Telerehabilitation Research: Emerging Opportunities: Annual Review of Biomedical Engineering February 2002

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Telerehabilitation Research: Emerging Opportunities
Article in Annual Review of Biomedical Engineering · February 2002

DOI: 10.1146/annurev.bioeng.4.112801.121923 · Source: PubMed
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10.1146/annurev.bioeng.4.112801.121923
Annu. Rev. Biomed. Eng. 2002. 4:287–320

doi: 10.1146/annurev.bioeng.4.112801.121923
Copyright °
c 2002 by Annual Reviews. All rights reserved
TELEREHABILITATION RESEARCH:
Emerging Opportunities
Jack M. Winters
Department of Biomedical Engineering, Marquette University, Milwaukee,
Wisconsin 53201-1881; e-mail: Jack.Winters@Marquette.edu
Annu. Rev. Biomed. Eng. 2002.4:287-320. Downloaded from www.annualreviews.org
Key Words telehealth, rehabilitation, telecommunications, telerobotics, healthcare

by Marquette University on 11/04/14. For personal use only.
■ Abstract The field of clinical rehabilitation is rooted in the premise that carefully
planned and delivered therapeutic intervention enhances patient outcomes. Underlying
this statement is a deeper scientific reality: The field exists because biosystems (e.g.,
tissues, cells, organs, persons) are inherently adaptive and can dynamically change
as a function of a sequence of inputs (e.g., exercise, pharmaceuticals). The tools of
telerehabilitation help minimize the barrier of distance, both of patients to rehabilitative
services and of researchers to subject populations. This enhanced access opens up
new possibilities for discovering and implementing optimized intervention strategies
across the continuum of care. Telecommunications technologies are reviewed from
the perspective of systems models of the telerehabilitation process, with a focus on
human-technology interface design and a special emphasis on emerging home and
mobile technologies. Approaches for providing clinical rehabilitation services through
telerehabilitation are addressed, including innovative consumer-centered approaches.
Finally, telerehabilitation is proposed as a tool for reinvigorating the rehabilitative
bioengineering research enterprise.
CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
SCIENCE AND ENGINEERING FOUNDATIONS:
A SYSTEMS ANALYSIS OF TELEREHABILITATION . . . . . . . . . . . . . . . . . . . . . 291
Rehabilitative Bioprocesses from an Optimization Framework . . . . . . . . . . . . . . . . 291
Telecommunication Technologies in Perspective:
Present and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Human-Technology Interface Design Principles
for Telerehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
CLINICAL TELEREHABILITATION: NEEDS,
STATUS, AND TRENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Recognition of Need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Clinical Telerehabilitation Research, Involving
Rehabilitation Practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Need for New Paradigms for Clinical Rehabilitation? . . . . . . . . . . . . . . . . . . . . . . . 309
1523-9829/02/0815-0287$14.00 287
288 WINTERS
Need for Functional Assessment Research and

Outcomes Measurement Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
TELEREHABILITATION FOR SCIENTISTS:
BRINGING IT HOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Remote Assessment for Scientific Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Therapeutic Teleinterventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
INTRODUCTION
To many, the term “telerehabilitation” may bring up images of futuristic high-
technology applications such as intelligent therapeutic robots that are supervised

from afar, or the use of intelligent gadgets for “televisits” between a clinician and an
aging baby boomer with a chronic health condition who doesn’t want to leave the
office (1–3). To others, telerehabilitation brings the hope of enabling access for all,
and could help address societal challenges in the delivery of rehabilitative services
once barriers such as distance and reimbursement are overcome (4–6). These are
appropriate visions. This review, however, focuses less on the moving targets of
emerging technologies or health policy and more on a scientific framework for
addressing optimal strategies for enabling telecommunications technologies to
improve access to and delivery of both rehabilitative services and research studies.
It is suggested that such a foundation is needed if there is to be a paradigm shift
in how we manage the rehabilitative intervention process within a twenty-first
century society.
Telerehabilitation is a remarkably new field, essentially “created” in 1997 when
the National Institute on Disability and Rehabilitation Research (U.S. Department
of Education) issued a set of proposed priorities for a new Rehabilitation Engineer-
ing Research Center (RERC) in the area of what was called “tele-rehabilitation.”
The scientific and technical objectives of the RERC on Telerehabilitation were
embodied in the four “priorities” originally defined in the request for applications
published in the Federal Register (7). Mildly paraphrased, these are:
1. Develop and evaluate telecommunication techniques for delivering training,
education, and counseling rehabilitation services at a distance;
2. Develop and evaluate technologies for assessment and monitoring of progress
and outcome of rehabilitation at a distance;
3. Develop and evaluate technologies for therapeutic intervention at a distance;
and
4. Conduct research on applications of virtual reality technologies to rehabili-
tation.
Notice the technology- and process-oriented nature of these objectives, the first
three of which can be procedurally viewed as teleconsultation, telemonitoring/tele-
assessment, and teletherapy, respectively. Notice also the emphasis on the delivery
of conventional clinical services, with a special focus on research that will yield
TELEREHABILITATION 289
access to services in underserved (e.g., rural) geographic areas. To these priorities,

we added a focus on telehomecare from within a rehabilitation context, which had
been an area of active research and in 1999 was a key focus within a supported
workshop coordinated by this author on Home Care Technologies for the 21st Cen-
tury (8, 9). Figure 1 provides representative process-oriented models for these three
areas, plus telehomecare, which are extracted from our 1998 proposal (and have
been presented many times at conferences). This review is largely based on this
author’s experiences during the first few years of our new RERC on Telerehabil-
itation. Our initial plan involved technical assessment of various teletechnologies
plus nine core R&D projects, at least one of which addresses each of these types of
models (10, 11). Target populations and applications included caregivers of persons
post-stroke, remote assessment of individuals with or at risk for pressure ulcers,
social/vocational training for autistic persons, neurocognitive telecounseling for
brain-injured persons, therapeutic play for children, and older adults with chronic
health challenges (e.g., cardiopulmonary). Although this may seem like a large
Figure 1 Four conceptual models of telerehabilitation service delivery. (A) Standard

“face-to-face” telemedicine model using interactive videoconferencing, typically with high
bandwidth between sites for a “teleconsultation,” to get access to specialty expertise (e.g.,
physiatrist, specialized therapist, rehab/vocational counselor). The “provider” is often a pre-
senter of a case. (B) Classic telehomecare model with a tele-nurse coordinating service
delivery, typically with a low or moderate bandwidth interactive connection, for “telesup-
port.” (C) Setup for unobtrusive telemonitoring, with possible interactive teleassessment.
(D) Model for teletherapy in which a client “plays” or “exercises” at home, with selective
telemonitoring of performance, and an ability of therapist to change settings remotely and
interactively participate in “telecoaching.”
290 WINTERS
number, of interest is that based on our discussions with various clinical prac-
titioners at various conferences and exhibits, there are many more possible ap-
plications. The needs and opportunities are real. Recently, our RERC hosted a
state-of-the-science (SOS) conference that brought together key groups involved
in telerehabilitation research and service delivery within the United States (11, 12).
A critical target of this article is to share these many and varied opportunities, with
a special focus on the scientific implications.
It is interesting that of the medical specialties listed in Figure 2 under tele-
medicine, by all accounts applications involving telerehabilitation are currently
rather low on the list. Yet, it is broadly believed that there is considerable potential
for telerehabilitation applications to expand (6–10), especially on the premise of

the emerging consumer-centered model as the foundation for a “reengineered”
twenty-first century healthcare system (2, 8). Indeed, at our recent conference on
the state-of-the-science in telerehabilitation, which was cosponsored by Ameri-
can Telemedicine Association (ATA), the president of ATA made closing remarks
that noted the unique attributes of the gathered collection of roughly 80 clinical re-
searchers, engineering scientists, and human factors specialists, and suggested that
telerehabilitation provided a vehicle for bringing a greater degree of scientific in-
quiry to the field of telehealth (11). In addition to natural ties to human-technology
interfaces and user-centered engineering, there is the reality that roughly 50 million
Americans currently live with a level of functional impairment that impacts on their
ability to perform daily activities, with many also dealing with a chronic health
disease. Although most do not receive special rehabilitative services, each year
millions receive some form of therapeutic intervention, ranging from over three
hours per day of therapy as an inpatient within a comprehensive rehabilitation hos-
pital, to only a few hours of therapy per week in settings such as a skilled nursing
Figure 2 Conceptual view of the emerging model of telehealth (commonly defined as the
use of telecommunications to provide health information and care across distance), with
telemedicine considered to be a subset of telehealth (16). Telehealth is viewed as distinct
from, yet synergistic with, the emerging e-health enterprise, which includes web e-health
and electronic medical records. Telerehabilitation falls under both telemedicine (delivery of
clinical services) and telehealthcare (management of disability and health).
facility, an outpatent clinic, or home visits. Access to services is often a chal-

lenge, as is access by researchers to larger subject populations. The opportunities
for bioengineers to integrate telerehabilitation methods and tools into healthcare
solutions are manifold.
The tools available for intervention may have an impact on the strategy, and
this review is motivated by the expectation that advances in telecommunications
and information technologies will help minimize the barrier of distance in the
delivery of rehabilitative services and have great potential to improve future in-
tervention strategies. This review extends Mun & Turner’s recent summary of the
evolving area of telemedicine (13), while also being synergistic with several of the
other Annual Reviews related to human movement research (14) and rehabilitation
bioengineering strategies for connective tissue remodeling and repair (15).
SCIENCE AND ENGINEERING FOUNDATIONS:

