INDIVIDUALIZED VIDEO-BASED STROKE REHABILITATION HOME PROGRAM

Dan W. Shafer, O.T.R., H.F. Machiel Van der Loos, Ph.D. and Michael Szotak, P.T. Rehabilitation R&D Center Veterans Affairs Palo Alto Health Care System Palo Alto, CA

Abstract

We have shown that evidence of stroke-related dysfunction can be elicited and examined through video observations of subject performance of specific transfer tasks. Based on this prior research, we hypothesize that such patient-specific video footage can be used to create a take-home educational videotape documenting correct vs. incorrect transfer performance and patient-specific therapist recommendations. A home program incorporating a customizable multimedia transfer training format is hypothesized to increase the effectiveness of subjectsÕ home transfer performance, increase educational carryover from the clinic to the home, and decrease caregiver injuries resulting from improper transfer techniques. The Videotape for improved Rehabilitation Activity Performance (V-RAP), being developed at the Veterans Affairs Palo Alto Health Care System Rehabilitation Research and Development Center (VAPAHCS RRDC), is the instrument which we will use to test this hypothesis.

Background

Demographic Factors of Stroke

There are currently 1.5 million stroke survivors in the United States. More than half of these individuals have significant residual physical disability and functional impairment. Survivors of stroke constitute the largest group of patients receiving rehabilitation services in this country (1). Family members of stroke victims also have their lives changed. Virtually all stroke survivors (97%) are able to continue living in the community with the assistance of a primary caregiver (2). Accordingly, efforts should be made to target family members and to potentiate their effectiveness as support providers through education and specialized training and assistance.

Work Accomplished

A prototype, termed the Functional Performance Assessment Tool (FÐPAT), was designed to conduct functional outcome efficacy studies of treatment interventions using a multimedia approach (3). In collaboration with the VAPAHCS Upper Extremity Clinic, a set of twelve functional tasks was derived to demonstrate the effects of repetitive strain injury (RSI) of persons with paraplegia who use manual wheelchairs. It was felt that the performance of these activities by patients with RSI, acting as study participants, would elicit visual evidence of dysfunction related to the subjects' RSI conditions. Analysis of video segments of these tasks effectively assisted a clinician in preparing a treatment plan for the patient, sharing patient information with members of the multidisciplinary team, and creating and implementing a patient-specific home program. The effectiveness of video analysis in rehabilitation as discussed here provided the basis for the development of the home rehabilitation program videotape. Furthermore, standardized task selection criteria and evaluation materials created for F-PAT were transferred to the development of V-RAP.

Statement of the Problem

Training in the performance of transfers, an integral aspect of a CVA education program, represents one of the most important issues in home carryover from the hospital setting. Wheelchair transfer skills are among the most important skills that must be mastered by persons with CVA (4). The need for carryover in transfer safety techniques to the patient's home environment is validated by the incidence of faulty transfer procedures. Of all the wheelchair accident locations in a recent study, over half occurred in the wheelchair user's home. Furthermore, transfer-related injuries to caregivers and family members accounted for approximately 14.1% of all wheelchair-related non-user injuries between 1986 and 1990, or about 1,600 reported injuries (5). When the injury affected a caregiver, lack of proper education was frequently implicated. Several recent studies, including a wheelchair- related fatal accident study, found that the skill level of attendants was an important consideration in wheelchair-related accidents (6).

Approach

Overview of study

Research staff from the RRDC are collaborating with therapy personnel from the Comprehensive Rehabilitation Center (CRC), where 15 subjects will be recruited. Subject selection criteria are the following: subjects must be hospitalized for having sustained a CVA, be in the age range 35-65, and exhibit no cognitive or psychological impairments severe enough to interfere with activity performance or ability to learn new information. The subjects will be randomly divided into three groups of five subjects each. The first group will serve as the control group for the hypothesis, and will leave the hospital with traditional home program materials (no videotape). The second group will leave the hospital with a premade educational videotape consisting of a therapist performing the closed set of V-RAP activities properly; footage of these subjects performing the task set will not be included on their videotape. The third group will be videotaped performing the transfer tasks, and a videotape containing subject- specific video footage will be compiled and sent home with the subject in addition to the premade tape of the therapist performing the activities.

The study has been designed to consist of three phases. In Phase I, the RRDC V-RAP staff and the CRC therapy staff will collaborate to break down each predetermined transfer into its specific performance components. For example, components of a wheelchair to bed transfer would include, but not be limited to, the following:

• Scoot forward to edge of w/c
• Lock brakes
• Lean trunk forward
• Proper placement of feet and hands

For each component, standardized videotaping and evaluation criteria and specific hazard areas will be identified during this phase. These areas will be given special attention by the therapist when performing the transfers on videotape.

In Phase II, the CRC therapist will videotape subjects performing a closed, predefined set of transfers according to the specified standardized criteria. In the proposed work, the specified videotaping criteria will be augmented by video templates and examples that will aid the therapist in recording the subjects performing the specific activities. These templates and examples will be presented visually, using graphics, storyboards, and video segments. These will help the therapist, who may have no training in video composition, to produce a consistent video record suitable for use as a basis for training and evaluation.

