IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 15, NO. 1, MARCH 2007 23

Technical Feasibility of Teleassessmentsfor Rehabilitation

William K. Durfee, Member, IEEE, Lynda Savard, and Samantha Weinstein

Abstract—Background: technical feasibility was evaluated forconducting standard motor assessment instruments in a remotesetting. Remote assessment was compared to co-located assess-ment for five clinical evaluation instruments: joint range-of-motion(ROM), manual muscle test (MMT), Berg sit-to-stand, Berg for-ward reach, and timed up and go (TUG). Methods: co-located andremote rooms were in the same building connected by broadbandvideo and audio. Ten subjects without impairments participated,but were given simulated impairments to mimic the patient pop-ulation commonly seen in rehabilitation clinics. One therapistperformed all co-located testing while another performed allremote assessments. Measurements followed standard clinicalmethods. Data were analyzed using repeated measures ANOVAand paired -tests. Results: no differences were found betweenco-located and remote assessments except for some cases usingscreen-based ROM measures. Remote ROM tests using snapshotsand a virtual goniometer were preferred. A digital dynamometeradded no additional information to a visually-based remote MMTassessment.

Index Terms—Assessment, telehealth, telerehabilitation.

I. INTRODUCTION

TELEHEALTH is experiencing rapid growth with new clin-ical applications and new technology products appearing

daily. Telerehabilitation, a subset of telehealth, is the provisionof rehabilitation services delivered at a distance using video-conferencing and other telehealth technologies. These servicesinclude evaluation and treatment, as well as education, consulta-tion, and coordination of care. Telerehabilitation remains in theformative stage with a growing body of research but with littleimpact to date on clinical practice. The state of telerehabilitationhas been reviewed several times [1]–[4] and has been the subjectof two special issues [5], [6] The reviews describe the promise oftelerehabilitation and list a growing number of research projects,but do not cite examples where telerehabilitation is used on aregular clinical basis. This mirrors the broader picture of tele-health where a recent metareview found only a few controlledtrials comparing telemedicine with face-to-face patient care, andwhile those studies demonstrated technical feasibility, they didnot show an obvious clinical benefit for telehealth [7]. However,

Manuscript received September 26, 2006; revised December 15, 2006;accepted December 19, 2006. This work was supported by the Sister KennyFoundation.

W. K. Durfee is with the Department of Mechanical Engineering, Universityof Minnesota, Minneapolis, MN 55455 USA (e-mail: wkdurfee@umn.edu).

L. Savard was with the Sister Kenny Rehab Institute, Minneapolis, MN 55407USA.

S. Weinstein is with Allen Medical Systems, Acton, MA 01720 USA.Digital Object Identifier 10.1109/TNSRE.2007.891400

because there is great potential for telerehabilitation to make asignificant impact on healthcare, and potential for telerehabili-tation to save money [8], there is a continuing need for studiesthat explore new ways of delivering mainstream rehabilitationassessment and therapies using telerehabilitation technologies.

Measuring the effectiveness of rehabilitative interventiondepends on outcome assessment tests that are reliable andvalid. Assessment tools are readily available to rehabilitationclinicians in the traditional on-site setting. However, one maynot assume that standard assessment measures can be appliedeffectively using telehealth methods. To date, only a few studieshave investigated standard assessment tests applied to telereha-bilitation. In one pilot study, the Kohlman Evaluation in LivingSkills and the Canadian Occupational Performance Measurewere reported to have agreement when completed in-person andremotely [9]. The National Institutes of Health stroke scale wasshown to have good reliability when administered remotely[10]. Internet-based assessment of motor speech disorders,including the Frechay dysarthria assessment and the assess-ment of intelligibility of dysarthric speech instruments wereshown to generally agree with face-to-face assessments [11].Measuring knee angle remotely from captured still picturesusing a computer program that calculated joint angles showedgood agreement with measuring knee angle in person with auniversal goniometer [12].