A SYSTEMS ANALYSIS OF TELEREHABILITATION
Based on a task analysis of telehealth services, the processes underlying the im-
plementation of telemedicine applications are often classified into two categories:
“store-and-forward” (asynchronous) and “interactive” (synchronous, real-time).
Although both are clearly important and often integrated, the former approach
typically involves a process not that different from attached files to email, which
is not particularly scientifically intriguing and thus will not be addressed fur-
ther in this section. In contrast, most telerehabiliation applications inherently
involve interactive telehealth and must face scientific issues related to human
performance.
Rehabilitative Bioprocesses from an Optimization Framework

Consider the following statement from the Executive Summary of the NIH-
sponsored Report of the Task Force on Medical Rehabilitation Research (16):
“. . . the Task Force concluded that three overriding needs are critically im-
portant to the field’s progress:
■ Develop meaningful quantitative measures of impairments, disabilities, and
handicaps, and of the outcome of rehabilitation interventions. . . .
■ Develop standards and guidelines for the design and application of evaluative
tools.
■ Evaluate the effectiveness of existing and emerging rehabilitation
procedures.”
From an engineering perspective, these come back to two classic processes: as-
sessment (first two bullets) and therapy (last bullet). These will re-emerge through-
out this review, and remain a scientific and engineering challenge.
292 WINTERS
Although targeting the whole person, the focus of rehabilitation science and
engineering, as developed in the Institute of Medicine’s seminal consensus book
entitled Enabling America—Rehabilitation Science and Engineering, is on a multi-
disciplinary understanding of the enabling-disabling process (17). The underlying
motivation is a fundamental principle: that tissues and systems of cells—ranging
from connective soft tissue to muscle to neurocircuitry—can “remodel” as long as
there is access to an adequate internal support infrastructure (e.g., blood supply),
and the involved structures are “used” appropriately (1, 15–20). This represents a
great scientific challenge, given the complexity of the human system and its adap-
tive processes. Although the functional principles underlying rehabilitative, adap-
tive, repairative, and healing phenomena are beyond the scope of this review and
remain an active area of discovery, the reality is that the field of medical reha-
bilitation exists because there is evidence—unfortunately mostly heuristic—that
there is merit to intervention by professionals trained in the art and science of
rehabilitative service provision (20–26).

Scientifically, to “rehabilitate” implies engaging in a rehabilitative process
yielding improvement in function beyond any spontaneous recovery. This is rep-
resented in Figure 3 for a timescale typical for neurorehabilitation. Although com-
monly viewed within the context of a “continuum of care,” the reality is that most
rehabilitation care is by way of “outpatient” therapy, delivered as a finite series of
bolus interventions. Because the patient or client resides outside of the clinic (e.g.,
home, work), typically there is no systematic sampling of the subsequent dynamic
temporal response due to such interventions.
From an engineering perspective, the “outcomes” axis in Figure 3 may seem
frustratingly vague, and indeed using the common definition “benefits that patients
receive from a rehabilitation program” suggests that the outcome relates to the dif-
ference between the two curves. Nonetheless, the process is tangible once outcomes
indicators are selected, as can be seen in Table 1. Figure 3 uses a patient-centered
model that delineates between outcome and efficiency. Also in common use is a
hospital-centered model, where “outcomes” refers to what is called efficiency in
Table 1; for instance, this was the more common interpretation in presentations by
rehabilitation hospital administrators during our recent SOS conference (11). From
this perspective, the objective of the clinical rehabilitative process is to employ an
optimum intervention strategy that will maximize desired outcomes (e.g., maxi-
mum function and social re-integration per unit cost). Rehabilitation bioengineers
need to fully appreciate these distinctions.
In a key telemedicine review article, Bashshur refers to a window of opportunity
to maximize the return on investment in telemedicine by designing optimal systems
structures that match the specific needs of target populations and communities, and
maximize beneficial effects in healthcare delivery while minimizing undesirable
effects (27). This sounds much like an engineering optimization problem.
Importantly, the allied health professions have uniformly integrated optimiza-
tion language into their mission statements and professional guidelines. Occu-
pational therapists, for instance, are said to enable occupation within the
Figure 3 Idealized representation of the continuum of interventional rehabilitative care and

its impact on outcomes for a typical client going through comprehensive neurorehabilitation
as a function of time, for instance following a stroke. Thin line represents the degree of “spon-
taneous recovery,” thick line the outcome due to intervention, and dotted line the idealized
final outcome (e.g., full recovery). “Outcomes” typically is measured by degree of indepen-
dence (e.g., FIM score) but could also relate to measures of functional skill, health fitness, or
patient satisfaction. In this example, at six months an experimental, high-intensity interven-
tion (for example, several weeks of constraint-induced movement therapy or robot-assisted
therapy) is introduced, further improving recovery. Research studies of interventions at later
times (e.g., over one year) have helped eliminate the myth that a “chronic” state exists at
six months after which further therapy is ineffective, at least for many (likely most) patients.
From the perspective of optimizing the allocation of healthcare resources, one challenge is
to determine the optimal bolus of inputs (i.e., vertical lines) that will yield the best outcome.
Another challenge is the best intensity and type of therapy during each of these sessions and
how to integrate it into home-based therapy. Movement therapy technology will likely play
a key role in meeting these challenges.
person-environment by identifying the key occupational tasks (e.g., at work, school,

home, vehicle), setting treatment goals that optimize performance and then imple-
menting a dynamic, iterative process aimed at a best outcome (28, 29). Physical
therapy texts and the American Physical Therapy Association’s (APTA) guide to
practice routinely talk about trying to determine a patient-centered optimal thera-
peutic intervention strategy (20, 30).
What has this to do with telerehabilitation? The addition of telecommunica-
tions technologies can be thought of opening a Pandora’s box of possibilities for
changing this process, based on new tools that decrease the barrier of distance for
remote assessment and/or for therapeutic intervention. This can affect both plan-
ning and delivery, including the optimum use of feedback pathways as suggested in
Figure 4. Using the terminology of Figure 1, approaches for assessments can range
from unobtrusive telemonitoring of key indicators to interactive televisits. Within
this context, this new field of telerehabilitation changes the “system constraints”
as well as the viable control (intervention) strategies, which in turn provides
294 WINTERS
TABLE 1 Three specific functional objectives generally associated with medical rehabilitation
[based on (21, 22)]
Outcomes Outcomes measurement: Systematic observation of outcome indicators

Outcomes monitoring: Repeated measurement over time of outcome indicators
in a manner permitting causal inferences about source of observations.
Outcomes management: Use of information and knowledge gained from
outcome monitoring to achieve optimal patient outcomes
through improved clinical decision making and service delivery.
Progress Type and degree of improvement, as function of time
Efficiency Functional gain/resources expended
alternative solutions, and thus new opportunities within a turf-oriented rehabil-

itative field that has not been particularly innovative. It is suggested that rehabil-
itation bioengineers have much to contribute, especially those who are willing to
frame their research agenda so as to anticipate and address these larger clinical
and societal needs.
An optimization process requires identification and utilization of reasonably
objective measures. One of the challenges facing rehabilitation bioengineering re-
searchers is the relative lack of use of sensor-based measures within rehabilitation.
The primary “quantitative” measures within the rehabilitation field remain ordinal
scales—practitioners (and often clients) assigning numbers (e.g., on scales such
as 1 to 7) to observations of attributes (or responses to questions). This is not a
criticism, as it remains the responsibility of researchers to identify sensor-based
objective measures with clinical utility. But what it does imply is that to be effec-
tive participants in clinical rehabilitation research, rehabilitation bioengineering
researchers must learn a new set of terminology. Any new instruments generat-
ing new measures of performance or health status must be subject to the test of
reliability and validity, including, if possible, ecological validity. From a research
perspective, an added value of telerehabilitation is that all of the information that
streams between sites—video, audio, signals from biosensors, mouse/keyboard
operations—can be collected and reduced if desired.
Telecommunication Technologies in Perspective:

