匹慈堡大学健康与康复科学学院康复科学与技术系 远程康复及其初步成果 Nigel Shapcott, M.Sc., A.T.P. 翻译：王季军，审校：王珏 博士 匹慈堡大学健康与康复科学学院康复科学与技术系 匹慈堡大学医学院健康系统辅助技术中心 This lecture is designed to introduce you to the main features and concepts that we currently understand about TeleRehabilitation. 1. Overview of Telemedicine and TeleRehabilitation 2. Technologies and nomenclature 3. Report on local findings 4. Future developments 5. Opportunity for interactive web based discussion

感谢下列机构 US Dept.of Agriculture SBIR I and II. Center for Excellence in Rural Medically Underserved Areas, PA. Veteran’s Affairs Rehab Research & Development Service Dept of Rehab Science & Technology at the University of Pittsburgh UPMC Center for Assistive Tech. UPMC Spinal Injury Center HERL VA Medical Center Pittsburgh Traditionally we acknowledge our main funding sources for the work that we carry out. In our case we have received funding from a number of different sources and throughout our work have received help of loaned equipment and free expertise from many others.

感谢下列人士 Laura Cohen PT Rory Cooper PhD Rosi Cooper PT Michael Boninger MD Laura Cohen PT Rory Cooper PhD Rosi Cooper PT Shirley Fitzgerald PhD Mark Schmeler OT Tricia Thorman OT Traditionally we acknowledge our main funding sources for the work that we carry out. In our case we have received funding from a number of different sources and throughout our work have received help of loaned equipment and free expertise from many others.

远程康复 第一篇——概述 Teamwork Two groups are loosely defined as the TeleRehab “experts” or specialists and those at TeleRehab personnel “rural” sites. However it is very important to understand that in order for the client to receive the best care the “expert” and the rural individuals are members of a team each of whom has different and equally pertinent information vital to a good outcome. Constituencies It is generally assumed that the two groups would be split as indicated in the slide, but it may well be that there is considerable overlap, depending on local resource issues. That is, in a particular health care system, who are the health care providers visiting clients in their homes or places of work.

专家中心 乡村站点 远程传输各种影响康复的因素：轮椅，创伤护理，治疗跟踪，培训等。 基于图像与声音的评价 传输评价数据 压力/空间数据 辅助技术从业人员 辅助技术厂商 注册护士 认证矫形及修复专家 OTR, PT 理疗医师 非专业 OTR or PT COTA or PTA RTS 技师 LPN 矫形或修复专家 上门服务护士 Teamwork Two groups are loosely defined as the TeleRehab “experts” or specialists and those at TeleRehab personnel “rural” sites. However it is very important to understand that in order for the client to receive the best care the “expert” and the rural individuals are members of a team each of whom has different and equally pertinent information vital to a good outcome. Constituencies It is generally assumed that the two groups would be split as indicated in the slide, but it may well be that there is considerable overlap, depending on local resource issues. That is, in a particular health care system, who are the health care providers visiting clients in their homes or places of work.

远程康复- 需求 资源与距离 大约 200 英哩 宾州- 西部/中心 没有足够的熟练人员 大量的服务不周 过于遥远 病人过早出院 死亡率 伤残率 帮助技术 The major issues revolving around the need can be summarized simply as distances, lack of local expertise, high cost of delivery in rural areas. The problems of delivery of Rehabilitation Service provision in rural areas parallels the delivery of health care to rural areas where the proportion of people with chronic illnesses is higher and the means to pay for them is reduced services (Witherspoon, Johnston, & Wasem, 1993). Large distances mean long travel times increasing costs associated with any service delivery and the time of travel consumes valuable time skilled professionals could be using to provide services. 大约 200 英哩 宾州- 西部/中心

远程康复- 为什么使 用基于电话的系统? AT&T, top picture 1994 ($1500) 性能差 ViaTV, 1998 1998, 普遍使用的基础部件 (POTS)- 价廉，性能好。如 ViaTV, Starview 新部件：价格超过300美元 The potential of modern low cost technologies as tools in the delivery of Assistive technology have been discussed (Shapcott, 1994). An example of the technology of the time was shown, the AT&T video phone- this was little better than an ordinary phone call in getting information to a remote party because of small picture size, low resolution and slow frame rates. New low cost POTS based video conferencing technologies are appearing rapidly. These are based around low cost digital video chips and sophisticated video compression techniques. These can cost little as approximately $400 (US) for each unit. See picture below. The units consist of a camera and all required electronics in a small box and are relatively easy to use. These systems are now able to transmit and receive reasonable video images and are being further developed to accept RS232 computer inputs which have the potential of enabling the transmission of accompanying electronic data.