Teleassessment could be an effective method for conductingfunctional assessments on remote populations and on patientsfor whom transportation is a significant barrier. A valid, reli-able teleassessment service would be particularly valuable forpatients who need periodic assessments to determine treatmentprogress or to determine if they qualify to be admitted into aspecialized rehabilitation program. The long range goal of thisresearch is to determine if standard assessment instruments usedby physical therapists can be conducted with the patient locatedfar from the therapist. The specific objective of this study wasto investigate the technical feasibility of teleassessment by de-termining whether the results of standard assessments of motorfunction conducted remotely are the same as those conductedin-person.

There are hundreds of methods and instruments used to as-sess motor function [13]. A small number of standard assess-ment instruments were selected to investigate. Criteria for selec-tion required that the instrument be: 1) a published measurementtool, 2) reliable and valid, 3) used widely by physical therapists,and 4) supported by standard instructions for administration andscoring.

1534-4320/$25.00 © 2007 IEEE

24 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 15, NO. 1, MARCH 2007

Fig. 1. Technology layout. PT in one room with a teleconferencing and video snapshot system. Simulated patient (P) and caregiver (CG) in another room with theother end of the teleconferencing system and a digital dynamometer interfaced to the PC. For co-located assessment, a second PT was in the room with the patient.

II. METHODS

A. Subjects

Ten healthy subjects (two male, eight female, ages 18–35)participated as simulated patients. An additional ten healthysubjects (four male, six female, ages 18–35) participated assimulated caregivers and were present in the examination roomduring remote assessment sessions. Subjects were assigned ran-domly to either the simulated patient or simulated impairmentgroup. Subjects were given the simulated impairment describedin the following section with the level of simulated impairmentdifferent for each subject. Two licensed physical therapistseach with over 10 years of clinical experience conducted theassessments. One completed all co-located measurements andthe other conducted all remote measurements. The project wasapproved by the appropriate Institutional Review Boards, andinformed consent was obtained from subjects.

B. Remote Assessment Technology

The study was conducted in one facility with the remote loca-tion being a different room in the same building (Fig. 1). For theremote assessments, the evaluating therapist was in one room(remote site), connected to the other room (co-located site) bya videoconferencing system (Polycomm, ViewStation) that pro-vided two-way, high-quality voice and video over a broadband,T1 network. The therapist could remotely pan, tilt, and zoomthe camera on the patient’s end. A video capture unit (Haup-pauge, USB-Live) captured the video image on the therapist’scomputer for taking and storing snapshots. A custom digitaldynamometer was connected to the serial port of the local PCthrough a sensor interface unit. As the caregiver pressed on thepatient’s limb with the dynamometer, a bar graph on the remotecomputer indicated the force level in real-time.

C. Assessments

Five assessments were studied, range-of-motion (ROM) ofthe shoulder and knee, manual muscle test (MMT) of the bicepsand quadriceps, item 1 (sit-to-stand) and item 8 (forward reach)components from the Berg balance test, and the timed up and go(TUG) (Fig. 2). The selection included hands-on and hands-offassessments and required a range of instruction complexity.Each assessment was conducted using a traditional co-located

method, and again using one or more teleassessment methods.For the remote assessments, the therapist gave scripted, verbalinstructions to the patient and caregiver on how the test shouldbe performed.

ROM assessment followed the methods in [14]. Joint motionsassessed were shoulder abduction, shoulder external rotationand knee flexion. The joint angle was set to a randomly assignedposition with a measurement jig anchored to sites proximal anddistal to the joint being measured Fig. 2(a). The jig ensured con-sistency of joint position. Angles were randomly selected as apercentage of the subject’s full available, pain-free range in in-crements of 10%. Three shoulder abduction, two shoulder ex-ternal rotation, and two knee flexion angles were selected. Thejoint positions were different for each subject but the same forco-located and remote measuring.