Present and Future
The current societal investment in telecommunication technologies is unprece-
dented. One of the goals of telerehabilitation is to take advantage of this
multi-billion dollar societal investment by performing concurrent research that
anticipates future mass-market technology developments (1). There are basically
four modes of human telecommunication: voice, video/images, data exchange
(typically by mouse/keyboard operation), and virtual contact. Each type of channel
may be uni-, bi-, or multi-directional. As a society, we are transitioning from uti-
lizing separate infrastructures for our key mass-market telecommunication modes
Figure 4 (A) Condensed form of the classic model for optimization problems in engineer-
ing (16, 17). Stated in words: Given a dynamic system (including constraints) and a set of
controls (tunable input parameters that act on the system and affect its behavior), determine
(via an optimization algorithm) the optimum solution(s) that extremize a specific perfor-
mance objective (goal, often as defined by a set of performance subcriteria). (B) For medical
rehabilitation, the “system” typically includes the individual client and their environment
(including any assistive technologies), the “control variables” are therapeutic interventions,
and the “goals” relate to desired outcomes (e.g., maximize independence, maximize function
or level of skill, maximize therapeutic benefit per unit cost).
to embracing integrated multimedia. A section on telecommunications technolo-

gies can quickly become obsolete. But there are a number of useful observations
that may help researchers understand some of the opportunities and limitations of
emerging telecommunications technologies.
First, the throughput on the communication link, i.e., the amount of informa-
tion that can be exchanged per unit time, is a critical constraint. To provide a
rough barometer for comparison, as signal codecs have improved and been stan-
dardized, the required bandwidth for a telephone-quality voice is about 16 Kbps
(current cell phones are 8–14 Kbps), for stereo-quality sound is about 64 Kbps,
and for near-TV quality video and voice about 400 Kbps. The bottom line is that
the “bandwidth hogs” tend to be video and detailed images, rather than audio,
data, or even virtual contact signals. Indeed, using the mouse pointer and joystick
296 WINTERS
channels as examples, contact signals can typically be sampled at rates of 110/sec

or lower, which even for a few channels turns out be a moderate level of band-
width. This is also true for most mechanically and chemically based physiologic
signals.
Second, the impact of teleconferencing standards by the International Telecom-
munications Union (ITU) has been considerable. Since introduced in roughly 1996,
the cost has come down dramatically while the quality has improved, and the sys-
tems have become considerably easier to use. These standards span both the clas-
sic phoneline infrastructure (H.320, H.324) and the packet-based Internet Protocol
(IP) infrastructure (H.323). Each overall standard defines messaging protocols that
govern transmission of audio, video, and data between two (or more) systems and
specifies additional viable standards for video and voice codecs, security, privacy,
and multiplexing and data control (31). Often, they share some features, such as
a specified video resolution at CIF (352 × 288 pixels) or QCIF (176 × 144) or the
standard TV resolution of 4CIF (704 × 576). Each is periodically updated. Our

RERC has considerable experience with each (32–34), and the following com-
ments are provided:
■ The H.320 standard is applied mostly to dedicated circuit-based (point-to-
point) connections of moderate or high bandwidth, such as through the ISDN
digital phone protocol (each 128K ISDN line requires use of two phone
lines in parallel). The industry norm is to use three ISDN lines (i.e., connect
at 3 × 128 Kbps = 384 Kbps) or a quarter of a 1.44 Gbps T1 line, giving
near-TV-level quality (30 fps, CIF or 4CIF image, options on audio and
video codecs). Throughout the 1990s, federal grants programs helped support
the implementation of T1 hub-spoke networks to rural communities, and
this H.320 protocol now sees widespread use for conferencing of all types,
ranging from telemedicine consultations between a tertiary and rural hospital
to our routine use of H.320 for our multi-site RERC staff meetings. For
telehealth applications, an especially useful feature is both local and remote
control of camera orientations—remote control by health specialists is part
of the telehealth reimbursement guidelines for the United States’ Medicare
program. Virtually all of the newer H.320 products are also H.323 compliant,
and can facilitate transmission of one or more channels of data (e.g., signals,
images, records, presentations).
■ The ITU’s H.324 protocol, intended for “videophones” over standard phone-
lines (available in 97% of U.S. households), is usually targeted toward tele-
homecare applications where ease-of-use is a high priority and high-quality
video is not critical. These systems are not much more difficult to use than
a high-end phone or a VCR, with the main user-controlled feature being in-
teractive control of the trade-off between refresh rate (e.g., typical range of
1 to 15 fps) and image quality (e.g., in pixels per second to update a QCIF im-
age). Our evaluation of H.324 products suggested that whereas most products
are interoperable (often with some effort), there is no way around the choppy
nature of the transmitted video, especially if color is desirable (32, 34). For
home telehealth products, a small screen (e.g., 300 by 500 ) is often used so
that pixelation is less noticeable. Such small screens can be integrated into
standard phones, with cameras also integrated and/or connected by wireless
means. The telehealth community commonly uses the term POTS (plain old
telephone systems) to refer to wireline telephone-based systems, and sev-
eral telehealth-specific products are on the market that integrate a H.324
videophone with physiologic measures such as vital signs and/or a digital
stethoscope (5, 12, 34).
■ H.323 is the packet-based IP conferencing and messaging standard that serves
as the umbrella for a large suite of other standards. An important subset of

H.323 is the “voice and data” mode (i.e., video is not required for compliance,
but if available, it must meet certain standards). There are many H.323 ven-
dors, as well as an open source forum called OpenH323 (35) with which our
group participates. There is no question that H.323 videoconferencing can

be integrated into electronic health records (EHRs), and will be furthermore
used for both desktop and mobile computing environments. Yet, despite all
the movement toward IP-based conferencing, there are barriers such as the
lack of guaranteed quality of service across the Internet, and the convention
for assymetric allocation of downstream versus upstream bandwidth for DSL
and cable modems.
Third, multi-modal integration is happening on many fronts, and there are a
number of developments that could change the face of conferencing. Examples
include:
■ Multimedia streaming and digital video software technologies, which employ
a strong collection of one-way audio and video codecs. Most notable is the
continually improving MPEG-4 (Moving Picture Experts Group) family of
standards that govern audio and video streaming across various bandwidths
and to various endpoints. There are many applications in telehealth where
one-way streaming could be integrated into a telehealth package; for instance,
telemonitoring.
■ The “instant messenger” (IM) phenomena, originally targeted for chatting
with text messages, is rapidly evolving into voice (voice over IP, or internet
telephony) and video streaming. In the United States, the more popular ap-
proach has been messaging between personal computers, whereas in certain
parts of Europe there has been a remarkable level of traffic for the Short
Message Service (SMS) protocol where store-and-forward text messages of
up to 160 characters are exchanged between cellphone handsets via a relay
center. The wireless cellphone industry is driving an international Multimedia
Messaging Service (MMS) standard that would allow multimedia messages
(but not real time interactive services). However, products such as Windows
Messenger (for Microsoft’s XP.Net and CE.Net operating systems) function
298 WINTERS
within a software development environment that could go well beyond MMS,

for instance, web-based services that are interactive and also tie to medical
informatics packages.With the latter product supporting the Session Initiation
Protocol (SIP) conferencing standard, Microsoft now has the de facto stan-
dard for both H.323 endpoints (i.e., Netmeeting) and SIP endpoints. There
is no technical barrier to using IM for interactive videoconferencing when-
ever adequate bandwidth is available. Although the form of IP conferencing
continues to evolve, the messaging environment does seem well suited for
Web-based telehealth services, especially when coupled with XML (eXten-
sible Mark-up Language, the international IP markup language standard, of
which HTML is a subset).

■ Gaming and virtual reality technologies continue to evolve. Most notable
are games that make use of several mass-market force-reflecting joysticks,
employing software from a certain vendor specializing in adding forces to
interactive desktop and Web-based games (36). Several groups, including

ours, are actively engaged in developing therapy tools for this application
(37, 38).
■ Within the disability research community there is considerable activity in
multi-model translation, especially between speech recognition and key-
board/mouse entry, and between speech production and screen readers (39).
With the recent implementation of certain federal regulations related to the
Telecommunications Act of 1996 (40) and the extension of the Rehabilita-
tion Act [Section 508, (41)], the level of universal telecommunications ac-
cessibility for persons with disabilities is growing, which in turn will enable
consumer-centered telerehabilitation applications.
Fourth, integrated wireless telecommunications holds considerable promise for

telerehabilitation applications. To place wireless in perspective, the classification
scheme being used in the IEEE wireless standards process (42) is useful: wMAN
(wireless metropolitan-area cellphone networks, also known as wide-area networks
or wWANs), wLAN (wireless local area networks), and wPAN (wireless personal
area networks). With the distinction between cellphone and personal digital assis-
tants (PDAs) quickly blurring, the mobile device of the future will exist within a
wMAN/wLAN/wPAN-enabled environment. For instance, this author has been in
wLAN-enabled work environments for three years (with laptop and PDA access),
and as of March 2002 has a wPAN-enabled PDA (IPAQ PocketPC with embedded
bluetooth chip, from Compaq) and wMAN-enabled cellphone with both voice and
24-hour packet/Internet access (Global Systems Mobile/Global Packet Radio Sys-
tem, or GSM/GPRS) that is fully supported in the two markets where this author
works (Milwaukee, WI; Washington, DC); a wMAN/wLAN/wPAN-enabled PDA
is finally a reality. Here is the current status:
■ For wMANs, the current “second generation” (2G) digital cellphone infras-
tructure, with low bandwidth (8–14 Kbps), is currently transitioning to the
hybrid 2.5G infrastructure that combines one of the cellphone voice standards
with a packet-based data transfer standard (typically GPRS). GPRS facilitates
packet transfer at rates up to about 144 Kbps, but more likely about 64 Kbps
for most metropolitan services. The 3G (fully packet-based) wMAN should
reach widespread global penetration by about 2005. Assuming that traffic
issues are addressed, wMANs will be able to routinely pass audio and mes-
saging data via IP, such as the Wireless Application Protocol (WAP) and other
emerging protocols based on XML messaging and data transfer. This should
include real-time transmission for most physiological signals during an audio
conference. However, many see both technical and cost-based barriers on the
horizon that may limit access to guaranteed moderate-to-high bandwidth for