远程康复的潜在效益 为居住在大城市外的人提供更方便的健康监护 缩短病人与医师到诊所和医院的路程 更多专家可参与到诊断评价 对出院病人实现疗效随访跟踪

远程康复 第二篇 —— 技术术语 This lecture is designed to introduce you to the main features and concepts that we currently understand about TeleRehabilitation. 1. Overview of Telemedicine and TeleRehabilitation 2. Technologies and nomenclature 3. Report on local findings 4. Future developments 5. Opportunity for interactive web based discussion

带宽- (信息速率) 已有和正在发展的技术 有线-T/4 光缆- 高带宽 有线 -ISDN 数字电话线- 中等带宽 有线 -POTS- 简单电话服务- 低带宽 有线 –Cable- 中等/高带宽 有线 - Power Utilities- 未知 有线 - *DSL 技术- 中等/高带宽 无线- Cell Phone 3G- 中等/高带宽 无线- 2 Way Satellite (0.5m)- 中等/高带宽 Bandwidth can be imagined as being analogous to the internal diameter of a water pipe, the larger the diameter the more water will flow- thus the larger the bandwidth the more data can flow and in this case, the better the video. Compression is a mathematical technique used in the software and hardware which uses "tricks" to squeeze better quality video for a particular available bandwidth. Technologies listed here are as of 1999 and by observation change on a 3-6 month cycle with new technologies appearing and old ones fading out. As time passes some of the older technologies repackaged an reappearing at more advantageous times.

通讯技术-小结 发展迅速 巨大的潜在市场 乡村市场持续增长 带宽增加 图像质量提高 数据处理能力进一步提高

远程康复 - 第三篇- 研究成果 This lecture is designed to introduce you to the main features and concepts that we currently understand about TeleRehabilitation. 1. Overview of Telemedicine and TeleRehabilitation 2. Technologies and nomenclature 3. Report on local findings 4. Future developments 5. Opportunity for interactive web based discussion

临床讨论的问题 谁对病人的安全性负责 具体操作的人 帮助移动的人 培训 指挥操作的人和具体操作的人要资格认证 双方都要接受专业培训，建立相互默契和理解 远程康复在认知上的限制来源于 没有触觉 去感受病人运动的范围 不能感受病人的抖动 需要更多的工具 ，如压力计等 需要多视角观察

用有线电话远程康复系统 评价轮椅系统处方的功效 目标与方法 为使用有线电话传输声、光信号来进行辅助技术远程处方服务的电视会议系统建立评价其可靠性与局限性的科学基础。 确定在由于地理、交通、经费原因而不能提供良好服务的社区中，增加辅助技术的处方服务能力的潜力。 用远程康复系统对患者所需轮椅或座位进行评价，并与现场康复评价的结果相比较。

用有线电话远程康复系统 评价轮椅系统处方的功效 研究问题 有经验的临床医师用远程康复技术和已定义的操作协议能否： 可靠地确定远程康复流程对特殊病人是否合适而安全？ 可靠地、在细节水平上提供关于所需轮椅精确决定？ 可靠地获取关于病史与体检结果的准确评估？

用有线电话远程康复系统 评价轮椅系统处方的功效 评估 面谈-从标准信息表获得病人信息以组成“模 型患 者”；与患者面谈确定灵活的目标、目标的合适性、诊断以及身体健康状况的任何变化。 坐垫评价- 由临床医师亲自进行运动测量评价或通过远程康复系统由临床医师指导助手进行评价。坐垫评价的目标是建立被动和主动的上、下肢运动范围、任何病理移动方式、坐姿和移动技术、脊椎定向，及与运动和其它目标相关的功能性能力。 测量- 临床医师或其助手用数据收集表要求记录线性或角度测量结果。

用有线电话远程康复系统 评价轮椅系统处方的功效 20 个测试者作为“模型患者” 4 个评价者 交叉学习 2 个本地 2 个现场In Person (IP) 2 个远程康复 (TR) 数据采集协定的细节（表格） 4 个临床医师 (2 OT, 2 PT) 9 个 “助手” 培训 远程康复评价 移动 ROM 尺寸测量