Co-located joint position was measured by the therapistusing a universal goniometer (Jamar EZ Read). Four methodsof remote ROM assessment were implemented. For methods 1and 2, the therapist instructed the caregiver on where to placethe goniometer while observing via videoconferencing. Formethod 1, the physical therapist (PT) zoomed the camera andread the goniometer directly. For method 2, the caregiver readthe number off the goniometer and reported to the therapist. Formethods 3 and 4, the PT captured the image from the camerafor offline analysis. Capturing the image meant the subjectdid not have to hold still during goniometer manipulation.For method 3, the joint angle was determined using a virtualgoniometer image processing program developed for the study(Fig. 3). Video snapshots were taken by the therapist of thesubject and the snapshots were later imported into the angleanalysis program where the therapist could click on the sub-ject’s bony landmarks to position a virtual goniometer. Whenthe therapist was satisfied with goniometer placement, theprogram calculated the joint angle. For method 4, the PT held auniversal goniometer up to the image on the computer screen.Both physical therapists independently measured the anglesin methods 3 and 4. Joint angles were measured in degreesrounded to integers.

In-person biceps and quadriceps MMT assessment followedthe methods in [14]. Two methods of remote MMT assessmentwere implemented. For both, the therapist observed the testingthrough the videoconferencing system and instructed the sub-ject and caregiver on how to conduct the test. For method 1, the

DURFEE et al.: TECHNICAL FEASIBILITY OF TELEASSESSMENTS FOR REHABILITATION 25

Fig. 2. Assessment methods and simulated impairments. (a) ROM. (b) MMTwith a digital dynamometer. (c) TUG. (d) Berg sit-to-stand. (e) Berg forwardreach.

therapist scored the MMT based solely on observing the sub-ject push against the caregiver. Method 2 added a digital dy-namometer which the caregiver placed between his hand andthe tested limb so that the force exerted by the patient appearedas a moving bar on the therapist’s computer. MMT was scoredfrom 0 to 5 according to standard procedure [14], including theassignment of plus and minus. In the subsequent analysis, a plusadded 0.33 to the integer score and a minus subtracted 0.33.Subjects were provided with a simulated impairment for co-lo-cated and remote MMT assessment. Weight was added distallyto mimic muscle weakness. For biceps testing zero to 60 lb were

Fig. 3. Virtual goniometer. After the patient position was set, the therapist cap-tured a snapshot from the televideo for storing on the local PC. Later, the imagewas brought into the virtual goniometer application where the therapist markedanatomic landmarks with the cursor and the angle was calculated automatically.

added to the distal forearm and for quadriceps testing zero to 70lb were added just proximal to the ankle. The amount of attachedweight was randomized across subjects, but for each subject thesame weight was used for co-located and remote assessments.

The Berg balance scale is a comprehensive, objective mea-sure of balance abilities [15]–[17]. Only two of the 14 Bergitems were measured to save time, but were representative ofthe assessment techniques needed for the full Berg test. Themethods described by Berg [15] were followed. For remote as-sessment, the therapist provided instruction to the subject andobserved the results. Item 1, sit-to-stand, was scored on a 0-4scale following Berg instructions, Subjects were given a sim-ulated balance impairment by standing on one or two 14 inair-filled rubber disks (Exertools Dynadisc, Novato CA). Theinflation pressure was adjusted and the disks were stacked in oneor two to adjust the difficulty of maintaining balance. For Item8, forward reach, subjects reached parallel to a board with ver-tical rule lines that could be read by the remote therapist usingthe camera pan and zoom. Reach was recorded in inches andwas not converted into a 0–4 Berg score. For forward reach, thefirst trial was with no disk and the second with one disk.

The timed up and go test measures the time to rise from achair, walk 10 ft, return and sit, and is a quick, practical methodfor testing basic mobility [18], [19]. The TUG methods in [18]were followed. Subjects were given a simulated impairment bywalking on top of a 12-ft-long, 4-in-wide balance beam whosetop surface was 5 in from the floor. Timing was accomplishedwith a stopwatch. Remote assessment was performed by thera-pist observation.