most people; for instance, whereas this author pays for GSM voice service by
the time of use, GRPS charges (by the same service provider) are based on
the number of packets that are transferred, which currently makes interactive
videoconference technically feasible yet not financially viable in comparison

to ISDN, cable modem, or DSL service.
■ For wLANs, the IEEE 802.11b “WiFi” standard (43) has emerged as the
consensus wireless Ethernet-based standard. It uses the 2.4 GHz license-free
ISM (industrial, scientific, medical) frequency band, works for distances up
to 100–1500 ft (depending on room obstructions and speed) with a reason-
ably high bandwidth (up to 11 Mbps for shorter distances), and is best viewed
as wireless connectivity in the local environment (e.g., computing peripher-
als). Many hospitals have now implemented wLAN-enabled wings or floors.
The medical device industry seems split between using the worldwide ISM
band (which allows voice and video as well as data) and the newly autho-
rized Wireless Medical Telemetry Service (WMTS) 608–614 MHz band for
physiological data transfer within the United States.
■ In contrast, wPANs are best viewed as short-range, person-centered, spon-
taneous, ad hoc mobile radio networks. The Bluetooth protocol (44), which
also works on the 2.4 GHz ISM band and has a throughput of up to 721 Kbps,
is emerging as the de facto standard over others such as HomeRF (2.4 GHz
ISM band with 2 Mbps throughput). Bluetooth-enabled devices are best
thought of as spontaneous, low-power, two-way radios that can network when
convenient and secure, for the most part unobtrusively. Both data and voice
transfer are supported. The potential for telehealth, and more generally as
electronic aids for daily living, is profound.
Because “hub” computing appliances such as cellphones and PDAs will be both
wPAN- and wWAN-enabled, within the very near future researchers can assume the
existence of wireless mobile conduits for information transfer of moderate band-
width (e.g., voice, sensor signals, human and activity performance sensors). Reha-
bilitation practitioners are the ideal professionals for exploring the long-awaited
concept of wearable computers and universal information appliances that are inher-
ently assistive and capable of spontaneous discovery, remote information access,
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and remote operation (8, 9, 45). For example, we envision that when a rehabilita-
tion nurse enters a room, the communication defaults and “picture frame” monitor
screen switches to those most appropriate for the expected job tasks (given the
patient on the schedule), professional skill and information access levels, and per-
sonal preferences. This author is currently supervising three graduate students who
are developing an intelligent telerehabilitation system that includes a mobile/fixed
telepractitioner terminal (TT) that can teleconference with and/or take over con-
trol of a mobile/fixed patient terminal (PT) and their personalized healthcare Web
server and repository (46). The driving forces are advances in:
■ wireless technologies mentioned above;
■ more powerful handheld mobile computing such as the new line of PocketPCs
based on the Windows CE.Net operating system and languages for embedded
devices;
■ technical advances in embedded and distributed computing, small wearable

gadgets with low power electronic componentry, information appliances, and
XML-coordinated Web services; and
■ the emergence of a focus on product accessibility and usability by the telecom-
munications and information industries (49).
In summary, this brief review suggests a paradigm shift in telehealth tools. Al-
though group teleconferences between sites using carefully planned and controlled
rooms continue to be important, there is a bright future for on-the-go, on-demand,
mobile telerehabilitation. Interestingly, from a human factors perspective, the sci-
entific and design challenges are in mobile telerehabilitation. There is a need for
study of optimal strategies for human-technology–human tele-interfaces, including
as they relate to usability, universal design, user performance, interpersonal inter-
action, and practical features such as minimizing risk and maximizing reliability.
Human-Technology Interface Design Principles

for Telerehabilitation
Telerehabilitation involves, at its core, new ways for humans to work interacti-
vely together to achieve certain aims. It includes many possibilities: teleconsul-
tation, telediagnosis, teleassessment, telementoring, telesupport, telesupervision,
telemonitoring, telecoaching, teletherapy.
The “system” most often involves two to three persons and the technology they
use to interact: human-technology–human systems. As seen in Figure 5, the modes
potentially include communication through sensory (auditory, visual, tactile) and
motor (speech, eye-head-hand-torso postural orientation, hand manipulation, mo-
bility) interaction and sharing of information. The effectiveness of the user interface
is critical to the success or failure of new telehealth technology. Although the prin-
ciple of “universal design” of interface technologies is a fundamental concept (47),
rehabilitation engineers have long been trained to recognize that for a given situa-
tion and goal, there is often a need to first identify client abilities and preferences
Figure 5 Information transmission modalities and for human-technology interfaces (left)

and human information processing (right). Left: Vision is a uni-causal sensor system, though
accomplished through an active gaze system (including fast voluntary saccadic eye move-
ments, smooth pursuit tracking movements, and the vestibulo-ocular reflex for eye stabiliza-
tion during head and body movement) and with certain indirect motor feedback (e.g., facial
expressions). Hearing is also a uni-causal information transfer interface, though involving
elaborate signal-noise extraction capabilities; when coupled with speech, a bidirectional
information exchange is created. The hand and other contact interfaces, in contrast, are inher-
ently bicausal, transferring both forces and position, enabling power transfer (force∗ velocity)
when the human-environment impedances are fairly matched, and a unidirectional signal
with impedance mismatch. Right: For interaction, the perceptual to working memory to
cognitive flow has a limited attentional capacity, and if overloaded, performance degrades.
Similarly, multiple motoric tasks require skill development, especially for contact tasks. It is
well documented that transmission time delays degrade performance.
and then design a customized interface (48, 49). By analogy, there is not a “perfect”
interface design for telerehabilitation applications, and as was seen in Figure 1,
there are many viable service delivery models. The key users are practitioners
[key issue—tele-productivity, (9)], other providers (e.g., caregivers), and targeted
consumers (patients, clients) (11).
In this section, we stress the science behind the key areas that will impact
telerehabilitation systems design.
USER-CENTERED ENGINEERING Human factors focuses on designing system inter-

faces to optimize the user’s ability to accomplish tasks successfully and error-free
within a reasonable time period (50, 51). It is an applied science with roots in un-
derstanding how people use tools, with the dual mission of enhancing performance
while also minimizing the risk of human error, injury, or frustration. Considering
that the eighth leading cause of death in the United States is said to be medical error
(52), and that rehabilitation technology abandonment is a long-standing problem,
it is apparent that there is a need for study of “science of people” as well as science
of rehabilitative processes.
In recent years, the use of computers in the clinical environment has increased.
Human-computer interaction (HCI) and interface design is a field that views
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the human-technology interface as a key to optimizing human performance

(53).
Central to many discussions is the concept of usability—the extent to which a
product can be used by specified users to achieve specified goals in an effective
and efficient manner, to the satisfaction of these users (54). Practical components
of a user-oriented design are (55, 56): ease of learning, high speed of user task
performance, low user error rate, subjective user satisfaction, and user retention
over time. Some of these are reasonably measurable, though it is an inexact science.
In addition to accessibility and usability, a critical barrier to product acceptance is
reliability. Practitioners in particular have little patience for new products that are
not immediately reliable (11).

Here, we focus on user interfaces from the perspective of optimizing perfor-
mance of the human-technology system.
COMMUNICATION THROUGH SPEECH AND HEARING, VISION, AND GAZE Consid-

erable engineering has gone into the transmission of speech for telecommunica-
tions applications, with international standards available for various speech codecs
and sound amplification commonly available. This is a mature area of telecommu-
nications, and although there is often a small time delay for transmission, all of
the key videoconferencing standards (H.320, H.323, H.324) give highest priority
to voice transmission. More intriguing is the emergence of mass-market technolo-
gies for both speech synthesis and speech recognition that are becoming more
reliable.
There has been considerable research activity studying the relation between
visual processing and eye-head movements. Humans only see 1◦ –2◦ of arc with
clarity, and routinely make fast, near time-optimal saccadic eye movements to
sample their environment (or a monitor) and smooth pursuit movements to track
objects of interest that are moving through their field of view at slow or mod-
erate rates (57). The use of “control systems” and optimization approaches to
study movement neurocontrol principles and neuropathologies by pioneers such
as Lawrence Stark represented some of the earliest utilization of control theory
such as optimal control, predictive control, sampled-data control systems, variable
feedback, and adaptive control (58). Where humans choose to look is itself a fasci-
nating problem in information processing, and the term scanpaths is often used to
document how humans normally extract information from their environment (59).
There are many types of brain impairments that can put attentional control at risk,
including neuropsychiatric disorders such as obsessive compulsive disorder and
schizophrenia, and communication disorders such as autism and stroke-induced
aphasia and/or left-sided visual field neglect. The RERC on Telerehabilitation is
currently using virtual environments (VE) to study scanpaths for autistic subjects
and interactive environments to encourage interest in the neglected part of the
visual field (60).
Study of the effects of discrete information and sampling time delays on per-
formance goes back to NASA-sponsored teleoperations and telerobotics research
of the 1970s (61). There are generally two types of tasks where time delays affect
performance:
■ Interpersonal communication tasks. Humans find lack of video-voice syn-
chronization irritating, and the H.32x standards have provisions to delay
voice so that it synchronizes better with video. One reason moderate-to-high
throughput point-to-point telecommunication (e.g., H.320 standard) is often
preferred to low-bandwidth point-to-point (H.324) and packet-based IP con-
ferencing (e.g., H.323, SIP) is that these delays are less (e.g., roughly 1/8 sec
versus over 1/4 sec). Because packet-based IP communication was originally
designed for less time-critical data transfer (with packets tranversing many
different paths to reach their destination), IP conferencing protocols tend to