2 个本地服务 匹慈堡大学医疗中心 辅助技术中心 匹慈堡 荣军医疗中心Highland Drive 匹慈堡

实验框图 第 2 天 第 1 天 两次评价间 隔 三到七天 临床医师3 评价 临床医师4 评价 临床医师 1 评价 临床医师2 评价 CAT TR CAT IP VA IP VA TR 临床医师 1 评价 临床医师2 评价 第 1 天 两次评价间 隔 三到七天

用有线电话远程康复系统 评价轮椅系统处方的功效 数据收集: 由一个物理治疗师、一个统计员、二个职业治疗师、二个理疗师、一个康复工程师组成的小组设计一系列综合数据统计表。这些表用于记录患者的特征、患者的环境及处方细节。它们是在对一系列已有表格及“图森辅助技术计划”的工作框架进行分析总结后建立起来的。

数据收集 - 表 1

数据收集 - 表 2

数据收集 - 表 3

数据收集 - 表格 3

数据收集 - 表格 4

初步评估 (9 of 20 被试者) 问题 1：进一步评价 多人评价 Kappa, 4 clinicians, 0.464 & p=0.07 远程康复评价与 现场评价：Kappa 0.615, p=013 simple agreement 90% (Weighted Kappa issue)

初步评估 (9 of 20 subjects) 问题2： 轮椅类型 手动轮椅- simple agreement 100% (n=4)

初步评估 (9 of 20 subjects) 问题3： 轮椅特征 手动轮椅: (折叠式, 固定式, TIS, 可躺式)-simple agreement 75% 电动轮椅特征: (可躺式, TIS)- simple agreement 94% 电动轮椅驱动: (前驱, 后驱, 中间驱动)- simple agreement 69% 小型摩托 : ( 3 轮或 4轮)- simple agreement 50%

初步评估 (9 of 20 subjects) 问题4： 座位尺寸 座宽: (<16英吋、16英吋、18英吋、>18英吋) - simple agreement 61% 依据患者的座位总宽度: (<16英吋、16英吋、18英吋、>18英吋)- simple agreement 66% 座长: (<16英吋、16英吋、18英吋、>18英吋) - simple agreement 75% 依据患者的座位总长度 : (<16英吋、16英吋、18英吋、>18英吋)- simple agreement 44%

初步评估 (9 of 20 subjects) 问题5： 座位的坐垫特征 支撑座垫: (大腿中部, 大腿侧部, 臀部)- simple agreement 86% 要求专用座垫 : (是, 否)- simple agreement 86% 要求减压座垫: (是, 否)- simple agreement 78%

初步评估 (9 of 20 subjects) 问题6： 座位的靠背特征 靠背侧部支撑: (左侧, 无)- simple agreement 83% 靠背侧部支撑: (右侧, 无)- simple agreement 83% 要求专用靠背: (是, 否)- simple agreement 80%

初步评估 (9 of 20 subjects) 问题7： 头靠与扶手 要求头靠: (是, 否)- simple agreement 94%

初步评估 (9 of 20 subjects) 结论: 易于建立与使用 必须有高质量的音频信号 要求专业的临床医师 长度测量结果太粗糙-要考虑更换简易测量工具 (Logan等 1998)

远程康复 - 第四篇- 未来技术 This lecture is designed to introduce you to the main features and concepts that we currently understand about TeleRehabilitation. 1. Overview of Telemedicine and TeleRehabilitation 2. Technologies and nomenclature 3. Report on local findings 4. Future developments 5. Opportunity for interactive web based discussion

远程康复- 未来的需求 基于视频的数据采集 压力 尺寸

远程康复- 未来的需求 基于视频的数据采集 创伤

远程康复- 未来的需求 基于视频的数据采集 温度

基于视频的数据采集 剪切力 湿度

远程康复- 未来的需求 基于视频的数据采集 数据手套

远程康复 -未来的服务传递 将用 有线数字电话或其它宽带系统 This lecture is designed to introduce you to the main features and concepts that we currently understand about TeleRehabilitation. 1. Overview of Telemedicine and TeleRehabilitation 2. Technologies and nomenclature 3. Report on local findings 4. Future developments 5. Opportunity for interactive web based discussion 宽带系统联接到德克萨斯州的中心，以有线电话接入用户家。目前，由于缺乏基金支持，远程康复服务被局限于用在特殊病例或演示方面。