D. Protocol

Testing for a subject was done in a single session that lastedabout 90 min. Prior to data collection, the subject practiced thetests with the imposed impairments to minimize learning ef-fects. For the first five subjects, the co-located tests were con-ducted before the remote tests while for the remaining five theorder was reversed to avoid order effects. A consistent test orderwas maintained so that learning or fatigue effects would impactco-located and remote assessments equally. The test order was

26 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 15, NO. 1, MARCH 2007

as follows: 1) MMT R quads with first weight; 2) MMT L quadswith second weight and digital dynamometer; 3) MMT R bi-ceps with first weight; 4) MMT L biceps with second weightand digital dynamometer; 5) Berg #1 on one disk; 6) Berg #1on two disks; 7) Berg #8 unimpaired; 8) Berg #8 on one disk; 9)TUG on balance beam; 10) repeat TUG on balance beam; 11)L shoulder abduction in three positions while sitting facing thecamera and the arm moving in the coronal plane with the elbowstraight; 12) L shoulder external rotation in two positions withthe subject supine and the elbow at 90 ; 13) L knee flexion intwo positions Fig. 2(a).

To control repeatability of the angle setting for the ROMmeasurements, co-located and remote assessments were donewithout the subject changing position between trials. The jointangle was first set by the experimenter using the jig. The localtherapist measured the angle with the goniometer, then leftthe room. The remote therapist enabled the videoconferencingsystem, adjusted the camera and took a photo of the joint. Next,the remote therapist instructed the caregiver on how to placethe goniometer and then zoomed in to read and record the jointangle. The remote therapist asked the caregiver to verballyreport the goniometer reading which was recorded. The processwas repeated for the next angle. The joint position photographswere measured off line with both therapists separately con-ducting the two on-screen measurement methods. Data werecollected from subjects 5–10 for the ROM protocol. The firstfour subjects followed a different protocol where the joint anglewas not guaranteed to be the same for all seven measurementmethods resulting in unreliable data that could not be analyzed.The data from subjects 1–4 were included in the analysis of theother four assessments.

E. Data Analysis

The ROM experiment was a single factor design with sevenlevels: (M1) co-located, (M2) remote with caregiver reportinggoniometer setting, (M3) remote with therapist zooming in andreading the goniometer directly, (M4) remote photo with anglemeasured by one therapist with a virtual goniometer, (M5) re-mote photo with angle measured by the second therapist with avirtual goniometer, (M6) remote photo with angle measured byone therapist using a universal goniometer held up to the snap-shot, (M7) remote photo with angle measured by the secondtherapist using a universal goniometer. The data were analyzedseparately for each joint as a repeated measures, within-sub-jects design [20], [21] with one block being one joint settingin one subject resulting in 18 blocks for shoulder abduction, 11blocks for shoulder rotation (one block was discarded becauseone data point was erroneous) and 12 blocks for knee flexion.The null hypothesis was that measurements of a single joint po-sition with the seven different measurement methods not differsignificantly. An alpha of 0.05 was used for the critical valuein the ANOVA analysis. If the analysis showed a significant dif-ference, a post-hoc Tukey’s multiple comparison [21] was usedto determine which pairs of methods differed.

Three MMT methods were compared: co-located, remotewith dynamometer assist, and remote by observation only.Because only two methods were used for any one muscle andsubject, the data were analyzed by paired -tests comparing

Fig. 4. ROM data shown as mean difference of a measurement method aboutthe mean for all methods at that angle. Columns indicate if one method had aconsistent bias away from the other methods. Black, gray, and white bars areshoulder abduction, shoulder rotation, and knee flexion. M1: co-located. M2:remote with CG reporting goni angle. M3: remote with PT reading goni on TV.M4: remote with PT #1 using virtual goni on stored image. M5=M4 but withPT #2. M6: remote with PT #1 using standard goni on stored image. M7=M6but with PT #2.

co-located with remote-dynamometer and co-located with re-mote-observation. The data were also analyzed by a Wilcoxonsigned-ranks test. Berg sit-to-stand, Berg reach, and TUGwere analyzed with paired -tests comparing co-located andremote scores. For TUG, trials 1 and 2 were averaged beforeperforming the -test.