Phase III will be implemented upon completion of videotaping. At this time, the therapist will collaborate with V-RAP research staff in identifying video clips most suitable for inclusion in a home program videotape. The VIRAP staff will create the videotapes, composed of correct and incorrect task set performance for subject identification and comparison purposes, using the VideoDirectorª software program (7). VideoDirector has been tested and shown to be capable of sequencing predetermined video clips onto a videotape in accordance with the needs of V-RAP educational videotape production. The sequencing and compilation of video clips to produce a finished home program videotape using VideoDirector will be done outside the clinic by the V-RAP research staff. Further studies may indicate the need and include recommendations for the therapist to become more active in the video clip compilation process.

V-RAP research staff will also videotape therapist performance of all transfers for inclusion in patient educational videotapes. Subjects in Group 2 will receive only this footage on their home program videotapes. Subjects in Group 3 will receive this footage alongside footage of their own performance of the identical transfers for analysis, comparison, and potential activity performance modification. Subjects will be given specific directions as to when and with whom to view the tape, what to look for, and how to view it most effectively.

Implications

Significance of this research

Functional assessment information obtained through observation of activity performance can provide numerous areas of focus for rehabilitation. For example, proper activity performance can be compared with dysfunctional performance of the same activities. A patient's videotaped activity performance can also be analyzed over time to establish specific progress made toward functional goals, thus promoting the facile establishment of new, farther-reaching goals based on specific functional improvements, not on chronological expectation timelines.

Analysis of video footage for educational purposes can be beneficial to caregivers as well as patients. Utilizing video, caregivers are given the ability to view their own deficit areas and obtain specific instructions from a therapist regarding home treatment program performance. This integration of therapist feedback into a patient's self-monitored home therapy program is seen as the first step toward interactive therapist-patient and therapist- caregiver relationships extended outside the acute setting. The future development of real-time video links connecting therapists, patients, and caregivers would eliminate the need for transportation to clinics while allowing high-quality interactive treatment and home program review and modification from a distance.

Discussion

The assessment of study effectiveness will be based on each subject's one-month follow-up visit with a physiatrist and physical therapist, and will be assessed in two ways: (1) The physical therapist will review the subjects' home program with them and monitor subject performance of standard transfer tasks as performed in the home program. (2) The physiatrist will record subject answers to routine questions. These answers will be utilized to evaluate effectiveness of V-RAP materials and will be compared across subject groups. Answers will be recorded for questions pertaining to subject satisfaction and motivation, subject ratings of transfer performance improvement, and incidence of subject or caregiver injury sustained from faulty transfer performance. Our hypothesis will be proven if the data analysis can demonstrate the following:

• Subject satisfaction ranking of the V-RAP home program will be at least as high as that of the conventional home program;
• Subjects using V-RAP will improve in transfer performance and feel comfortable performing transfers more quickly than subjects using traditional home program materials; ¥
• Subjects using V-RAP will report fewer transfer-related accidents or injuries than subjects using traditional home program materials.

Future plans include the complete incorporation of V-RAP into a rehabilitation clinic and the use of V-RAP by all therapists in that setting for the creation of home treatment program videotapes. Additionally, therapist criteria regarding transfer safety and training techniques will be recorded to form the basis for the future design of a transfer training expert system.

References

1. Ottenbacher KJ & Jannell S (1993). The results of clinical trials in stroke rehabilitation research. Archives of Neurology, 50: 37-44.

2. Brocklehurst JC, Morris P, Andrews K, Richards B, Laycock P (1981). Social effects of stroke. Soc Sci Med, 15a, 35-39.

3. Shafer D & Van der Loos HFM (1995). Integrated Video and Computerized Functional Assessment. Proceedings RESNA '95, Vancouver, BC, Canada, 146-148.

4. Pedretti LW & Zoltan B (1990). Wheelchairs and wheelchair transfers. In L. Pedretti & S. Gregory (Eds.)Occupational therapy: Practice for physical dysfunction (3rd ed.). St. Louis: Mosby

. 5. Ummat S & Kirby RL (1994). Nonfatal wheelchair-related accidents reported to the national electronic injury surveillance system. American Journal of Phys. Med. Rehab., 73:3, 163- 167.

6. Calder CJ & Kirby RL (1990). Fatal wheelchair- related accidents in the United States. American Journal of Phys Med & Rehab, 69:184-190.

7. VideoDirector, Gold Disk Co., Ontario, Canada

Acknowledgments

Support for this project is provided by Core funding of the Rehabilitation R&D Center of the VA Palo Alto Health Care System. The authors wish to thank the staff of the VA Palo Alto Health Care System Comprehensive Rehabilitation Center for their contributions to the project. AuthorÕs Address Dan Shafer Rehabilitation R&D Center VA Palo Alto Health Care System 3801 Miranda Ave., MS 153 Palo Alto, CA 94304-1200 office: 415-493-5000 #65972 fax: 415-493-4919 e-mail: shafer@roses.stanford.edu