have the most time delay.
■ Remote manipulation and control. For simple control tasks, it has generally
been found that subjects can perform reasonably well with low frame rates,
such as 10/sec for inexperienced subjects and about 2/sec for trained subjects
(62). Yet, for “immersion” experiences, the update rates must be considerably
higher, approaching that of television (25/sec in Europe, 30/sec in the United
States).
MANUAL CONTACT, HAPTICS, AND MANIPULATION Many of the tasks of life in-
volve physical contact with the environment, typically to manipulate the environ-
ment or move within the environment so as to meet certain goals. In this section,
we develop a scientific perspective on tele-interfaces involving contact.
A key observation from Figure 5 is that physical contact is fundamentally
bicausal: Human performance depends on the dynamic properties of the contacted
environment. Two variables are passed during the period of contact: force and
position (velocity). The product of force and velocity is power, which is transferred
across the interface. As seen in Figure 5, design of contact interfaces can be broadly
classified into two categories (63, 64):
1. “Impedance” devices (low-inertia “back-drivable” systems that measure the
motion applied by the human and can apply force) [e.g., commercial force-
reflecting joysticks (see 36), the Phantom haptic interface (65), and MIT
Manus therapeutic robot (66)]. By default, such devices have low stiffness,
often making them the choice for hand and head interfaces.
2. “Admittance” devices where the human acts as an impedance and the envi-
ronment (device) prescribes a motion and measures the human-applied force
(e.g., a high-inertia or rigid interface, or a conventional robot that is driven
by a position or velocity servo loop).
An important reality is that given a relatively brief period of practice, humans
are normally adept at functioning either as an admittance or impedance (67–69); for
instance, both position and force mouse pointers are common for laptop computers.
Yet, for therapeutic applications, impedance devices tend to be preferred for upper
extremity contact, whereas admittance devices are preferred for lower extremity
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contact where postural stability is a concern. This is not surprising given that the
human’s dynamic interface is highly nonlinear; for instance, the human can change
the transient stiffness at the hand by an order of magnitude in a fraction of a second,
via co-contraction of muscles (69). One intriguing approach is to employ exercise
devices that include embedded light-weight pneumatic artificial muscles that can
provide variable (low to moderate) impedance (70).
There are other issues that must be considered for subsystems that mechanically
interact, such as contact (or coupled) instability (63): a tuned feedback control
system that behaves appropriately without contact can become unstable when in
contact with an environment with certain attributes. Most objects that the human
interacts with are passive, with the recoverable energy being less than that stored.
For telerobotic therapy, the key point is that dynamic interaction can profoundly
affect stability.
This helps illuminate an important concept: the inherent nature of biosystems
toward using holistic “inclusion” as a dynamic control strategy. In upper extrem-

ity prosthetics, the development of bifunctional power transmission systems for
routing residual proximal body power (e.g., shoulder shrug) to a distal hand and/or
elbow location(s) via effective body harnesses and Bowden cables proved to pro-
vide a remarkably functional and robust interface for amputees. This helps explain
why, despite considerable efforts by distinguished research groups, most upper
limb prosthetic users still prefer conventional body-powered prostheses to exter-
nally powered, especially for the hand (terminal device) interface (71). In a very
real sense, they can subconsciously “feel” a cup or egg in the grip via the bicausal
force and velocity mapping to the shoulder, thus requiring fewer attentional re-
sources. This is the principle behind extended physiological proprioception (EPP),
first coined by Simpson (72): Humans possess a remarkable capacity to, with suf-
ficient practice, become skilled at utilizing a device such as a pencil as if it were a
subconscious extension of their own bodies. Technologies that allow such inclu-
sion via predictable mapping plus yield control to the human are more likely to be
accepted. Systems designed for teletherapy, especially with virtual touch, should
be cognizant of this principle.
INTEGRATION OF CONCEPTS: INTERACTION WITHIN VIRTUAL ENVIRONMENTS The

integration of various sensors, displays, and computers can allow users to interact
with artificial computer environments in a reasonably natural and synergistic man-
ner. As defined here, the VE infrastructure includes the graphics workstation and
software (to coordinate the actions of the various sensors, process user inputs, and
define the nature of the user virtual world), plus the sensors (to measure real-time
position/orientation of any prescribed body segment). Although both interactivity
and immersion are considered the cornerstones of virtual reality (VR) (73), in the
opinion of this author, the key aim for telerehabilitation applications need not be
full sensory immersion (which has proven difficult to achieve). Rather, immersion
is an attentional state of mind, and the aim is to integrate these technologies into
a coherent unit that promotes effective interaction and has embedded mechanisms
for data collection. A related concept is telepresence (74)—the use of telecommu-
nications to allow a remote operator to be “present” (e.g., to manipulate objects,
televisits). The perceptual aspect of telepresence—a person’s sense of being at
another place—ties to VR.
A key focus of therapeutic intervention is to enable individuals with compro-
mised motor and/or cognitive function so as to reacquire motor or interpersonal
skills to function in the real world. By creating an environment based on their abil-
ities and therapeutic needs where “success” is more achievable and “therapy” is
reasonably fun, the therapeutic value of a rehabilitation regimen can be improved,
which may accelerate recovery and the reacquisition/relearning of certain skill sets.
A potential advantage of the VE-based therapy approach is the ability to embed
real-time diagnostics into the therapeutic simulations (75). VEs have been used for
orthopedic and neuromotor therapy (76, 77), for addressing psychotherapy (78),
as a cuing device for individuals with Parkinson’s akinesia (79), for autism (80),
neurocognitive assessment (81, 82), to train ataxic individuals to use propriocep-
tive rather than visual feedback to maintain balance or enhance gait (83), and for
driving simulation (11). A book sequence by Riva (84) summarizes a range of
applications. However, it should also be noted that to date, few VR applications
have made it into common therapeutic practice. The onus is on the VR advocate
to make the case that therapy in a virtual world has some advantage over that in
the real world (which is where the individual must ultimately function); to date
the main added value of VR seems to be that the simulated interactive environ-
ment allows researchers to study how manipulating VE variables affect functional
performance.
CLINICAL TELEREHABILITATION: NEEDS,

STATUS, AND TRENDS
As noted in the introduction, NIDRR’s main motivation in creating an RERC
on Telerehabilitation was quite practical: to minimize the barrier of distance in
the delivery of comprehensive rehabilitation services. This recognized the great
potential for telecommunications and information technologies to provide con-
sumers with access to clinical services and providers with access to patients, as
well as the need for numerous societal and technological barriers to be addressed.
It comes at a time when the rehabilitation service delivery field is trying to tran-
sition toward a more outcomes-oriented process that seeks to maximize function
and social re-integration, subject to constraints on resources (17, 21–26). Telere-
habilitation provides new possibilities for re-engineering the system to maximize
value, enhance access, and optimize the infrastructure for effective rehabilita-
tive problem-solving. This section addresses the needs, current status, and future
possibilities.
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Recognition of Need
In terms of unmet needs, the potential for telerehabilitation is profound; engineers
need to appreciate the magnitude of this potential. The following very large target
populations have needs that suggest opportunities for telerehabilitation solutions.
ADULT NEUROREHABILITATION FROM TRAUMA This is the largest client base

within a typical comprehensive rehabilitation hospital, typically representing the
majority of all inpatients, and includes stroke [also called cerebrovascular accident,
CVA), traumatic brain injury (TBI), and spinal cord injury (SCI)]. NIH considers
stroke the leading cause of significant disability in the United States, with over
4 million stroke survivors living with significant functional impairment (20). The
continuum of care of Figure 3 is common, and practice guidelines based mostly
on expert consensus do exist [e.g., (85, 86) for stroke rehabilitation]. At compre-
hensive facilities, inpatients can receive physical and occupational therapy and
typically speech-language therapy (if needed), and psychological, social, and/or
vocational counseling. Yet, during the 1990s the reimbursable period of time as
an inpatient in a comprehensive rehabilitation facility dropped dramatically, and
has often even been replaced with stays at skilled nursing facilities [at consi-
derably less cost, but also poorer outcomes (25, 86)]. The burden for healthcare
services has shifted toward outpatient and home visits, where distance can be a
barrier.
CHILDREN WITH NEUROMOTOR IMPAIRMENT Often, families travel long dis-