III. RESULTS

The pooled ROM data for shoulder abduction showed a sig-nificant difference between the measurement methods (

, , ), as did the data for kneeflexion ( , , ), while thedata for shoulder rotation showed no significant difference be-tween measurement methods ( , ,

). Tukey’s multiple comparison procedure showed thatfor the shoulder abduction tests, M6 differed from M1, M3,and M5, and M7 differed from M1, while for the knee flexiontest M5 differed from M2, M3, and M6. A power analysis [21]showed the power of the experiment to detect a clinically sig-nificant angle measurement method difference of 5 was 100%for all three joints and the power to detect a difference of 2 was90%, 95%, and 70% for shoulder abduction, shoulder rotationand knee flexion.

To determine if one method had a consistently high or lowbias, the difference of the seven methods about the mean foreach angle setting on each subject was computed (Fig. 4). Theplot shows no consistent trends or patterns for any particularmethod. The seven methods had an average deviation from themean between 3.3 and 4.5 and approximately equal scatterwith a standard deviation about the mean between 2.2 and5.32 .

One issue was whether there was a difference in goniometerangle readings based on whether the caregiver or the remote PTperformed the reading. A paired -test for all 10 subjects showed

DURFEE et al.: TECHNICAL FEASIBILITY OF TELEASSESSMENTS FOR REHABILITATION 27

there was no significant difference between the two methods,, , . For 68 of

the 69 observations, the two methods differed by 0 or 1 . Forone observation, the methods differed by 2 . Another issue waswhether using a virtual goniometer was different than holdinga universal goniometer to the screen for remote assessment ofdigital snapshots taken during the test session. A paired -testshowed no significant difference between the methods whenthe pairing was blocked for the therapist, , ,

, , and over all observations,there was a mean absolute difference between the two methodsof 4.4 degrees .

MMT data were pooled across the 10 subjects and all ap-plied weights. Paired -tests showed no significant differencebetween co-located assessment and remote assessment by vi-sual observation, , ,

, and no significant difference between co-located assess-ment and remote assessment by visual observation augmentedwith the digital dynamometer, ,

, . The power of the test to detect differences inMMT scores of .33 (a plus/minus increment) and 1 was 60% and100% for co-located versus remote observation, and 51% and100% for co-located and remote dynamometer. The WilcoxonSigned-Ranks Test showed no difference between co-locatedand remote assessments.

Berg sit-to-stand data were pooled across all subjects. Datafrom trial 1 of each subject were not analyzed as all Berg scalescores were 4 which indicates the activity was performed safelyand independently by the subject. For trial 2, 13, of 20 obser-vations scored a 4 with some differences between remote andco-located for the rest. A paired -test of the trial 2 data showedno significant difference between co-located and remote mea-sures, , , . Foursubjects received scores in trial 2 that differed between co-lo-cated and remote. Of these, three had a remote score of zerowhich meant the subject stepped off the disc during the remoteobservation.

Berg forward reach data were pooled across all subjects andboth trials. A paired -test showed no significant difference be-tween co-located and remote methods, ,

, . The power of the test to detect a dif-ference of one inch and two inches was 48% and 95%. Over allthe data, the average absolute value of the difference betweenco-located and remote measures was 1.8 inches .The absolute difference for trial 2 data, for which subjects stoodon an air disk for a balance impairment, ( , )was almost double that of trial 1 ( , ). In trial1 subjects reached an average of 15.5 in but only 11.3 for trial2, a significant difference, , ,

.For TUG, a paired -test of the averaged trials showed no

significant difference between co-located and remote methodsof timing, , , . Thepower of the test to detect differences of 1 s and 2 s was 32%and 85%. When the data were resorted by observation order,they showed that most subjects improved their TUG score on thesecond trial, demonstrating the existence of a learning effect.

