Telemedicine systems
A telemedicine system was installed in the Telemedicine Center of Asahikawa Medical University (Figure 1A). The VidyoRoom HD230 software program (Vidyo, Inc., Hackensack, USA) was used for telemedicine conferences, lectures and rehabilitation sessions in the telemedicine center. The VidyoMobile software program (Vidyo, Inc., Hackensack, USA) was used in the institutions, which included elderly group homes and nursing homes. Each institution can connect to the telemedicine network via a broadband Internet connection (e.g., an asymmetric digital subscriber line [ADSL] or fiberoptic line) using a tablet or laptop PC. The maximum image quality of the system is 1080pHD and the images are shrinked by H.264/Scalable Video Coding (SVC), an original signaling protocol developed by Vidyo, Inc.. The security of our telemedicine system consists of Advanced Encryption Standard (AES) encryption and a Secure Sockets Layer (SSL) (Figure 1B). Two tablet terminals are used as video cameras in each institution. To view all participants, one tablet terminal was placed diagonally to the participant and the other was placed by their side (Figure 1C). Specialists, including medical doctors (MDs) from the rehabilitation department, PTs and nurses gave lectures to staff members in all institutions and created a personalized telerehabilitation plan for each patient.
Education for caregivers
Before the telerehabilitation was started, medical staff (MDs, nurses and PTs) in Asahikawa Medical University gave lectures on rehabilitation to staff members at elderly institutions, including caregivers and nurses using the teleconference system. In these lectures, nurses talked about the mechanism of falling and fall prevention and PTs explained the actual methods of the rehabilitation using original materials based on the guidelines or consensus. To evaluate the efficacy of the lectures, 13 staff members from elderly institutions took the same test regarding knowledge in relation to falls before and after the lectures. The test contained 20 questions in eight categories: the relationship between falls and Living environments, bone fracture, medication use, a past history of falls, disease, the reasons for requiring nursing care, and dementia (Figure 2).
Participant selection
- Inclusion criteria
The inclusion criteria were as follows: 1) clear consciousness ; 2) stable respiratory and circulation status ; 3) ability to communicate and exercise while following directions; 4) ability to walk with or without walk aids; 5) ability to exercise with a caregiver’s assistance with or without knowledge about rehabilitation, 6) the provision of informed consent by the participant or their family. Even when a participant met all of these conditions above, rehabilitation was cancelled when the following conditions were not met just before the rehabilitation session: 1) a resting heart rate of 40–120 beats/min; 2) a resting systolic blood pressure from 70–200 mmHg; 3) a resting diastolic blood pressure of <120 mmHg; 4) no effort angina pectoris; 5) no atrial fibrillation with remarkable bradycardia or tachycardia; 6) a stable circulation status without recent history of cardiac infarction; 7) no remarkable arrhythmia; 8) no chest pain at rest; 9) no palpitations, shortness of breath or chest pain; 10) no nystagmus, cold sweat or nausea; 11) body temperature <38°C; 12) blood oxygen saturation (SaO2) at rest >90%.
- Exclusion criteria
The following exclusion criteria were applied: 1) resting systolic blood pressure outside the range of 70–200 mmHg; 2) resting diastolic blood pressure ≥120 mmHg; 3) resting heart rate of ≤40 beats/min or ≥120 min; 4) poorly controlled arrhythmia; 5) ischemic heart disease such as acute myocardial infarction, unstable angina pectoris with symptoms of heart failure; 6) pulmonary disease with cyanosis and/or a SaO2 value of ≤ 90 %; 7) poorly controlled diabetes mellitus (DM); DM with complications, including neuropathy, retinopathy and nephropathy.
- Questionnaire
We modified the Physical Activity Readiness Questionnaire (PAR-Q) to assess the health status of the telerehabilitation participants. The participants or their family members answered the questions. The questionnaire consists of ten questions related to the patient’s health history, current symptoms, and risk factors to determine the safety of rehabilitation and possible risks associated with their participation (Figure 3A).
- Fall screening sheet
To evaluate the indications for rehabilitation, the participants’ information was searched by nursing staff using the fall screening sheet. The fall screening sheet contained information about the participants, including their age, present illness, past history of falls and stroke, nursing care levels, usage of fall prevention alarm systems, and rehabilitation experience (Figure 3B)
- Selection of participants
Based on the above information, MDs, PTs and nurses in Asahikawa Medical University discussed the selection of participants with staff members of elderly institutions using telemedicine systems, then the telerehabilitation participants were selected.
Telerehabilitation programs
MDs, nurses and PTs selected a personalized program for each participant from the following rehabilitation menus based on the “Questionnaire” and “Fall screening sheet” as well as the physical and mental condition of each participant using the telemedicine system. The rehabilitation menus contained six exercises (rising training, high knee training, straight leg raise training, side lying leg lift training, heel raise training and a knee straightening exercise), which mainly focused on muscular strength training of the lower limbs and the improvement of sitting balance. At the first session, the rehabilitation session was observed by MDs, nurses and PTs using the telerehabilitation system. The participants were required to continue the rehabilitation two or three times per week by themselves with caregiver’s support in their nursing home. The interval between rehabilitation sessions depended on the participants’ rehabilitation program and condition. All participants underwent telerehabilitation five times in three months (first time, one week, one month, two months and three months later, respectively). (Figure 3C-E)
Points of evaluation
The efficacy of the telerehabilitation for each participant was evaluated using quantitative scales, including muscle strength, the Berg Balance Scale (BBS) [16], the Timed Up & Go test (TUG test) [17] and the Mini-Mental State Examination (MMSE) [18].
- Muscle strength
We measured knee extensor muscle strength using hand-held dynamometer (HHD;μTas F-1, Anima Corp., Tokyo) [19]. Briefly, with the participant sitting on a chair, the HHD sensor is attached to the limb with a belt that is anchored to a fixed structure. The participant extends the limb, and then knee extensor muscle strength is measured using the HHD.
- Berg Balance Scale
To evaluate participants’ balance ability, all participants were assessed by the BBS [16]. The BBS is thought to be reliable and widely accepted method for the evaluation of balance [20]. Briefly, this scale contains 14 items related to sitting balance, standing balance and dynamic balance. The scores for each item range from 0 to 4, with a score of 0 representing inability to complete the task and a score of 4 representing independent completion of the task.
- Timed Up & Go test
The TUG test has been widely used to evaluate basic mobility maneuvers that are frequently performed by the elderly population [17, 21]. The TUG test measures the time that it takes for a person to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down [17].
- Mini-Mental State Examination (MMSE)
The MMSE was developed to measure cognitive impairment in 1975 [18] and is currently used for dementia screening. The MMSE is a 30-point questionnaire, with five sections (orientation [10 points], registration [3 points], attention and calculation [5 points], recall [3 points] and language [9 points]) [22]. The cut-off score for the diagnosis of dementia is reported to be <24, which is considered to be a standard criterion [23, 24].