tances to get to comprehensive hospitals for children. Many children’s hospitals,
including the Shriners network of 26 hospitals, are actively considering roles for
telerehabilitation. Obvious choices are H.320 conferences clinics/hospitals/schools
and specialty hospitals with unique expertise. An emerging area is family-centered
intervention in which therapists and family members function as a team (87),
which implies opportunities for home telehealth that includes rehabilitation (88).
Of considerable interest to our group has been the concept of interactive teleplay,
including therapeutic toys with embedded objective measurements (89).
CARDIOPULMONARY REHABILITATION If cardiopulmonary rehabilitation is inclu-

ded within the “telerehabilitation” umbrella, this may be the largest current applica-
tion of telerehabilitation. The need is staggering, both for rehabilitation following
an episode (e.g., open-heart myocardial revascularization, myocardial infarction,
where there are over one million new survivors per year in the United States),
and for persons with chronic conditions (e.g., 5 million persons in the United
States with congestive heart failure, 16 million with chronic obstructive pulmonary
disease). Post-traumatic and post-surgical intervention typically includes only a
few days as an inpatient. Most receive intervention as outpatients and/or through
community/home programs, which include aggressive use of exercise rehabilita-
tion, medication, behavior modification (e.g., diet), and management of secondary
complications; evidence supporting the benefits of exercise programs for these

populations continues to mount (90). These areas represent some of the primary
targets for many telehomecare programs, which may include both a telesupport/
tele-education program and selected sensor-based telemonitoring (e.g., ECG, vital
signs). On the high end, a transtelephonic telemonitoring family of products does
exist that targets interactive exercise telerehab for cardiopulmonary patients (91).
SUPPORTIVE TELEHOMECARE One of the most intriguing developments during

the latter half of the 1990s has been the grass-roots emergence of telehomecare
activities, primarily by visiting nursing practitioners in rural areas who recognized
unmet needs. The systemic need is real: Within the United States there are over
500,000 home health visits per year, mostly by nurses. Each visit by a nurse or
rehabilitation therapist costs about $100 (less if made by aids), whereas a typical
“televisit” costs about one-quarter of this amount (5). This implies that there could
be more “televisits” for the same cost, or more likely, a mix of face-to-face and
televisits over the continuum of care. Several retrospective studies have suggested
that roughly 70% of nursing visits could have been accomplished remotely, in that
direct hands-on care was not necessary (5, 92). This has the potential to enhance
access to services, and our group and a number of others are currently exploring
various “tele-nurse” models, for instance as in Figure 6 (11, 34, 93, 94).
Clinical Telerehabilitation Research, Involving

Rehabilitation Practitioners
To date, clinical telerehabilitation applications have been driven by creative teams
of rehabilitation practitioners seeking to pragmatically address clinical rehabili-
tative needs. Applications have included distance consultation by clinical reha-
bilitation engineers or specialized therapists for seating and positioning (95) and
the provision of assistive technology (96) using simple POTS videophones; pres-
sure sore management by physicians using higher-quality camera images (97) or
through teams including nurses using lower-quality images from interactive H.324
POTS systems (98); remote therapy for stroke or brain injury using tools such as
EMG-controlled games for stroke rehabilitation (99) or remote interactive story
retelling for brain injury rehabilitation (100); and remote rehabilitation manage-
ment or teleconsultation by physiatrists and specialized therapists for clinics using
mostly H.320 group videoconferencing systems over established telemedicine net-
works (101–104). Most of these groups recently assembled at our RERC-sponsored
SOS conference on telerehabilitation (11, 12). One of the benefits of having some
of the leading groups providing clinical telerehabilitation services (98–102) re-
porting on diverse applications ranging from spinal cord injury management to
prosthetics-orthotics clinics was that many common insights surfaced. There were
several recurring take-home messages (11):
■ Most existing projects use conventional teleconferencing tools, such as group
conferencing rooms connected by ISDN or T1 (H.320 standard) or H.324
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Figure 6 Schematic model for home telehealthcare that includes rehabilitation telemoni-
toring and teletherapy. The tele-nurse coordinates healthcare management (monitoring, data
collection, first line of interaction) that includes rehab. In such a framework, either the tele-
nurse or the patient (or caregiver) may potentially initiate a televist, subject to certain agreed-to
rules for interaction. While one reason for the visit may involve telemonitoring or teleassess-
ment related to possible secondary complications, others could range from telesupport (e.g.,
patient/caregiver education) and to telecoaching (e.g., of movement therapy program). Notice
the critical role for the electronic healthcare record.
videophones (sometimes embedded within a more costly home telehealth

system that includes vital signs).
■ There are two key consumers: consumers of services (patients, caregivers)
and providers of services (practitioners, caregivers). Patients are looking for
convenience and access to services. Key criteria for practitioners is enhanced
productivity and ease of use (and to learn). Providers include physicians
(e.g., physiatrists who diagnose, management the treatment plan, provide
pharmaceuticals), therapists (e.g., neurorehabilitation, orthopedic rehabilita-
tion, pediatric rehabilitation), and nurses (e.g., homecare management that
includes a rehabilitation program).
■ Numerous groups can point to success stories. Yet to date, the types of large-
scale controlled randomized studies that provide conclusive evidence of im-
proved client outcomes or cost-effectiveness do not exist.
■ Many practical barriers remain, such as reimbursement, concerns about pro-
fessional practice boundaries, and lack of a training infrastructure.
■ There is considerable enthusiasm about the future of telerehabilitation.
Need for New Paradigms for Clinical Rehabilitation?

In the 1999 Workshop on Home Care Technologies for the 21st Century, coor-
dinated by this author (8, 9), a consensus emerged around the vision of a more
consumer-driven healthcare system driven more by a cooperative health patient-
clinician partnership and less by the episodic model of care. At the foundation
of this is self-care and caregiver support. Motivations range from the common
perception that most home exercise equipment ends up in closets to the estimation
that lack of compliance with medication (taking too much or too little) costs the
U.S. society about $20–$50 billion per year. Areas for home telehealth that relate
to rehabilitation include:
■ management (telecoaching) of therapeutic rehabilitative programs (e.g., home

exercise);
■
management of secondary risks and conditions;

■ management of drug therapy through an integrated approach that could in-
clude not only reminders, but also objective indicators related to perfor-
mance evaluation (e.g., neurocognitive reaction times, neuromotor coordina-
tion tests, tremor levels during mouse operation, activity monitors).
Variations of Figure 6 can be conceptualized for each of these areas, and there
is a need to study what is optimum for various situations. For instance, caregivers
represent the largest “provider” of services and should often be part of the model
(94). There are many challenges associated with implementing new technological
tools for assessment and therapy. Although it is generally accepted that the current
approach toward delivering clinical rehabilitation services is suboptimal (20–23),
allied health professions tend to take a cautious approach toward implementing
change. For instance, the rehabilitation field has been one of the slowest to adopt
electronic patient records (EPRs). This is important because our RERC has iden-
tified this low penetration of EPRs within the rehabilitation field as one of the key
barriers to the growth of telerehabilitation.
Based on the experiences of our RERC with allied health practitioners and
their professional societies during various conferences and workshops, it is clear
that technology-motivated arguments for telerehabilitation carry little weight. In-
deed, telerehabilitation (especially “teletherapy”) is often seen as a threat. The
allied health professional societies have taken a cautious stand on the concept
of therapy at a distance, and allied health professionals were not on the new list
of health providers that can be reimbursed for interactive telehealth services by
Medicare (October 2001), which in addition to physicians now includes many
types of nurses, clinical psychologists and social workers, and physician assis-
tants (105). Yet, our recent SOS conference in Washington included representa-
tives from the national bodies of the three allied health societies (APTA, AOTA,
ASHA). Recently, the APTA Board announced that “Physical therapy services may
be provided via telehealth when consistent with APTA policies, positions, guide-
lines, Standards of Practice, Code of Ethics, and the Guide to Physical Therapist
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Practice”; AOTA recently approved a slightly more cautious statement. Although

it is unknown whether any telerehabilitation-inspired paradigm shift in rehabili-
tative healthcare will bypass or include conventional therapists, what is clear is
that there is a need for biomedical engineers to study teleproductivity of clinical
stakeholders (11).
Need for Functional Assessment Research and