IV. DISCUSSION

A. ROM

Remote measurement of joint angles is feasible as the resultsshowed that with some exceptions, remote measures did notdiffer from co-located measures. For shoulder abduction andknee flexion, M5 differed from M6 which means there was adifference between one therapist holding a goniometer up toa screen shot and the second therapist using the virtual go-niometer on the screen shot. The difference is likely interraterbecause the secondary analysis showed that virtual and realgoniometer yielded no difference when compared within therater. For shoulder abduction, M6 also differed from M3, M5,and M7 and for knee flexion, M5 also differed from M2 andM3 which implies that additional training may be required forthe screen shot methods.

Caregivers can be instructed to place and read a universalgoniometer. The method of reading the goniometer by zoomingwas less useful as it required a pan/tilt/zoom camera with goodoptics, and the process of zooming is time consuming. Themethod of taking a snapshot for later measurement is techni-cally feasible, assuming that the camera can be positioned sothat its axis aligned with that of the patient’s joint to avoid par-allax errors. Subjects sat or lay on a motorized plinth that couldbe raised and lowered for optimum positioning for viewing bythe camera. Motorized hi-lo mats are not available in the homewhich will make camera positioning more challenging.

The therapists reported no difficulty in identifying anatomiclandmarks for angle measurements from digital snapshots.Although using real and virtual goniometers to measure thephotos were equivalent within therapists, the virtual was easierto use and required fewer instructions to the patient. Identifyinganatomic landmarks in obese patients will be more challenging.

B. MMT

The remote therapist was able to score manual muscle testsreliably based on observation alone. MMT scores are differ-entiated by the ability to maintain position against “maximal,”“moderate,” and “minimal” resistance by the therapist [14]which could be detected by the therapist by observing thepatient and the caregiver to estimate exertion. While the digitaldynamometer did not appear to impact the ability to measure,it may give the remote therapist a sense of being more incontrol and eliminates the need for the therapist to estimate theresistance force being applied by the caregiver.

C. Balance

Scoring of the Berg Item #1 (sit-to-stand) is based on visualobservation, and the resulting close match between co-locatedand remote scores was expected. All of the subjects were ableto stand quietly on a single disk which explains why all trial 1scores were the same for remote and local assessment. The diffi-culty with making inferences from the second set of trials is thatthere was no guarantee that the remote and local therapists wereobserving the same performance as standing on two balancedisks is extremely difficult. Thus, variations in the sit-to-standscores most likely resulted from trial-to-trial variation.

28 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 15, NO. 1, MARCH 2007

Video observation was effective in assessing Berg Item #8(Functional Reach). While a 1.8 in difference in reach can beclinically significant, the therapists reported that the remotemeasuring scheme was accurate so that the differences seenwas likely caused by subject trial to trial variation. The largervariation of trial 2 data resulted from subjects being given abalance impairment which likely resulted in a larger variationin their performance between trials. Additional technologycould eliminate the ruled board and camera zooming.

D. TUG

It was relatively easy for the remote therapist to observe andtime the TUG after the camera was oriented for a good view ofthe chair and walkway. The power to detect differences of onesecond was low but this was because the subjects walked fasteron each successive trial as they learned how to balance on thebeam.

E. Communication Bandwidth

A high quality, real-time audio link was essential for com-municating instructions between the therapist and the caregiverand patient. A one-way video link was needed so that the thera-pist could visually confirm that instructions were being carriedout and to record observations based on assessment measures.Video in the other direction was not required but may help inpatient interactions.

The quality of the teleconferencing video and audio impactsthe accuracy of remote assessment [22]. This study used idealtelevision quality audio and video and a pan/tilt/zoom camera.For remote assessments done in the home, the quality of thevideo will degrade based on what the phone lines can transmitunless the home has wired or wireless broadband access. Theeffect of video quality on remote measurement methods is un-known. For example, the administration of the gait assessmentrating scale has been reported to be as accurate using store-and-forward video clips transmitted at 128 kbps and 18 kbps com-pared to the full-resolution video camera clips [23].

