berg Balance Test (BBT)

Twelve-Item Multiple Sclerosis Walking Scale (MSWS-12)

(Conroy, J Telemed Telecare 2017)

Self-directed exercise in MS: Evaluation of Home Automated Telemanagement System Study Participation:

Control: 25 PwMS randomized

68% attrition (17 lost)

MS HAT: 26 PwMS randomized

38% attrition (6 lost)

Disability Score Control: 50% minimal disability (PDDS 1- 2)

MS HAT: 93% moderate-severe (PDDS 4-5)

more likely to have progressive MS

Wide range of baseline abilities. Limited response in the T25FW and BBS.

(Conroy, J Telemed Telecare 2017)

Exercise Adherence Mean usage of the asynchronous texting option was 14.6 text

messages over the course of the six-month intervention (n=16)

We found an equal split of adherent (≥54 exercise days) and non-adherent participations in the MS HAT group

Participants with baseline PDDS>4 had higher odds of adherence than those with PDDS<4

Exercise adherence had a positive correlation with MSWS-12 score

MS Exergaming Telerehabilitation Program

Telerehabilitation Considerations

Patient Selection

Speed of Connection

Safety and Privacy (HIPAA)

Technology Format and Design

Technological and Family Support

Seek stakeholder input and consider technology options.

Chumbler et al. 2010 “Lessons Learned”

AssessmentAppropriateness Acceptable to new

technologies Cognitive/physical ability to

negotiate technology or caregiver support to support consistent usage

Significant difficulty making in-person appointments

EDSS 3.0 - 6.5

In-person Assessment PMHx ROM Strength Functional mobility Gait Balance

Equipment

Dell Tablet configured by GovSphere Inc. with Kinect sensor

Instructed to complete HEP 3 times per week

TreatmentMotion-controlled exergaming powered by Jintronix Inc.

Follow-up and HEP progression

~15-20 min. CVT 1 time per week for 8-12 weeks based on need

Topics covered:

Adherence/performance

Technique

Overall challenge

Enjoyment

Technical issues

27

Demographics & Preliminary Results

N = 14 (8 DC VA, 6 Baltimore VA)

AVG Age: 52.8 y/o [27 – 72]

Sex: 8 F; 6 M

AVG EDSS: 4.8 [3.0 - 6.5]

MS Type: 11 RRMS, 3 SPMS

AVG distance (1-way): 21.2 miles [15.3 – 134]

AVG commute (1-way): 80.65 min [35 – 165]

Primary reasons for referral: Gait difficulty and balance dysfunction

Follow-up and Adherence Metrics

Metric Average Total

HEPs completed 27.8 389

HEPs/Wk 2.38

30

25 ft Walk Time

31

* - Wilcoxon Signed Rank Test (p < .05)

*

2-Minute Walk

** - Wilcoxon Signed Rank Test (p < .01)

**

MS Walking Scale - 12

** - Wilcoxon Signed Rank Test (p < .01)

**

Modified Fatigue Impact Scale

** - Wilcoxon Signed Rank Test (p < .01)

**

Travel Reduction

Metric Average Total

Miles 891.4 11587.6

Commute Time (hrs) 23.9 310.2

Cost($0.415/mile) $369.90 $4,808.84

35

Lessons Learned

Jintronix exergaming platform well-suited for balance and LE strength/endurance

Notable reduction in travel barriers to improve access

Routine follow-up is critical to address adherence and technological issues

Difficult to implement and monitor comprehensive cardiovascular component with this technology alone

Difficult to challenge highest level participants

Current and Future Directions

Remote EvaluationPT led/supervised evaluation via CVT Telehealth technician

onsite for guidance, safety, and recording of measures

Standardization of appropriate procedure and outcome collection Adult myopathy assessment tool

(AMAT)

Validated for video assessment, can adequately replace manual muscle testing

CVT evaluation to patient’s home Appropriate for higher

function individuals Concerns for challenging

balance/mobility during assessment

Can a low-cost webcam be used for a remote neurological exam? (Wood J, et al. 2013) Kurtzke Expanded Disability Scale Scores (EDSS)

Broad Implementation and DevelopmentHub and Spoke Extension of current

remote evaluation methods

Rehab therapists able to provide entire bouts of skilled therapy remotely with remotely supervised evaluation

Specialty Virtual Clinic Maximal leverage of

‘Anywhere to Anywhere’

A centralized virtual clinic in which any provider could consult for specialty care

Specialty provider can deliver care from anywhere to numerous settings including home

Acknowledgements

MS CoE – East Staff and Clinicians

Mitchel Wallin, MD, MPH and Heidi Maloni, NP, PhD at the Washington DC VA Medical Center (DCVAMC) Multiple Sclerosis Center of Excellence

Amy Kunce, MS, BSRS : National Office of Rural Health Promising Practice Manager

George Mazevski at GovSphere Inc. for technical support

THANK YOU!

Questions?

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