Outcomes Measurement Tools
The three specific functional objectives that are generally associated with med-
ical rehabilitation (21) are given in Table 1. Much like in an engineering opti-
mization problem (Figure 4), the desired outcome typically includes a balanc-
ing act between subcritiera that may be competing or orthogonal (e.g., measures
of function, quality of life, quality of rehabilitation, customer satisfaction, cost-

effectiveness). Adding complexity is the trend within rehabilitative medicine from
“service-based” to “outcome-oriented” rehabilitation (8, 25), which impacts on
telerehabilitation (106). A 2001 editorial in the journal Physiotherapy calls this
drive toward greater accountability and outcomes-driven practice a “tidal wave.”
A key challenge for rehabilitative bioengineers is to develop outcomes measures
that are reasonably quantitative and objective, and integrate with respected clin-
ical scales. By objective evaluation, we refer to using sensor-based measures as
part of the evaluation process. Possible uses for evaluation include: (a) diagnosis,
(b) treatment planning, and (c) outcomes assessment.
There is a push toward uniform, standardized tools. Uniformity in functional
assessment allows comparability of results over time and between providers, thus
increasing the likelihood for improving the processes of care (21) and helping
establish cost-benefit guidelines. The best known of these within rehabilitation,
designed to be discipline- and disease-independent, is the Functional Independence
Measure (FIM) (107). Of importance is that such scales are often used to classify
patients into intervention categories, which in turn can be used to establish viable
desired outcomes, required costs, and discharge dispositions (108). Although such
scoring schemes are not sensor-based and thus may seem “subjective” rather than
“objective” to rehabilitative bioengineers, the reality is that these scales have been
subject to considerable interrater reliability and validity testing (23–28). The onus
is on engineers to come up with better measures; to date we have not met the
challenge. Thus, our group is currently involved in a systematic study to determine
which of the scales commonly used for neurorehabilitation clinical research can
be effectively measured remotely using telerehabilitation tools.
It is well accepted that most rehabilitation procedures have evolved from clinical
theories and approaches that have not been subject to the rigorous scrutiny of
randomized controlled trials (RCTs). Although RCTs are essential to establish
and test causal relationships, it is well recognized that they often do not provide
the type of evidence needed to guide decision making by practitioners. Rather, the
field has come to embrace “practice guidelines,” which are intended as tools that
help promote quality assurance and cost-effective practices and improve processes
of care for certain target populations. There are now well over 100 published
guidelines spanning the field (22). Concern that these are suboptimal has caused
clinical researchers to propose other, more process-oriented research schema for
understanding and improving practice, such as principles underlying “treatment
theory” (109), the concepts of “clinical practice improvement” (26, 28), and the
development and use of larger national datasets such as FIM.
TELEREHABILITATION FOR SCIENTISTS:

BRINGING IT HOME
Telerehabilitation provides one of the better venues for bringing scientific inquiry
into a technology-driven telemedicine field.
Remote Assessment for Scientific Research

Fundamental scientific questions permeate rehabilitation, ranging from basic sci-
entific questions about rehabilitative bioprocesses to applied clinical science
addressing optimum therapeutic intervention strategies. Most published rehabilita-
tion research projects are based on recruiting a small number of subjects (e.g., 5–20)
to come to a research laboratory. As has been emphasized by NIH panels (16, 17),
there is a need for larger studies that target measures of impairment, disability, and
functional performance. Telerehabilitation tools open up new ways for rehabilita-
tion scientists to perform research: bring the “virtual” research study to the person
in their natural environment rather than bring the person into a research lab. The
immediate result can be larger population sizes, longitudinal studies with a better
continuum of research access to enabling-disabling processes, better ecological
validity, and the potential to help facilitate coordinated multi-site research studies.
Also, rehabilitative processes occur as a function of time, and often researchers use
a limited number of samples (e.g., only before and after an intervention protocol).
Telerehabilitation can be viewed either as an alternative to a conventional protocol
or as a supplement to a laboratory session (e.g., to collect data between laboratory
visits). Whereas for an isolated research team this may seem like more work, if the
appropriate infrastructure of validated teleassessment tools was in place it might
actually be easier. It would also allow new research questions to be asked that are
currently not feasible. These validated tools could be made available through a
national repository, as recommended by a recent Workshop on Innovations in
Neurorehabilitation (110). New technological tools such as interactive websites
or telerehabilitation should make it possible to collect data for a large number of
subjects (perhaps targeting fewer measures), as well as access to a more natural
setting (ecological validity) and to a temporal continuum of data. It would also help
address one of the main challenges in fields such as neurorehabilitation, where the
variability between subjects often makes is hard to statistically document training
312 WINTERS
effects. Larger repositories would also allow emerging tools such as fuzzy logic
and data mining to be applied to rehabilitation (1, 8).
START BY INTEGRATING SENSORS WITH VALIDATED CLINICAL SCALES The use of

biosignals to study human movement and performance has a long history, and
by 1950 the Biomechanics Laboratory at the University of California at Berkeley
had developed quantitative 3-D motion analysis and EMG assessment capabilities
(111). There was a solid fundamental understanding of muscle mechanics (112),
speed-accuracy trade-offs in movement (113), and movement coordination (114).
These pioneering research breakthroughs predate the development of the allied
health field as we know it, and yet with few exceptions have not had a significant
impact on clinical assessment and therapeutic intervention. Although the number
of 3-D motion analysis facilities in the United States alone now numbers well over
100, the primary clinical use continues to target orthopedic surgical intervention
strategies for children with cerebral palsy (88). We can collect massive amounts
of sensor-based information but are not sure how to make it clinically useful, in
part because human movements are truly complex. Also, many observations by a
highly trained expert practitioner will never be able to be captured by a sensor. This
is why the norm of clinical rehabilitative practice still involves observer ratings
and clinical scales for motor tasks, with relatively few objective (sensor-based)
measures going into a patient’s chart.
The ideal twenty-first century clinical research teleassessment tool would be
a hybrid that includes both sensor-based information and rater scales. It could be
conveniently collected by the researcher because their study could build on an
infrastructure that facilitated telemonitoring, such as a national repository of tools.
Hybrid telerehabilitation approaches are needed to help move the rehabilitation
field toward the use of more objective measures that meet reliability and validity
criteria. An example of a hybrid approach is the RERC on Ergonomics’ effective
use of video that is collected from on-the-job workers, integrated into an Internet
site that facilitates easy access and an off-line yet interactive observer scoring
(115). Another example, from the RERC on Telerehabilitation, involves the use of
Tele-ANAM (116) to study remote neuropsychological assessment via telephone.
Many of the tasks within the test battery relate to reaction times for neuromotor
and neurocognitive tasks, where data collection is easy to embed within tele-
transmission. In some cases, there may actually be certain advantages to remote
observation because a session can be taped for later review and thus the practitioner
can focus more fully on the client. One of the more intriguing applications for
telerehabilitation tools, as yet largely unexplored, is to study whether many of
the classic clinical scales used for research could be scored remotely. We are
currently involved in a study that is addressing this issue for many of the most used
clinical instruments for neurorehabilitation research (117). Our aim is to compare
interrater reliability and validity for face-to-face assessment versus assessment
using programs proactively designed to enhance tele-productively (running on
desktop PCs and PocketPCs).
RESEARCH THROUGH ACTIVITY TELEMONITORING Another relatively untapped

area is unobtrusive telemonitoring. Such telemonitoring has seen some application
for classic physiologic measures such as heart rate, use of accelerometers as ac-
tivity monitors, use of video and/or audio to monitor persons with neurocognitive
impairment, and use of environmental sensors within simulated rooms such as a
kitchen (118). Notice that some of these employ wearable sensors, whereas others
use sensors embedded within the environment. But with emerging mobile telecom-
munications technologies such as wMAN/wPAN-enabled computing devices and
intelligent appliances, the potential is enormous.
In addition to physiologic signals, the following activity signals could be rou-
tinely obtained: wearable kinematic sensors such as tilt, angular velocity, and
accelerometers; wearable contact force or pressure sensors (within shoes, gloves);
environmental switches and motion sensors; EMG sensors for strategic muscle
activity; and wearable audio sensors.
There is, however, the challenge of data reduction and interpretation. This was
anticipated by the Workshop on Homecare Technologies for the 21st Century, which
scored the following as the top recommendation from over 60 produced by eight
working groups (8):
“Fund research for intelligent processing of large amounts of data, including:
1) knowledge assimilation techniques required to optimize the effectiveness
of care decisions, 2) information reduction tools for avoiding information
overload; and 3) data mining tools for acquiring relevant data from distributed
repositories . . .”
There is a need for greater focus on the process and form for providing informa-
tion to clinical decision makers. This includes approaches for more aggressively
reducing, synthesizing, and presenting data.
Notice that this section has not mentioned continuous video monitoring, which
is generally viewed as obtrusive. Yet, conferencing may have many selective roles
that could help manage cooperative activity monitoring, such as interactive trou-
bleshooting and periodic reminders.
Therapeutic Teleinterventions
The ultimate challenge in telerehabilitation is clearly to achieve location-indepen-
dent, integrated therapeutic intervention at a distance, or teletherapy (1, 11). Simi-
larly, for researchers studying enabling-disabling rehabilitative bioprocesses, the
dream is to be able to apply therapeutic interventions. Such interventions could
range from interactive virtual reality games to monitoring and adjusting home
exercise equipment to remotely administering and monitoring pharmaceuticals.
Perhaps more pragmatically, telesupported home therapy could augment lab-based
sessions.
An area where this takes on added significance is neurorehabilitation, where the
major trends of the 1990s had been the drop in the time across the continuum of
314 WINTERS
care shown in Figure 3. Scientific studies in neurorehabilitation now challenge this