F. Technology

Other than video conferencing, little technology was used.More technology could easily be added to support more accuratemeasurement while keeping the essentials of the measurementinstrument the same. The digital dynamometer is one example.Recording the data in pounds from the digital dynamometermight help the therapist to assign an MMT score, but the ac-tual resistance in pounds is only a part of the MMT score be-cause there is a large variation in how may pounds a person canproduce based on their body type. An MMT score takes intoaccount a person’s body type, ability to move a limb againstgravity and ability to move against manual resistance. If this in-formation can be gathered through observation, adding a digitalforce reading in pounds could assist the therapist in assigning a0–5 MMT score.

A pressure sensor on the chair could detect the start and endof a TUG test, and a range sensor could record forward reach.While these sensors could be small, light, wireless and easy touse, they would require additional training for the therapist andwould increase system cost. Whether this would lead to faster,simpler, and more reliable remote assessments remains to beseen.

G. Limitations

Subjects were nonimpaired and their simulated impairmentswere clearly different from the impairments seen in actual pa-tients. For example, subjects with simulated impairments couldfall off the Dynadiscs with no consequences while elderly pa-tients with balance impairments must be caught by the care-giver. Subjects acting as patients and caregivers were highlyeducated and had no trouble following instructions which maynot be the case for real patients and their caregivers, particu-larly for patients with cognitive impairments. For the purposeof the study, the simulated impairments were successful in elic-iting the range of assessment scores that would be expected in aclinical population. Subjects were not in their own homes whichmay have changed their behavior and performance. Trial-to-trialvariation in task performance may have contaminated the re-sults. It was not possible to conduct the co-located and remoteassessments simultaneously as therapist instructions are part ofthe comparison and each therapist must be blinded to what theother is doing. Inter-rater reliability for teleassessment must bedetermined. In this study, one physical therapist conducted allof the co-located assessments, and a second conducted all ofthe remote assessments. A future study should include severaltherapists to measure reliability. The small number of subjectslimited the power to detect Type II errors, however, it was ad-equate to investigate technical feasibility of the teleassessmentmethods. Cost was not addressed although cost has a dominatinginfluence on reimbursement and adoption. A financial feasibilityanalysis would be complicated by the rapidly changing costs oftechnology and broadband communications, and changing atti-tudes towards reimbursing teleconsults.

V. CONCLUSION

Remote rehabilitation assessment using traditional as-sessment instruments is technically feasible. Assessmentsadministered remotely were conducted without difficulty andyielded approximately the same results as when administeredlocally. A high quality, two-way audio link, as least as good asa standard telephone connection, is required for effective verbalcommunication. A clinical study with rehabilitation patientsis needed to determine the efficacy and reliability of the testinstruments with a patient population and additional work isneeded to determine the inter-rater reliability of the screen shotangle measuring methods. No conclusions can be drawn fromthis study about whether teleassessment can be done safely athome with only the patient and caregiver present.

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William K. Durfee (M’XX) received the A.B. de-gree in engineering and applied physics from HarvardUniversity, Cambridge, MA, and the M.S. and Ph.D.degrees in mechanical engineering from the Massa-chusetts Institute of Technology, Cambridge.

He is currently Professor and Director of De-sign Education in the Department of MechanicalEngineering at the University of Minnesota, Min-neapolis. His professional interests include medicaldevice design, rehabilitation engineering, musclebiomechanics, and design education.

Lynda Savard received the M.S. degree in physicaltherapy from Duke University, Durham, NC, in 1993.

At the time of this study, she was practicing atSister Kenny Rehabilitation Institute in Minneapolis,MN, where her main area of emphasis was adultneurological rehabilitation. She was also the leadPhysical Therapist for the Advanced RehabilitationTechnologies Program at Sister Kenny, which in-vestigates innovative ways to integrate technologyinto rehabilitation. Her areas of special interestinclude telerehabilitation, virtual reality training and

research.

Samantha Weinstein received the S.B. degreein chemical engineering from the MassachusettsInstitute of Technology, Cambridge, in 2002 andthe M.S. degree in mechanical engineering at theUniversity of Minnesota, Minneapolis, in 2004.

She is currently a Senior New Product Develop-ment Engineer with Allen Medical Systems, Acton,MA, where she is managing a project to develop anew device to position the head for cervical spinesurgery.