conventional wisdom that therapy is ineffective after a few months, and indeed the
whole clinical rehabilitative process (38, 108, 119, 120). Studies utilizing intensive
movement therapies, including constraint-induced movement therapy (120) and
robot-assisted therapy (65, 121–123), have shown that significant improvements
are possible even years after the initial injury onset. Despite such results, intense
financial pressures make it unlikely that conventional rehabilitation practices will
be restructured to incorporate a longer duration of therapy. Two of the overriding
recommendations of a recent Workshop on Innovations in Neurorehabilitation
were (110):
“Participants felt that technology-assisted rehabilitation tools need to be op-

timized to address needs of specific patients, but must do so as part of an
integrated approach that includes other interventions. . . . There are . . . gaps
in knowledge where utilization of technology-assisted rehabilitation tools

may be helpful in promoting a paradigm shift: i) Timing and Intensity. . .;
ii) Components of Therapy. . .; iii) Context/Infrastructure of Healthcare De-
livery System. . .; iv) Optimizing Delivery Based on Initial and Ongoing
Assessment. . . .”
“Participants felt that there is a need for low-cost rehabilitation tools that can
extend consumer access to supervised therapy into the home. . . .”
Within this context, the role of telerehabilitation is manifold because it can be
used as a tool for addressing each of the four aforementioned scientific challenges.
Of special interest would be systems (perhaps robotic) that combine assistive and
therapeutic technologies with remote telesupport (1, 123). By enabling access,
telerehabilitation tools provide a variety of new research opportunities for the field
of rehabilitative bioengineering.
The Annual Review of Biomedical Engineering is online at

http://bioeng.annualreviews.org
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107. Granger C, Fielder RC. 1997. The mea- organization of Function After Brain In-
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103–26 New York: Oxford Univ. Press
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approach to stroke rehabilitation: robot- Lehman S, Lum P. 2000. Rehabilitators,
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P1: FRK
June 20, 2002 10:12 Annual Reviews AR164-FM
Annual Review of Biomedical Engineering

Volume 4, 2002
CONTENTS
Frontispiece—Kenneth R. Foster xii
HERMAN P. SCHWAN: A SCIENTIST AND PIONEER IN BIOMEDICAL
ENGINEERING, Kenneth R. Foster 1

ROLES FOR LEARNING SCIENCES AND LEARNING TECHNOLOGIES IN
BIOMEDICAL ENGINEERING EDUCATION: A REVIEW OF RECENT
ADVANCES, Thomas R. Harris, John D. Bransford, and Sean P. Brophy 29

SPINE ERGONOMICS, Malcolm H. Pope, Kheng Lim Goh,
and Marianne L. Magnusson 49
THREE-DIMENSIONAL CONFOCAL MICROSCOPY OF THE LIVING
HUMAN EYE, Barry R. Masters and Matthias Böhnke 69
BIOENGINEERING OF THERAPEUTIC AEROSOLS, David A. Edwards
and Craig Dunbar 93
DENATURATION OF COLLAGEN VIA HEATING: AN IRREVERSIBLE
RATE PROCESS, N.T. Wright and J.D. Humphrey 109
DNA MICROARRAY TECHNOLOGY: DEVICES, SYSTEMS, AND
APPLICATIONS, Michael J. Heller 129
PEPTIDE AGGREGATION IN NEURODEGENERATIVE DISEASE,
Regina M. Murphy 155
MECHANO-ELECTROCHEMICAL PROPERTIES OF ARTICULAR
CARTILAGE: THEIR INHOMOGENEITIES AND ANISOTROPIES,
Van C. Mow and X. Edward Guo 175
ELECTROMAGNETIC FIELDS: HUMAN SAFETY ISSUES, Om P. Gandhi 211
ADVANCES IN IN VIVO BIOLUMINESCENCE IMAGING OF GENE
EXPRESSION, Christopher H. Contag and Michael H. Bachmann 235
PHYSICS AND APPLICATIONS OF MICROFLUIDICS IN BIOLOGY,
David J. Beebe, Glennys A. Mensing, and Glenn M. Walker 261
TELEREHABILITATION RESEARCH: EMERGING OPPORTUNITIES,
Jack M. Winters 287
BIOMECHANICAL DYNAMICS OF THE HEART WITH MRI, Leon Axel 321
ADVANCES IN PROTEOMIC TECHNOLOGIES, Martin L. Yarmush
and Arul Jayaraman 349
v
P1: FRK
June 20, 2002 10:12 Annual Reviews AR164-FM
vi CONTENTS
ON THE METRICS AND EULER-LAGRANGE EQUATIONS OF

COMPUTATIONAL ANATOMY, Michael I. Miller, Alain Trouvé,
and Laurent Younes 375
SELECTIVE ELECTRICAL INTERFACES WITH THE NERVOUS SYSTEM,
Wim L.C. Rutten 407
INDEXES
Subject Index 453
Cumulative Index of Contributing Authors, Volumes 1–4 475
Cumulative Index of Chapter Titles, Volumes 1–4 477
ERRATA
An online log of corrections to Annual Review of Biomedical
Engineering chapters (if any, 1997 to the present) may be found at
http://bioeng.annualreviews.org/
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Telerehabilitation Research: Emerging Opportunities

Article in Annual Review of Biomedical Engineering · February 2002

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Annu. Rev. Biomed. Eng. 2002. 4:287–320

Key Words telehealth, rehabilitation, telecommunications, telerobotics, healthcare

Need for Functional Assessment Research and

technology applications such as intelligent therapeutic robots that are supervised

access to services in underserved (e.g., rural) geographic areas. To these priorities,

Figure 1 Four conceptual models of telerehabilitation service delivery. (A) Standard

for telerehabilitation applications to expand (6–10), especially on the premise of

facility, an outpatent clinic, or home visits. Access to services is often a chal-

SCIENCE AND ENGINEERING FOUNDATIONS:

Rehabilitative Bioprocesses from an Optimization Framework

rehabilitative service provision (20–26).

Figure 3 Idealized representation of the continuum of interventional rehabilitative care and

person-environment by identifying the key occupational tasks (e.g., at work, school,

Outcomes Outcomes measurement: Systematic observation of outcome indicators

alternative solutions, and thus new opportunities within a turf-oriented rehabil-

Telecommunication Technologies in Perspective:

to embracing integrated multimedia. A section on telecommunications technolo-

channels as examples, contact signals can typically be sampled at rates of 110/sec

standard TV resolution of 4CIF (704 × 576). Each is periodically updated. Our

as the umbrella for a large suite of other standards. An important subset of

group participates. There is no question that H.323 videoconferencing can

within a software development environment that could go well beyond MMS,

which HTML is a subset).

interactive desktop and Web-based games (36). Several groups, including

Fourth, integrated wireless telecommunications holds considerable promise for

horizon that may limit access to guaranteed moderate-to-high bandwidth for

videoconference technically feasible yet not financially viable in comparison

■ technical advances in embedded and distributed computing, small wearable

Human-Technology Interface Design Principles

Figure 5 Information transmission modalities and for human-technology interfaces (left)

USER-CENTERED ENGINEERING Human factors focuses on designing system inter-

the human-technology interface as a key to optimizing human performance

not immediately reliable (11).

COMMUNICATION THROUGH SPEECH AND HEARING, VISION, AND GAZE Consid-

different paths to reach their destination), IP conferencing protocols tend to

toward using holistic “inclusion” as a dynamic control strategy. In upper extrem-

INTEGRATION OF CONCEPTS: INTERACTION WITHIN VIRTUAL ENVIRONMENTS The

CLINICAL TELEREHABILITATION: NEEDS,

ADULT NEUROREHABILITATION FROM TRAUMA This is the largest client base

CHILDREN WITH NEUROMOTOR IMPAIRMENT Often, families travel long dis-

CARDIOPULMONARY REHABILITATION If cardiopulmonary rehabilitation is inclu-

complications; evidence supporting the benefits of exercise programs for these

SUPPORTIVE TELEHOMECARE One of the most intriguing developments during

Clinical Telerehabilitation Research, Involving

videophones (sometimes embedded within a more costly home telehealth

Need for New Paradigms for Clinical Rehabilitation?

■ management (telecoaching) of therapeutic rehabilitative programs (e.g., home

management of secondary risks and conditions;

Practice”; AOTA recently approved a slightly more cautious statement. Although

Need for Functional Assessment Research and

of function, quality of life, quality of rehabilitation, customer satisfaction, cost-

TELEREHABILITATION FOR SCIENTISTS:

into a technology-driven telemedicine field.

Remote Assessment for Scientific Research

START BY INTEGRATING SENSORS WITH VALIDATED CLINICAL SCALES The use of

RESEARCH THROUGH ACTIVITY TELEMONITORING Another relatively untapped

care shown in Figure 3. Scientific studies in neurorehabilitation now challenge this

“Participants felt that technology-assisted rehabilitation tools need to be op-